餐后血糖与心血管病课件.ppt

1、编辑版ppt1餐后血糖与心血管病餐后血糖与心血管病编辑版ppt2正常人餐后状态的定义及持续时间正常人餐后状态的定义及持续时间早餐早餐 午餐午餐 晚餐晚餐 0:00 4:00 早餐早餐 am am 8:00 11:00 2:00 5:00 am am pm pmTime of blood samplingto obtain adiurnal blood glucose profile餐后状态餐后状态餐后吸收状态餐后吸收状态空腹状态空腹状态编辑版ppt3编辑版ppt4餐后高血糖对餐后高血糖对HbA1c有非常大的影响有非常大的影响HbA1cFBG餐后高血糖餐后高血糖造成的差造成的差随机化水平随机化水

2、平0369Years编辑版ppt5020406080100-12-10-8-6-4-20246Beta 细胞功能下降细胞功能下降Adapted from UKPDS 16:Diabetes 1995:44:1249-1258Beta 细胞功能细胞功能(%)自诊断的年份自诊断的年份UKPDS编辑版ppt62型DM的自然病程与-C功能的关系-24 -10 0 30年年 DM100%IGT编辑版ppt7胰岛素抵抗胰岛素抵抗肝葡萄糖输出肝葡萄糖输出内源性胰岛素内源性胰岛素餐后血糖餐后血糖空腹血糖空腹血糖内源胰岛素内源胰岛素IGT糖尿病糖尿病 微血管并发症微血管并发症大血管并发症大血管并发症 4-7 年

3、年 “诊断为糖尿病诊断为糖尿病”糖尿病的严重性糖尿病的严重性Clinical Diabetes Volume 18,Number 2,2000编辑版ppt82 型糖尿病的三个阶段型糖尿病的三个阶段阶段阶段 Pathophysiology 指示指示第一阶段第一阶段 -胰岛素抵抗胰岛素抵抗 -胰岛素分泌胰岛素分泌 -正常正常 PGPG第二阶段第二阶段 -更严重的胰岛素抵抗更严重的胰岛素抵抗 -早期餐后胰岛素分泌受损早期餐后胰岛素分泌受损IGT(IGT(餐后高血糖）餐后高血糖）第三阶段第三阶段 -严重的胰岛素抵抗严重的胰岛素抵抗 -受损的胰岛素分泌受损的胰岛素分泌 -空腹高血糖空腹高血糖 -增高的内

4、源性葡萄糖代谢增高的内源性葡萄糖代谢 -餐后高血糖餐后高血糖1.Warram J,et al:Ann Intem Med 1990,113:909-9151.Warram J,et al:Ann Intem Med 1990,113:909-9152.Mitrakou A,et al:N Engl J Med 1992,326:22-292.Mitrakou A,et al:N Engl J Med 1992,326:22-293.Ninneen SF:Diabetic Med 1997,14(suppl 3):s19-s243.Ninneen SF:Diabetic Med 1997,14(

5、suppl 3):s19-s24编辑版ppt9“Ticking ClockTicking Clock”(钟摆钟摆)假说假说 钟摆动已始于钟摆动已始于微血管并发症微血管并发症 高血糖出现时高血糖出现时大血管并发症大血管并发症 发展在糖尿病前期发展在糖尿病前期Haffner SM et al JAMA 1990;263:2893-2898Haffner SM et al JAMA 1990;263:2893-2898编辑版ppt10IMPORTANDCE OF MEALTIME GLUCOSE EXCURSIONS Mealtime and postprandial hyperglycemia a

6、re typically the earliest clinical manifestations of Type 2 diabetesnWorsens pre-existing prediabetic defects of insulin secretion and action,and contributes to overall daily hyperglycemia(as reflected in HbA1c)nControl of PBG optimizes overall glycemic controln “Therapy focused on lowering PBG,not

7、FBG may be superior for lowering HbA1c”(Basyr et al Diabetes Care 23:1236,2000)nLeads to reactive hyperinsulinemianAssociated with increased risk for macrovascular complicationsn-IGT is a risk factor for CVD complicationsn-Epidemiologic studies show a relationships between PBG and risk for CVD compl

