1. 营养处方Nutrition Medical Nutrition Therapy
ADA 2026 强调"没有单一的'糖尿病饮食'"，应根据患者偏好、文化背景、代谢目标个体化设定。 但下列饮食模式在 RCT 和 Meta 分析中均显示对血糖与心血管获益：
ADA 2026 emphasizes that "there is no single 'diabetes diet'"; it should be individualized to patient preferences, cultural background, and metabolic goals. The following dietary patterns have all shown glycemic and cardiovascular benefits in RCTs and meta-analyses:
地中海饮食 🫒Mediterranean diet 🫒
以橄榄油、坚果、鱼类、全谷物、蔬果为主；PREDIMED 等大型 RCT 显示 T2D 发病率降低 30%，CVD 复合事件降低 28%。2026 ADA 推荐为首选模式之一。
Centered on olive oil, nuts, fish, whole grains, vegetables and fruit; large RCTs such as PREDIMED show a 30% reduction in T2D incidence and a 28% reduction in composite CVD events. ADA 2026 recommends it as one of the preferred patterns.
低碳水化合物 🥑Low-carbohydrate 🥑
50–130 g/d。Meta 分析中对 HbA1c 改善优于标准饮食； ADA 评定其证据等级最高用于改善血糖。可持续性中等。
50–130 g/d. In meta-analyses it improves HbA1c more than standard diets; ADA rates its evidence level highest for improving glycemia. Sustainability is moderate.
生酮饮食 🥩Ketogenic diet 🥩
碳水 < 50 g/d，脂肪 70–75%。可显著降 HbA1c、减重， 42 RCT 网状 Meta 显示生酮在 HbA1c 改善方面最优。但长期依从性差， SGLT2i 同用时增加 DKA 风险。
Carbohydrate < 50 g/d, fat 70–75%. Can substantially lower HbA1c and reduce weight; a network meta-analysis of 42 RCTs shows ketogenic diets are best for HbA1c improvement. But long-term adherence is poor, and co-use with SGLT2i increases DKA risk.
植物性饮食 🌱Plant-based diet 🌱
素食 / 弹性素食。胰岛素敏感性改善、肠道菌群优化。 注意 B12、铁、ω-3 补充。
Vegetarian / flexitarian. Improves insulin sensitivity and optimizes gut microbiota. Mind B12, iron, and ω-3 supplementation.
DASH 饮食 🥬DASH diet 🥬
高蔬果、低钠；血压改善证据强，对 T2D 心血管风险有获益。
High in vegetables and fruit, low in sodium; strong evidence for blood-pressure improvement and benefit for cardiovascular risk in T2D.
间歇性禁食 ⏰Intermittent fasting ⏰
16:8 或 5:2 模式。短期血糖与体重改善，对老年/胰岛素治疗者需谨慎避免低血糖。
16:8 or 5:2 patterns. Short-term glycemic and weight improvement; use caution to avoid hypoglycemia in elderly or insulin-treated patients.
