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目的:探讨联合营养团队的程序化随访对2型糖尿病患者随访管理的效果，为临床提供实践依据。方法:采用便利抽样法，选择2016年3月—2017年12月在新疆医科大学第一附属医院糖尿病专科随访门诊就诊的2型糖尿病患者144例，应用联合营养团队的程序化随访进行前瞻性观察，完成2年随访后采用重复测量方差分析比较基线、第12个月、第24个月患者肥胖、血糖、自我管理行为的变化。结果:最终141例患者完成2年随访，第24个月时141例患者BMI（21.73±1.89）kg/mn 2，腰围（77.57±1.68）cm，腰臀比（0.87±0.04），空腹血糖（5.14±0.92）mmol/L，糖化血红蛋白（5.27±0.73）%，总胆固醇（3.92±1.67） mmol/L，甘油三酯（1.94±0.68） mmol/L，低密度脂蛋白（1.04±0.31） mmol/L，干预后第24个月、第12个月、基线3个时间点上述指标比较，差异有统计学意义（n F值分别为32.629、5.556、5.640、89.734、122.451、43.373、74.888、35.887；n P<0.05）。第24个月时患者糖尿病自我管理行为量表中饮食（20.33±3.09）分、运动（11.13±1.54）分、血糖监测（11.78±1.99）分，足部护理（10.42±1.91）分，与基线和第12个月比较评分升高，差异有统计学意义（n F值分别为25.276、72.250、74.503、37.928；n P<0.01）。n 结论:联合营养团队的程序化随访可以改善2型糖尿病患者肥胖、血糖、血脂相关指标，提高患者自我管理能力。“,”Objective:To explore the effect of programmatic follow-up of joint nutrition team on the follow-up management of type 2 diabetes mellitus patients and to provide a basis for clinical practice.Methods:Using the convenient sampling method, a total of 144 patients with type 2 diabetes mellitus who were treated at the Diabetes Specialist Follow-up Clinic of the First Affiliated Hospital of Xinjiang Medical University from March 2016 to December 2017 were selected, and the programmatic follow-up of joint nutrition team was used for prospective observation. After the completion of 2-year follow-up, the changes in obesity, blood glucose, blood lipids and self-care activities of patients at baseline, 12th month and 24th month were compared using repeated measurements analysis of variance.Results:In the end, 141 patients completed the 2-year follow-up. Of the 141 patients, body mass index (BMI) was (21.73±1.89) kg/mn 2, waistline was (77.57±1.68) cm, waist-to-hip ratio was (0.87±0.04) , fasting blood glucose was (5.14±0.92) mmol/L, glycosylated hemoglobin was (5.27±0.73) %, total cholesterol was (3.92±1.67) mmol/L, triglycerides was (1.94±0.68) mmol/L and low density lipoprotein was (1.04±0.31) mmol/L at the 24th month. The differences were statistically significant (n F=32.629, 5.556, 5.640, 89.734, 122.451, 43.373, 74.888, 35.887; n P<0.05) among the 24th month, the 12th month and the baseline of the above indicators. At the 24 months, scores of diet, exercise, blood glucose monitoring and foot care in diabetic self-management behavior scale were respectively (20.33±3.09) , (11.13±1.54) , (11.78±1.99) and (10.42±1.91) . Compared with baseline and the 12th month, scores increased, and the differences were statistically significant (n F=25.276, 72.250, 74.503, 37.928; n P<0.01) .n Conclusions:The programmatic follow-up of joint nutrition team can improve indexes related to obesity, blood glucose and blood lipids in patients with type 2 diabetes mellitus and improve self-management ability of patients.