8、ications编辑版ppt11Mealtime Glucose Excursions and risk of Cardiovascular Disease(1)Honolulu heart program,1987Diabetes Intervention Study,1998Funagata Diabetes Study,1999The Rancho Bernardo Study,1998CHD incidence and mortality increase stepwise with increasing IGTPBG,but not FBG is associated with CH

9、D IGT,but not IFG,is a risk factor for CVD2-hPBG alone more than doubles the risk of fatal CVD and CVD in older adults“the use of FBG alone for DM screening or diagnosis may fail to identify most older adults at high risk for CVD and should be re-evaluated”编辑版ppt12Mealtime Glucose Excursions and ris

10、k of Cardiovascular Disease(2)Paris Prospective Study,1999Whitehall Study,1999HOORN Study,1999Death rates for CHD increasing 2hPBG levelsMen in the upper 2.5%of the 2hPBG distribution had significantly higher CHD mortalityHigh PBG levels,especially 2h-load PBG concentrations and to a lesser extent,H

11、bA1c values,indicate a risk for CVD mortality编辑版ppt13Mealtime Glucose Excursions and risk of Cardiovascular Disease(3)Pacific and Indian Ocean Population Study,1999DECODE study,1999Theodora S.et al,2000Isolated 2h PBG challenge increases total mortality and CVD mortality,and carries a greater risk t

12、han isolated FBGCHD mortality is more related to 2-h PBG than to FPG.FPG does not identify subjects at risk for CHDPG and PGS are more strongly associated with carotid IMT than FBG and HbA1c编辑版ppt14Importance of mealtime glucose excursionsMealtime and post-mealhyperglycemia are typically the earlies

13、t manifestations of Type 2 diabetesvPBG Contributes to overall daily hyperglycemia(e.g as reflected in HbA1c and microvascular complications)vPBG Associated with increased r i s k f o r m a c r o v a s c u l a r complications -IGT is a risk factor for vascular complications -numerous epidemiologic s

14、tudies show a relationship between PBG levels and risk for cardiovascular complications编辑版ppt15Adjusted Survival According to Diabetes Category:Pacific and Indian Ocean Population0.70.70.80.80.90.91 11000100020002000300030004000400050005000Time(days)Time(days)Cumulative survivalCumulative survivalIF

15、H-isolated fasting hyperglycemia(FPG7mmol/L;2h PG11.1mmol/L)IPH-isolated 2h post-glucose hyperglycemia(FPG11.1mmol/L)KD-known diabetesKDIPHnormalIFHmalesJ.E.Shaw et al.Diabetologia 1999;42:1050编辑版ppt16组别组别(例例)(20)(20)(20)男男/女女 9/11 9/11 9/11 年龄（岁）年龄（岁）46.82.6 47.71.5 45.52.0 0.28 0.7599 SBP(mmHg)102

16、3 1133 120 2 4.91 0.0125 DBP(mmHg)691 741 74 1 1.49 0.2399 MBP(mmol/L)802 891 89 1 2.98 0.0625 FBS(mmHg）4.850.02 9.06 0.69 9.06 0.69 6.64 0.0034 PBS2h(mmol/L)6.14 0.06 12.6+0.89 12.6+0.89 13.9 0.000724hSBP(mmol/L)1083 1082 1052 0.64 0.5301 24hDBP(mmol/L)721 731 721 0.17 0.8473 NGT IGT DM2 F值值 P值值 血压

17、正常的不同糖耐量患者的临床特征（1）李春霖，潘长玉，陆菊明等李春霖，潘长玉，陆菊明等 中华内科杂中华内科杂1997;36(8):536-539编辑版ppt17 NGT IGT DM2 F NGT IGT DM2 F值值 P P值值组别组别(例例)（2020）（2020）（2020）男男/女女 9/11 9/11 9/11 9/11 9/11 9/11 夜夜DBP(mmHg)61DBP(mmHg)614 654 652 702 702 3.15 0.0505 2 3.15 0.0505 SBP SBP（%）13.613.61.4 5.6 1.4 5.6 2.0 1.9 2.0 1.91.8 1.