- 限制添加糖与精制谷物，优选未加工或最少加工食物
- 每日膳食纤维 ≥ 14 g/1000 kcal
- 蛋白质 15–20% 总能量（CKD 患者根据分期调整）
- 替换饱和脂肪为不饱和脂肪（橄榄油、坚果、鱼油）
- 限酒、限钠（< 2300 mg/d）
- 避免含糖饮料；甜味剂可替代但不鼓励常规依赖
- Limit added sugars and refined grains; prefer unprocessed or minimally processed foods
- Dietary fiber ≥ 14 g/1000 kcal per day
- Protein 15–20% of total energy (adjust by stage in CKD patients)
- Replace saturated fat with unsaturated fat (olive oil, nuts, fish oil)
- Limit alcohol and sodium (< 2300 mg/d)
- Avoid sugar-sweetened beverages; sweeteners can substitute but routine reliance is not encouraged
2. 运动处方Exercise Physical Activity
ADA 推荐：ADA recommendations:
- 有氧运动：≥ 150 min/周中等强度（快走、骑车、游泳），或 ≥ 75 min/周高强度
- 抗阻训练：每周 ≥ 2 次，覆盖主要肌群
- 柔韧/平衡（老年）：每周 2–3 次（如太极、瑜伽）
- 避免久坐：每 30 min 站立活动几分钟
- Aerobic exercise: ≥ 150 min/week moderate intensity (brisk walking, cycling, swimming), or ≥ 75 min/week vigorous intensity
- Resistance training: ≥ 2 times/week, covering major muscle groups
- Flexibility/balance (elderly): 2–3 times/week (e.g., tai chi, yoga)
- Avoid sedentary time: stand and move for a few minutes every 30 min
2.1 运动与血糖管理2.1 Exercise and glycemic management
- 有氧运动：急性效应主要降低血糖（GLUT4 转位增加）
- 抗阻运动：增加肌肉量与基础代谢，长期改善胰岛素敏感性
- 高强度间歇 HIIT：时间效率高，HbA1c 改善与持续训练相当
- Aerobic exercise: the acute effect mainly lowers blood glucose (increased GLUT4 translocation)
- Resistance exercise: increases muscle mass and basal metabolism, improving insulin sensitivity over the long term
- High-intensity interval HIIT: time-efficient, with HbA1c improvement comparable to continuous training
运动可引起延迟低血糖（最长达 24 h）。 策略：运动前监测血糖；< 5.6 mmol/L 先补碳水；调整胰岛素剂量（短效减 25–75%）； 运动后睡前低血糖风险增加，必要时减少基础胰岛素。
Exercise can cause delayed hypoglycemia (up to 24 h). Strategies: monitor blood glucose before exercise; if < 5.6 mmol/L, take carbohydrate first; adjust insulin dose (reduce short-acting by 25–75%); post-exercise bedtime hypoglycemia risk increases, so reduce basal insulin if needed.
3. 血糖监测Glucose Monitoring Glucose Monitoring
三种主要监测方式：Three main monitoring methods:
- HbA1c：3–6 个月一次，反映长期平均血糖
- SMBG (指尖血糖)：未使用 CGM 者；T1D 与胰岛素治疗 T2D 每日多次
- CGM (连续葡萄糖监测)：组织间液葡萄糖，每 1–5 分钟读数
- HbA1c: every 3–6 months, reflecting long-term average blood glucose
- SMBG (fingerstick blood glucose): for those not using CGM; multiple times daily in T1D and insulin-treated T2D
- CGM (continuous glucose monitoring): interstitial fluid glucose, with a reading every 1–5 minutes
3.1 CGM 衍生指标3.1 CGM-derived metrics
- TIR (Time in Range)：70–180 mg/dL 时间占比；目标 > 70%
- TBR (Time Below Range)：< 70 mg/dL 时间；目标 < 4%
- TAR (Time Above Range)：> 180 mg/dL 时间；目标 < 25%
- GMI (Glucose Management Indicator)：由 CGM 平均血糖估算的 HbA1c
- CV (Coefficient of Variation)：血糖变异性；目标 < 36%
- TIR (Time in Range): percentage of time at 70–180 mg/dL; target > 70%
- TBR (Time Below Range): time < 70 mg/dL; target < 4%
- TAR (Time Above Range): time > 180 mg/dL; target < 25%
- GMI (Glucose Management Indicator): HbA1c estimated from CGM mean glucose
- CV (Coefficient of Variation): glycemic variability; target < 36%
4. CGM 系统CGM Devices CGM Devices (2025–2026)
