糖尿病共同照護對社區基層醫療網第二型糖尿病患者營養素攝取改變以及血糖控制之影響

A prospective randomized trial to evaluate effectiveness of diabetes management through an integrated delivery system (DMIDS) on glycemic and diet control in primary care setting in Taiwan.

王煥森(Huan-Sen Wang)

指導教授 ： 辛錫璋

高雄醫學大學/醫學院/醫學研究所/碩士(2008年)

https://doi.org/10.6832/KMU.2008.00068

摘要

目的：為了評估糖尿病共同照護計畫在基層診所執行成效。以探討糖尿病整合照護對第二型糖尿病患者之血糖、血壓、血脂及其他生化代謝指標的影響。並觀察營養素攝取的改變對血糖控制的相關性。
方法：本研究招募對象為高雄市基層診所控制血糖之第二型糖尿病患者。並透過派遣合格營養師至基層診所，觀察營養衛教的介入對基層診所執行糖尿病整合照護計劃的成效。本研究採隨機分組試驗，將受試者隨機分派至介入組以及對照組。介入組每三個月由營養師執行各案管理與追蹤乙次。介入課程的安排則是依據美國糖尿病學會所公佈的標準作依據，由營養師依受試者生化檢查結果以及生活型態的不同個別來設計。而對照組則接受基層診所提供的照護服務，本研究不予介入。資料收集上，除了基礎的體位測量與臨床生化檢查外，本研究利用24小時飲食回憶紀錄作為飲食資料的依據，並以營養分析軟體分析飲食的組成，觀察受試者飲食行為的改變。
結果：本研究共有154名受試者完成12個月的研究追蹤。其中介入組共75名；對照組完成追蹤者共79名。從整體的資料分析，本研究未觀察到臨床指標上，兩組之間在營養衛教介入後具有顯著性的差異。因此本研究以美國糖尿病學會建議為依據，將起始糖化血色素是否小於7%做切點。研究發現起始糖化血色素＜7%者，介入後糖化血色素改變量兩組之間未達統計上的顯著。而在起始糖化血色素≧7％的族群中，介入後糖化血色素上，介入組改變量為-0.7±1.1%，對照組則是-0.2±1.7% (P=0.034) ；空腹血糖則在介入組下降了-13.4±55.2mg/dl)，對照組則是增加(16.9±63.6mg/dl) (p<0.007)。此外，收縮壓前後測改變量上，介入組增加了0.5±16.8 mmHg；對照組則增加了8.6±17.4mmHg達統計上顯著(p=0.012)，但舒張壓的改變量上兩組間則無顯著差異（介入組0.6±11.5 mmHg；對照組0.4±10.0 mmHg，P=0.945）。在飲食攝取方面，起始糖化血色素≧7％的族群在介入後，介入組熱量攝取減少了291.4±347.2 kcal/day；對照組增加76.4±241.9 kcal/day (p<0.001)。醣類的攝取上，介入組平均減少37.4±62.1 g/day；對照組增加13.4±48.5 g/day。然而，三酸甘油酯、總膽固醇、低密度脂蛋白膽固醇、麩丙酮酸轉氨脢等臨床生化指標的前後測上，雖然在介入組呈現下降的趨勢，但與對照組之間並未達到統計上的顯著。而在體重及腰臀圍方面，本研究並未觀察到兩組之間的顯著差異。而在多變量迴歸分析中，我們調整年齡、性別、糖尿病罹病年數、起始體重以及起始糖化血色素等可能的干擾因子後，以熱量及醣類攝取攝取的改變當作主要的自變項，發現每增加一個醣類計算當量(15克醣類)的攝取，可能與糖化血色素 0.14%的改變量有關。
結論：本研究認為營養衛教的介入具有改善基層診所糖化血色素≧7%之第二型糖尿病患者血糖的控制。且發現醣類攝取量的改變與糖化血色素的改變具有顯著的相關。

關鍵字

第二型糖尿病 ； 社區基層醫療網 ； 營養衛教 ； 台灣

並列摘要

Objective The aim of this study was to evaluate the effectiveness of diabetes management in type 2 diabetes with regard to glycemic and diet control in primary care setting in Taiwan, and assess associations between nutrient intake and glycemic control.
Methods We randomly assigned 154 adult patients with type 2 diabetes recruited from 5 primary care stations in Kaohsiung to intervention (n=75) or control group (n=79). The control subjects received the standard care, and intervention subjects additionally received diabetes education focusing on nutrition based on recommendation of American Diabetes Association by certified diabetes educators (2 registered dietitians) every three month.
Results After 12 month follow up, we did not observed significant changes in clinical parameters in subjects with baseline glycosylated hemoglobin A1c (HbA1c)＜7%. On the other hand, in patients with baseline HbA1c≧7%, changes of fasting plasma glucose (mg/dl) (-13.4 vs 16.9, p=0.007), HbA1c (%) (-0.7 vs -0.2, p=0.034) and systolic blood pressure (mmHg) (0.5 vs 8.6, p=0.012) were significantly different between intervention and control groups. In these patients with baseline HbA1c≧7%, changes of energy and carbohydrate intake between the two groups were also significantly different (p＜0.05). Energy intake decreased by -291 (±347.2) Kcal/day in intervention and increased by 76.4 (±241.9) Kcal/day in control subjects (p＜0.001); carbohydrate intake decreased by -37.4 (±62.1) g/day in intervention group and increased by 13.4 (±48.5) g/day in the control (p＜0.001). However, we didn’t observed significant change in weight after 12 month intervention. After adjusting for possible confounders (age, gender, duration of diabetes, baseline weight, baseline HbA1c), increasing every 15 grams in carbohydrate intake (one carbohydrate counting) was significantly related to changes of HbA1c at increments of 0.14% (SE=0.03, p＜0.001).
Conclusion Glycemic and dietary improvements can be achieved through diabetes education addressing nutrition aspects ≧7% in primary care setting in Taiwan. The improvements of glycemic status may be related to nutrition intervention and changes in diet such as amount of carbohydrate intake.

並列關鍵字

Type 2 diabetes ； primary care ； nutrition education ； Taiwan

參考文獻

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