18、07 0.0020 1.8 1.07 0.0020 DBP DBP（%）17.617.62.0 13.3 2.0 13.3 1.8 4.1 1.8 4.11.9 5.30 0.0005 1.9 5.30 0.0005 MBP MBP（%）15.915.91.6 9.41.6 9.41.7 3.21.7 3.21.6 3.93 0.00011.6 3.93 0.0001 血压正常的不同糖耐量患者的血压正常的不同糖耐量患者的动态血压改变动态血压改变(X(XSx)Sx)为昼夜差值 李春霖，潘长玉，陆菊明等 中华内科杂1997;36(8):536-539编辑版ppt18组别(例)(20)(20)(20

19、)男/女 12/8 14/6 13/7 年龄（岁）52.22.3 52.0 1.9 53.2 1.9 0.10 0.9007 FBS(mmol/L)5.13 0.23 6.940.20 9.58 0.72 22.79 0.0001 PBS2h(mmol/L)6.37 0.19 8.65 0.26 13.01.13 23.00 0.0001ch(mmol/L)3.870.16 5.460.23 5.040.17 17.39 0.0001 HbA1c(%)5.390.15 7.42 0.21 9.790.71 23.42 0.0001 UAE(mg/L)4.17/9.12/17.4/4.26 0.

20、0202 0.48 0.43 0.29 FIns(mu/L)3.63/4.47/8.13/5.90 0.0073 0.28 0.35 0.44 Ins2h(mu/L)22.4/22.9/27.5/0.27 0.7638 0.33 0.42 00.42 IAI -2.98 -3.35 -4.07 9.69 0.000624hSBP(mmHg)129 4 1272 133 4 0.67 0.5160 NGT NGT IGT IGT DM2 DM2 F F值值 P P值值血压正常的不同糖耐量患者的临床特征（血压正常的不同糖耐量患者的临床特征（X XSxSx）UAE和Ins呈偏态分布，结果用几何均数/

21、可信因素表示，IAI 为胰岛素敏感指数 李春霖，潘长玉，陆菊明等 中华内科杂1997;36(8):536-539编辑版ppt19 NGT IGTDM2F值P值 组别(n=)（20）（20）（20）昼SBP 921 912 862 3.54 0.0356 夜SBP(mmHg)1084 1184 1294 3.34 0.425 DBP(%)37.16.0 46.45.5 42.05.1 0.69 0.5049 SBP (%)7.12.5 9.92.0 3.7 2.1 2.31 0.0186 MBP(%)10.0 2.5 11.22.2 4.32.0 3.27 0.0452 血压正常的不同糖耐量患者

22、的动态血压改变血压正常的不同糖耐量患者的动态血压改变（X XSxSx）李春霖，潘长玉，陆菊明等李春霖，潘长玉，陆菊明等 中华内科杂中华内科杂1997;36(8):536-5391997;36(8):536-539编辑版ppt20血糖异常心电图明尼苏达编码分析检出频率 例（）*0(0)10(96.2)18(173.1)3(28.8)32(95.2)228(543.5)256(579.5)62(176.8)6(45.8)18(137.4)15(114.5)10(76.3)11(22.5)112(229.8)128(261.8)28(57.3)15(26.9)98(176.3)113(203.2)2

23、4(43.2)Q/QS(1-X)ST压低（4-X）T波（5-X）室内阻滞（7-X)104 合计(176)NOD(131)IGT（489）DM（556）与血糖异常比较*0.05 朱艳 陆菊明等 中国糖尿病杂志 1997；5（1）：11-14 项目 血糖异常 耐量正常编辑版ppt21ST压低 178(210.4)*46(138.9)6(139.5)*4(66.7)（4-X）T波 198(234.0)*33(178.2)13(302.3)*5(83.3)（5-X）糖异常 血糖正常 肥胖 正常体重 肥胖 正常体重 （N=846）（N=331）（N=43）（N=60）血糖异常合并与不合并高血压的心电图明

24、尼苏达编码分析比较 例()与正常体重组比 *0.01 朱艳，陆菊明等 中国糖尿病杂志 1997；5（1）：11-14编辑版ppt22血糖异常合并与不合并高血压的血糖异常合并与不合并高血压的心电图明尼苏达编码分析比较心电图明尼苏达编码分析比较 例例()R R波高电压波高电压 35(65.9)35(65.9)*39(60.5)3(150.0)16(192.7)39(60.5)3(150.0)16(192.7)（3-X)3-X)STST低电压低电压 146(273.9)146(273.9)*142(220.5)6(300.0)142(220.5)6(300.0)*9(108.4)9(108.4)（4

