2型糖尿病患者自我管理水平与糖尿病视网膜病变的相关性研究

目的了解2型糖尿病患者自我管理的总体水平，及其与糖尿病视网膜病变（DR）的相关性。方法横断面研究。2009年11月至2011年5月在北京市德胜社区收集1100例已确诊的2型糖尿病患者资料，按照统一标准进行眼科检查及问卷调查，依据ETDRS眼底病变分级标准分为DR组和无糖尿病视网膜病变（DWR）组，DR组又分为增生性糖尿病视网膜病变（PDR）组和非增生性糖尿病视网膜病变（NPDR）组。分析受检人群糖尿病自我管理的状况，包括糖化血红蛋白水平、饮食控制和体育锻炼情况、是否规律检测血糖和进行眼科检查等，比较DR与DWR组、PDR与NPDR组间相关因素的差异。对相关因素进行logistic回归分析。结果研究共纳入1100例2型糖尿病患者。DR患病率为32．1％（353／1100），PDR患病率为4．8％（53／1100）；糖化血红蛋白控制达标率（〈7．0％）为63．0％（652／1035），85．4％（916／1072）的患者控制饮食，77．3％（827／1070）的患者进行体育锻炼，56．0％（609／1088）的患者规律测量血糖，56．8％（416／733）的患者糖化血红蛋白检测频率≥1次／6个月。71．7％（762／1062）的患者在确诊糖尿病后进行过眼科检查，其中47．9％（525／1097）进行过散瞳眼底检查。单因素研究发现，糖尿病病程≥10年（OR：3．90，95％凹：2．97～5．51，P〈0．05），糖化血红蛋白控制未达标（≥7．0％）（OR=3．23，95％C1：2．44～4．28，P〈0．05）和使用胰岛素治疗（OR：4．82，95％C1：3．55—6．57，P〈0．05）与DR发生存在显著相关性，其他因素包括男性（OR：1．41，95％CI：1．08～1．84，P〈0．05）、受教育程度较低（OR=1．90，95％CI：1．39～2．62，P〈0．05）、个人月收入较低（〈2000元）（OR=1．46，95％CI：1．12～1．9l，P〈0．05）、对饮食指导依从性低（〈75％）（OR=1．72，95％C／：1．22～2．43，P〈0．05）、未进行体育锻炼（OR=1．42，95％CI：1．04～1．94，P〈0．05），5年内治疗方案变化（OR=1．78，95％CI：1．32～2．41，P〈0．05）和有糖尿病家族史（OR：1．35，95％C1：1l0l～1．78，P〈0．05）与DR发生相关；糖尿病发病年龄（OR=0．92，95％CI：0．89—0．95，P〈0．05）、糖尿病病程≥10年（OR=4．54，95％口：1．95～12．32，P〈0．05）、使用胰岛素治疗（OR：4．85，95％C1：2．34—10．90，P〈0．05）与PDR发生相关。在多因素logistic回归分析模型中，男性（OR=2．21，95％CI：1．57～3．11，P〈0．05）、受教育程度较低（OR=1．98，95％CI：1．33～2．94，P〈0．05）、个人月收入较低（OR=1．66，95％CI：1．15～2．39，P〈0．05），糖尿病病程≥10年（OR：2．46，95％CI：1．77～3．41，P〈0．05），糖化血红蛋白水平控制未达标（OR=2．24，95％C／：164—3．07，P〈0．05）、使用胰岛素治疗（OR=3．38，95％CI：2．38—4．80，P〈0．05）与DR的发病相关；糖尿病发病年龄（OR=0．94，95％CI：0．91～0．98，P〈0．05）、使用胰岛素治疗（OR=3．49，95％C1：1．47～8．27，P〈0．05）与PDR发病相关。结论糖尿病病程长、使用胰岛素治疗、较高的糖化血红蛋白水平、男性及较低的受教育程度与DR的发病风险相关，DR发病高风险还与对饮食指导依从性低和较少体育锻炼有关，提示糖尿病自我管理水平较低可增加DR的患病风险。

Objective To investigate the association of diabetic self-management with the risk of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus.Methods Cross-sectional study.Recruited patients with type 2 diabetes mellitus in the Desheng community of urban Beijing between November 2009 and May 2011.All patients were surveyed using a standardized questionnaire and underwent detailed ophthalmic examination.Patients were classified into DR group or diabetic without retinopathy (DWR) group according to the grading of fundus color photographs using the Early Treatment of Diabetic Retinopathy Study (ETDRS) standard grading protocol.In the DR group,proliferative diabetic retinopathy (PDR) was further defined.The overall levels of diabetes self-management in the study population were assessed and compared for the differences between DR and