目的 探讨玉渊潭社区卫生服务中心与首都医科大学附属北京同仁医院(三甲医院)对社区中心性肥胖的2型糖尿病患者的干预效果,以期为社区卫生服务提供参考与帮助.方法 本研究为北京社区糖尿病研究的子课题.2012年10月-2013年2月,共纳入由玉渊潭社区卫生服务中心管理的2型糖尿病患者119例,根据体质指数(BMI)、腰围/身高比值(WHtR)将患者分为非中心性肥胖组45例和中心性肥胖组74例.在三甲医院主任医师的全程指导下,根据《中国2型糖尿病防治指南(2010年版)》,三甲医院主任医师与社区全科医师制订患者管理规范,并由固定的主管全科医师对相应患者进行多因素干预管理,干预36个月后观察干预效果.比较干预前后体检、生化指标〔体质量、收缩压、舒张压、空腹血糖(FPG)、糖化血红蛋白(HbA1c)、三酰甘油(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、尿酸〕及干预后终点事件发生情况.结果 干预前,中心性肥胖组患者体质量、收缩压、TG高于非中心性肥胖组(P<0.05);干预前,两组患者舒张压、FPG、HbA1c、TC、HDL-C、LDL-C、尿酸比较,差异无统计学意义(P>0.05).干预后,中心性肥胖组患者FPG高于非中心性肥胖组(P<0.05);干预后,两组患者体质量、收缩压、舒张压、HbA1c、TG、TC、HDL-C、LDL-C、尿酸比较,差异无统计学意义(P>0.05).非中心性肥胖组患者干预后收缩压、FPG、LDL-C较干预前降低,HDL-C较干预前升高(P<0.05);中心性肥胖组患者干预后体质量、收缩压较干预前降低,HDL-C较干预前升高(P<0.05).两组患者干预后脑卒中、冠心病、糖尿病肾病、糖尿病视网膜病变、颈动脉斑块发生率比较,差异无统计学意义(P>0.05).结论 中心性肥胖的2型糖尿病患者血压、血脂控制较差,社区卫生服务中心与三甲医院联合管理模式可以有效改善社区中心性肥胖的2型糖尿病患者的代谢指标,并减少终点事件的发生情况.%Objective To investigate the effect of intervention on type 2 diabetic patients with central obesity in the community through joint management mode between the Yuyuantan Community Health Service Center(YCHSC) and Beijing Tongren Hospital,CMU(hereafter referred to as a tertiary grade A hospital),which might be of great significance for the delivery of community health services.Methods This study is a sub-project of the Beijing Community Diabetes Study(BCDS).Totaled 119 subjects with type 2 diabetes mellitus were recruited from YCHSC between October 2012 and February 2013.Based on body mass index(BMI) and waist to height ratio(WHtR),central obesity was found in 74 cases of them(diabetes with central obesity group),but not in other 45 cases(diabetes without central obesity group).The study was implemented under the instructions of the endocrinology chief physicians of a tertiary grade A from the beginning to the end.Patient management standards were formulated by endocrinology chief physicians of a tertiary grade A and general practitioners(GPs) of YCHSC based on China Guideline for Type 2 Diabetes(2010 edition).All the participants received a 36-month multifactorial intervention delivered by the appointed chief general practitioner.The physical measurements and biochemical indicators〔body weight,systolic blood pressure(SBP),diastolic blood pressure(DBP),fasting plasma glucose(FPG),glycosylated hemoglobin(HbA1c),triacylglycerol(TG),total cholesterol(TC),high-density lipoprotein cholesterol(HDL-C),low-density lipoprotein cholesterol(LDL-C),and uric acid〕 were measured before and after intervention.And prognostic endpoints occurred after intervention were recorded.The effect of the intervention was assessed after the intervention by evaluating and comparing the improvement achieved in both groups and between the groups,and comparing the incidence of prognostic endpoints between the groups.Results Before the intervention,body weight,SBP and TG in diabetes with central obesity group were higher than those in diabetes without central obesity group(P<0.05),while there were no significant differences in DBP,FPG,HbA1c,TC,HDL-C,LDL-C,and uric acid between the two groups(P>0.05).However,after the intervention,except the average value of FPG was higher in the diabetes with central obesity group(P<0.05),other indicators were similar in both groups(P>0.05).After the intervention,SBP,FPG and LDL-C were found to be decreased significantly but the average value of HDL-C increased obviously in the diabetes without central obesity group(P<0.05);in the diabetes with central obesity group,body weight,SBP were identified to be declined substantially but the average value of HDL-C increased notably(P<0.05).There were no significant differences in the incidence of stroke,coronary heart disease,diabetic nephropathy,diabetic retinopathy,and carotid plaque between the two groups after intervention(P>0.05).Conclusion Bad control of blood pressure and lipid profiles could be seen in type 2 diabetic patients with central obesity.Joint management mode between the community health service center and the tertiary grade A hospital for these patients can effectively improve the values of metabolic markers,and reduce the incidence of prognostic endpoints.
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