25、-X4-X）T T波波 156(292.7)156(292.7)*157(243.8)10(500.0)157(243.8)10(500.0)*16(192.7)16(192.7)（5-X5-X）血糖异常血糖异常 血糖正常血糖正常 高血压组高血压组 非高血压组非高血压组 高血压组高血压组 非高血压组非高血压组 （N=533N=533）（N=644N=644）（N=20N=20）（N=83N=83）与非高血压组比与非高血压组比 *0.050.05 朱艳，陆菊明等朱艳，陆菊明等 中国糖尿病杂志中国糖尿病杂志 19971997；5 5（1 1）：）：11-1411-14编辑版ppt23 结果显示与正

26、常糖尿病患者相比，结果显示与正常糖尿病患者相比，IGTIGT组组2424小时小时ABPMABPM的变化具有夜间血的变化具有夜间血压增高和昼夜血压差值减小的趋势，压增高和昼夜血压差值减小的趋势，表示表示IGTIGT患者已开始出现早期高血压患者已开始出现早期高血压改变改变编辑版ppt24DECODE欧洲糖尿病诊断标准的流行病学调查研究nFPG（ADA诊断标准）及OGTT2hPG（WHO）诊断标准与死亡率相关性研究n欧洲实施13项前瞻性研究分析n对象：30岁以上25364名（男：18048，女：7316）n研究开始时非糖尿病患者24089名，糖尿病患者1275名）n追踪时间：7.3年n累积追踪时间：

27、男：132,785人年 女：48,900人年DECODE study group:Lancet,354,617,1999编辑版ppt25FPG及2hPG与总死亡率的相对危险度的关系0 00.50.51 11.51.52 2110110110-125110-125126126FPG(mg/dl)FPG(mg/dl)年龄、性别、设施、年龄、性别、设施、BMIBMI、SBPSBP、吸烟、吸烟DECODE study group:Lancet,354,617,1999.DECODE study group:Lancet,354,617,1999.Tuomilehto J.:17Tuomilehto J

28、.:17thth IDF,Mexico City,November,2000 IDF,Mexico City,November,2000 200 200 140-200 140-200 140 1402hPG(mg/dl)2hPG(mg/dl)总死亡率的相对危险度编辑版ppt26总死亡率与2hPG的关系(DECODE study)4,0004,0003,0003,0002,0002,0001,0001,000 0 04 43 32 21 10 0相对危险度 0 40 80 120 160 200 240 280 320 360 0 40 80 120 160 200 240 280 320 3

29、602hPG2hPG(mg/dl)(mg/dl)Tuomilehto J.:17Tuomilehto J.:17thth IDF,Mexlco City,November,2000 IDF,Mexlco City,November,2000 FDP126 mg/dl FDP126 mg/dlr=0.71099+0.09866Xr=0.71099+0.09866X参加试验人数编辑版ppt27总死亡率与FPG的关系(DECODE study)8,0008,0006,0006,0004,0004,0002,0002,000 0 0 0 40 80 120 160 200 240 280 320 36

30、0 0 40 80 120 160 200 240 280 320 360FPG(mg/dl)FPG(mg/dl)Tuomilehto J.:17Tuomilehto J.:17thth IDF,Mexlco City,November,2000 IDF,Mexlco City,November,2000 2hPG200 mg/dl 2hPG200 mg/dl r=5.24638-1.30249X+0.09802X r=5.24638-1.30249X+0.09802X2 2 参加试验人数8 86 64 42 20 0相对危险度 编辑版ppt28心血管疾患死亡率与2hPG的关系(DECODE

31、study)4,0004,0003,0003,0002,0002,0001,0001,000 0 04 43 32 21 10 00 40 80 120 160 200 240 280 320 3600 40 80 120 160 200 240 280 320 3602hPG(mg/dl)2hPG(mg/dl)Tuomilehto J.:17Tuomilehto J.:17thth IDF,Mexlco City,November,2000 IDF,Mexlco City,November,2000 r=0.71099+0.09866X r=0.71099+0.09866X相对危险度参加试验

32、人数编辑版ppt29心血管疾患死亡率与FPG的关系(DECODE study)8,0008,0006,0006,0004,0004,0002,0002,000 0 08 86 64 42 20 0 0 40 80 120 160 200 240 280 320 360 0 40 80 120 160 200 240 280 320 360FPG(mg/dl)Tuomilehto J.:17th IDF,Mexlco City,November,2000 r=5.24638-1.30249X+0.09802X r=5.24638-1.30249X+0.09802X2 2参加试验人数相对危险度 编