| 系统 | 佩戴时间 | MARD 准确度 | 特点 |
|---|---|---|---|
| Dexcom G7 / G7 15-Day | 10 / 15 天 | ≈ 8.2% | 提前 20 min 预警；多人 Share；与多款泵集成 |
| Abbott FreeStyle Libre 3 Plus | 15 天 | ≈ 8–9% | 体积最小；BLE 33 ft；每分钟读数 |
| Medtronic Guardian 4 / Simplera | 7 天 | ≈ 9–10% | 与 MiniMed 780G 配合 |
| Senseonics Eversense E3 | 180 天（植入式） | ≈ 9% | 皮下植入；每日校准 |
| System | Wear time | MARD accuracy | Features |
|---|---|---|---|
| Dexcom G7 / G7 15-Day | 10 / 15 days | ≈ 8.2% | 20 min advance alerts; multi-user Share; integrates with multiple pumps |
| Abbott FreeStyle Libre 3 Plus | 15 days | ≈ 8–9% | Smallest size; BLE 33 ft; reading every minute |
| Medtronic Guardian 4 / Simplera | 7 days | ≈ 9–10% | Works with MiniMed 780G |
| Senseonics Eversense E3 | 180 days (implantable) | ≈ 9% | Subcutaneous implant; daily calibration |
2026 ADA 标准：CGM 被推荐用于所有 T1D 与胰岛素治疗的 T2D； AID (CGM + 算法 + 泵) 为 T1D 首选；准入门槛大幅降低（取消 C-肽、抗体等先决条件）。
ADA 2026 Standards: CGM is recommended for all T1D and insulin-treated T2D; AID (CGM + algorithm + pump) is the first choice for T1D; entry barriers are greatly lowered (removing prerequisites such as C-peptide and antibodies).
5. 体重管理Weight Management Weight Management
2026 ADA 标准明确体重管理是 T2D 治疗的核心目标。减重 5–10% 显著改善 HbA1c、血压、血脂； ≥ 15% 可逆转部分 T2D（"remission"）；DiRECT 试验证实强化减重可使近半数 T2D 患者停药缓解。
ADA 2026 Standards make clear that weight management is a core goal of T2D treatment. Weight loss of 5–10% significantly improves HbA1c, blood pressure, and lipids; ≥ 15% can reverse some T2D ("remission"); the DiRECT trial confirmed that intensive weight loss can produce drug-free remission in nearly half of T2D patients.
治疗阶梯Treatment ladder
- 生活方式 (饮食 + 运动)：可达减重 3–7%
- 药物（按减重效力排序）：
- Tirzepatide — SURMOUNT 系列：15–22.5%
- Semaglutide 2.4 mg (Wegovy) — STEP：14–17%
- Orforglipron (2026 获批) — 14.7% (ATTAIN-1)
- Liraglutide 3.0 mg (Saxenda) — 5–8%
- 奥利司他、纳曲酮/安非他酮等老药
- 代谢手术：BMI ≥ 35 (亚洲 ≥ 32.5) 合并 T2D；减重 25–35%，可达长期缓解
- Lifestyle (diet + exercise): can achieve 3–7% weight loss
- Medications (ordered by weight-loss efficacy):
- Tirzepatide — SURMOUNT series: 15–22.5%
- Semaglutide 2.4 mg (Wegovy) — STEP: 14–17%
- Orforglipron (approved 2026) — 14.7% (ATTAIN-1)
- Liraglutide 3.0 mg (Saxenda) — 5–8%
- Older agents such as orlistat and naltrexone/bupropion
- Metabolic surgery: BMI ≥ 35 (Asian ≥ 32.5) with T2D; 25–35% weight loss, can achieve long-term remission
2025–2026 年减重药竞争白热化：oral semaglutide (Wegovy 片剂 2025 年 12 月获批) 与 orforglipron (Foundayo 2026 年 4 月获批) 让 GLP-1 类药物迈入口服时代； retatrutide 在 III 期减重达 26%，但安全信号需进一步评估； cagrisema (司美 + 卡格鲁肽 amylin 类似物) 与 maridebart cafraglutide (GLP-1 RA + GIP 拮抗) 是后续重点。
Competition among weight-loss drugs intensified in 2025–2026: oral semaglutide (Wegovy tablet approved Dec 2025) and orforglipron (Foundayo approved Apr 2026) have brought GLP-1 drugs into the oral era; retatrutide achieved 26% weight loss in phase III, but its safety signal needs further evaluation; cagrisema (semaglutide + cagrilintide, an amylin analog) and maridebart cafraglutide (GLP-1 RA + GIP antagonist) are the next focus.