DWR,PDR and NPDR groups.Results One thousand one hundred patients with type 2 diabetes mellitus were recruited.The prevalence of DR was 32.1％ (353/1100) in the study population.Sixty-three percent (652/1035) of patients had glycated hemoglobin(HbAlc) level less than 7.0％.The majority of patients(85.4％,916/1072) conducted a diet control,77.3％ (827/1070) exercised,56.0％ (609/1088) monitored blood glucose regularly,56.8％ (416/ 733) detected HbA1 c more than once every six months,71.7％ (762/1062) had ophthalmologic examination after the diagnosis of diabetes mellitus,and 47.9％ (525/1097) had mydriatic check-up.Increased risk of DR was associated with longer duration of diabetes (more than 10 years) (OR =3.90,95 ％ CI:2.97-5.51,P ＜ 0.05),higher HbA1 c level of ≥ 7.0％ (OR =3.23,95 ％ CI:2.44-4.28,P ＜ 0.05),insulin therapy (OR =4.82,95 ％ CI:3.55-6.57,P ＜ 0.05),male gender(OR =1.41,95％ CI:1.08-1.84,P ＜ 0.05),lower level of education(OR =1.90,95％ CI:1.39-2.62,P ＜ 0.05),lower monthly income (OR =1.46,95％ CI:1.12-1.91,P ＜ 0.05),lower obedience to diet control (OR =1.72,95％ CI:1.22-2.43,P ＜0.05),no exercise (OR =1.42,95 ％ CI:1.04-1.94,P ＜ 0.05),change of therapeutic protocol during the last five years (OR =1.78,95％ CI:1.32-2.41,P ＜ 0.05),and family history of diabetes (OR =1.35,95％ CI:1.01-1.78,P ＜0.05).Increased risk of PDR was associated with the diagnosis age of diabetes (OR =0.92,95％ CI:0.89-0.95,P ＜ 0.05),longer duration of diabetes (more than 10 years) (OR =4.54,95％ CI:1.95-12.32,P ＜ 0.05),and insulin therapy (OR =4.85,95％ CI:2.34-10.90,P ＜0.05).In the multifactor logistic regression model,male gender(OR =2.21,95％ CI:1.57-3.11,P ＜0.05),lower level of education (OR =1.98,95 ％ CI:1.33-2.94,P ＜ 0.05),lower monthly income (OR =1.66,95 ％ CI:1.15-2.39,P ＜ 0.05),longer duration of diabetes (more than 10 years) (OR =2.46,95 ％CI:l.77-3.41,P＜0.05),HbAlc≥7.0％(OR=2.24,95％ CI:1.64-3.07,P＜0.05) and insulin therapy(OR =3.38,95％ CI:2.38-4.8,P ＜0.05) were associated with higher risk of DR.The diagnosis age of diabetes (OR =0.94,95％ CI:0.91-0.98,P ＜ 0.05) and insulin therapy (OR =3.49,95％ CI:1.47-8.27,P ＜ 0.05) were associated with PDR.Conclusion Higher risk of DR is associated with longer duration of diabetes,insulin therapy,higher HbA1 c level,male gender,and lower level of education,whereas higher risk of DR is also associated with lower obedience to diet control and less exercise,which suggest that lower level of diabetic self-management increased the risk of DR.