33、辑版ppt30总死亡因子与2hPG的重要性(FPG、HbAIC）比较1 10.820.821.361.361.831.830 01 12 23 3I IIIIIIIIIIIIVIV 年龄、性、设施、年龄、性、设施、BMIBMI、SBPSBP、LDL-CLDL-C、HDL-CHDL-C、TGTG、F-IRIF-IRI、吸烟、吸烟总死亡率2hPG(mg/dl)140&200&140&200&FPG(mg/dl)126&(126 or 6.5)6.5 6.5)Number 2000 88365 87分析对象：糖尿病诊断男性1,416名，女性1,277名，平均追踪期间8年，累积追踪年数19,980人年

34、Qiao Q.et al.,17 th IDF,Mexico City,November,2000编辑版ppt312hPG是与总死亡率相关的因素（与空腹及糖化血红蛋白比较）各参数上升1个标准偏差与总死亡之间的比较（*FPG：19mg/dl 2hPG:52mg/dl HbA1c:0.68%)FPG 2hPG HbA1c男性各种变数补正1.10 1.17 1.13血糖值/HbA1c补正 0.94 1.17 1.09女性各种变数补正 1.18 1.22 1.13血糖值/HbA1c补正 1.13 1.19 0.89全体各种变数补正 1.13 1.19 1.13血糖值/HbA1c补正 0.98 1.17

35、 1.04*年龄、医院、BMI、SBP、LDL-C、HDL-C、TG、F-IRI、吸烟等被正FPG、2hPG、HbA1c的补正Qiao Q.et al:17th IDF,Mexico City,November,2000编辑版ppt32IGT是心血管疾病死亡的危险因素，而IFG不是The Funagata Diabetes Study0.940.940.950.950.960.960.970.970.980.980.990.991 10 01 12 23 34 45 56 67 7IGT(n=382)NGT(n=2,016)DM(n=253)DM(n=253)*p0.05(与N GT比 较）0

36、.940.940.950.950.960.960.970.970.980.980.990.991 10 01 12 23 34 45 56 67 7DM(n=189)IFG(n=155)NFG(n=2,307)*P180mg/dl (n=246)n空腹时血糖(饭前)良好:80-110mg/dl(n=363)正常:140mg/dl(n=391)不良:140mg/dl (n=372)0 05050100100150150200200250250300300不良不良正常正常良好良好良好良好正常正常不良不良饭后血糖FPG对象：新的2型糖尿病，运动疗法的病人1139例追踪11年Hanefeld M.et

37、 al.,17 th IDF,Mexice City,November,2000心肌梗塞的发病率（千人）编辑版ppt34餐后血糖控制不良对心血管疾病死亡影响DIS:糖尿病干预治疗餐后血糖餐后血糖良好良好正常正常不良不良各组间差异显著各组间差异显著1.001.00 .98 .98 .96 .96 生生 .94.94 存存 .92.92 率率 .90.90 .88 .88 .86 .86 0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16生存期生存期(年年)Hanefeid M.et al.:17Hanefeid M.et al.:17thth IDF,Mexi

38、co City,November,2000 IDF,Mexico City,November,2000餐后血糖累积心血管疾患死亡率餐后血糖累积心血管疾患死亡率 追踪期间追踪期间1111年以上年以上(Kaplan-Meter(Kaplan-Meter法法)编辑版ppt35餐后高血糖、高血脂症对血管壁的影响餐后高血糖餐后高血糖餐后高血脂餐后高血脂血管壁血管壁 血管内皮细胞障碍血管内皮细胞障碍动脉硬化动脉硬化 Haller H.:Diab.Res.Clin.Prac.,40(Suppl),S43,1998Haller H.:Diab.Res.Clin.Prac.,40(Suppl),S43,1998

39、餐餐编辑版ppt36餐后血糖/空腹血糖的持续时间餐后 吸收后移行期餐后餐后吸收后移行期空腹时吸收后移行期早餐 午餐 晚餐 0.00am 4.00am 早餐 Monmer L.:Eur.J.Clin.Linvest.,30(Suppl.2),3,2000编辑版ppt37Decode研究的临床意义Source:DECODE Study Group.Br J Med.1998;317:371-375Postprandial hyperglycaemiaPostprandial hyperglycaemiaNGTNGTLow riskLow riskLow riskLow riskHigh detec