来源：Source: IQVIA — Outlook for Obesity 2026 · BioSpace — Retatrutide Triple Trial Triumph
6. 心理与教育Mind & Education DSMES & Mental Health
ADA 推荐所有糖尿病患者在四个关键节点接受糖尿病自我管理教育与支持 (DSMES)： ①新诊断时；②每年评估；③出现新并发症或治疗变化；④护理过渡期（如住院→出院）。
ADA recommends that all diabetes patients receive diabetes self-management education and support (DSMES) at four key moments: ① at new diagnosis; ② at annual assessment; ③ when new complications or treatment changes arise; ④ during care transitions (e.g., hospitalization → discharge).
- 糖尿病窘迫 (Diabetes Distress)：50% 患者经历过；与依从性、血糖控制相关
- 抑郁与焦虑：糖尿病患者风险增加 2 倍；筛查工具 PHQ-9, GAD-7
- 饮食失调：T1D 女性中"diabulimia"（故意减少胰岛素以减重）值得关注
- 认知障碍：老年 T2D 痴呆风险增高，应纳入综合评估
- Diabetes Distress: experienced by 50% of patients; associated with adherence and glycemic control
- Depression and anxiety: 2-fold increased risk in diabetes patients; screening tools PHQ-9, GAD-7
- Eating disorders: "diabulimia" (deliberately reducing insulin to lose weight) deserves attention among women with T1D
- Cognitive impairment: elderly T2D patients have increased dementia risk and should be included in comprehensive assessment
7. 特殊场景Special Situations Sick Days · Surgery · Travel
Sick Day 规则Sick Day rules
- 多饮水，监测血糖每 2–4 h 一次
- T1D 同时监测尿/血酮
- 持续注射胰岛素（即便不能进食）— 不可擅自停药
- SGLT2i 在严重应激/脱水/急性病期间应暂停
- 持续呕吐、酮体升高、血糖 > 16.7 mmol/L 须就医
- Drink plenty of fluids, monitor blood glucose every 2–4 h
- In T1D, also monitor urine/blood ketones
- Continue insulin injections (even if unable to eat) — do not stop on your own
- SGLT2i should be paused during severe stress/dehydration/acute illness
- Seek medical care for persistent vomiting, rising ketones, or blood glucose > 16.7 mmol/L
围手术期Perioperative period
- 术前评估 HbA1c：择期手术理想 < 8.5%
- 术前停 SGLT2i 3–4 天（避免血糖正常型 DKA）
- 术前停 GLP-1 RA（恶心呕吐风险）— 美国麻醉医师学会 2023 共识
- 大手术多用静脉胰岛素，目标血糖 7.8–10 mmol/L
- Assess HbA1c preoperatively: ideally < 8.5% for elective surgery
- Stop SGLT2i 3–4 days before surgery (to avoid euglycemic DKA)
- Stop GLP-1 RA before surgery (nausea/vomiting risk) — American Society of Anesthesiologists 2023 consensus
- Major surgery generally uses IV insulin, target blood glucose 7.8–10 mmol/L
出行Travel
- 处方与字典备份；胰岛素随身携带（避免行李托运冰冻）
- 跨时区调整基础胰岛素时机
- CGM 可正常通过机场安检（部分需走人工通道，提前告知）
- Back up prescriptions and documentation; carry insulin in hand luggage (to avoid freezing in checked baggage)
- Adjust the timing of basal insulin across time zones
- CGM can normally pass airport security (some require manual screening lanes; notify staff in advance)