40、tionHigh detectionFastingFastinghyperglycaemiahyperglycaemiaHigh detectionHigh detectionHigh riskHigh riskNFGNFGLow detectionLow detectionHigh riskHigh risk编辑版ppt38DECODE:DECODE:结论结论l餐后餐后2 2小时血糖（小时血糖（2H2HBGBG）是糖尿病死亡是糖尿病死亡的独立危险因素。的独立危险因素。DECODE Study Group.Lancet 1999;354:617-621编辑版ppt39RAIDRAID研究的结果

41、研究的结果Adapted from Temelkova-Kurktschiev T et al.Diabetes und Stoffwechsel 1998;7:227-232*Significantly different from healthy controls and NGT*Significantly different from healthy controls,NGT and IGT00.20.40.60.811.2IMT min(mm)IMT max(mm)HealthycontrolsIGTType 2diabetesNGTN=100N=152N=109N=68*编辑版ppt

42、400123normalIGTDiabetes*relative risk of CHDRelative risks of cardiovascular disease for impaired glucose tolerance and diabetes compared with normal glucose tolerance after adjustment for age and sex()and for systolic blood pressure,body mass index,abnormal electrocardiogram,total and high-density

43、lipoprotein cholesterol,smoking and drinking (n n).*p0.05 *p0.01 compared with normal individuals.Fujishima Diabetes 1996;45(suppl 3):514-516Relative Risks of CHD for NGT,IGT and Diabetes 编辑版ppt41Incidence of myocardial infarction()and mortality rate()in relation to quality of control of fasting blo

44、od glucose postprandial blood glucose,triglycerides,and blood pressure:11-year follow-up to the Diabetes Intervention Study(DIS),*p0.05GoodBorderline PoorFasting blood glucose250200150100500GoodBorderline PoorPostprandial blood glucoseRate per 1000*Hanefeld M.et al,Diabetic Medicine 1997,14:s6-s11餐后

45、高血糖与心血管并发症餐后高血糖与心血管并发症编辑版ppt42餐后高血糖与心血管并发症餐后高血糖与心血管并发症2520151050Rate per 1000BorderlineTriglyceridesGoodBorderlinePoorBlood pressureIncidence of myocardial infarction()and mortality rate()in relation to quality of control of fasting blood glucose postprandial blood glucose,triglycerides,and blood pr

46、essure:11-year follow-up to the Diabetes Intervention Study(DIS),*p0.05;*p0.01Hanefeld M.et al,Diabetic Medicine 1997,14:s6-s11*GoodPoor编辑版ppt43Other studies which support the associationcontinuedChinese Study(Da Qing IGT+Diabetes Study)577 IGT 519 controls 4%IGT 0.4%NGT Diabetes Care 1993:16.150-15

47、6ECG abnormalities of CHD IGT and Cardiovascular Risk编辑版ppt44Prevalence of Microalbuminuria in Newly-Diagnosed Diabetic and IGT Patients N MAU n%Newly Diagnosed DM494 164 21.05*Known Case245 51 20.82*IGT772 81 10.49*Normals787 34 4.32*p0.01 v.s normals Source:Diabetologia 1997 40(supp l.l)A2752编辑版pp

48、t45Expected values of plasma glucose for HbA1c levels of 7%Time Plasma glucose sensitivity specificity (mmol/L)8 am pre-breakfast 8.2 75%80%(fasting)11 am pre-lunch 10.5 65%80%2 pm post-lunch 8.3 85%85%5 pm extended post-lunch 6.9 85%78%Avignon et al.Diabetes Care 1997;20:1822-1826编辑版ppt46Importance

49、 of PPGEGlycemicFluctuation(Spikes)GlucoseautooxidationLabileglycationGeneration of free radicalsNO Super-Oxide anions Activate coagtulation Pathway TissuebdamageAdhesion protein Micro-&Macro-complication编辑版ppt47Postchallenge Plasma Glucose and Glycemic Spikes Are More Strongly Associated With Atherosclerosis Than Fasting Glucose or HbA1c Level编辑版ppt48Dr.A.Golay