Abstract: Background　Many patients with liver cirrhosis and diabetes mellitus（DM）suffer from protein-energy malnutrition as well as disorder of glycometabolism.With poor glycogen reserve and insulin resistance，these patients are prone to hypoglycemia in the morning.Previous studies have reported that late-evening snack（LES） is able to shorten the time of hunger and reduce the energy supply of oxidative decomposition of fat and protein to prevent hypoglycemia in the next morning in patients with cirrhosis.However，whether LES plays a role in cirrhosis patients with DM is still worth exploring.Objective　To investigate the effect of 200 kcal of LES on energy metabolism and glucose metabolism in patients with liver cirrhosis and DM.Methods　Twenty-five patients with hepatitis B cirrhosis and DM who met the research criteria were selected from January 1，2015 to December 30，2017 in the Department of Severe Liver Diseases in Beijing You'an Hospital，Capital Medical University. They were divided into high-carbohydrate LES management group with low-glycemic index（intervention group，n=13） and cirrhosis and DM diet group（non-intervention group，n=12） according to the random number table method.All patients continued to have antiviral，liver protection and hypoglycemic treatment.The non-intervention group maintained three meals a day；the intervention group changed the traditional three meals to four meals，and each meal reduced 67 kcal（16.7 g carbohydrate），and added a meal one hour before bedtime.The baseline demographic data（sex and age），baseline anthropometric data（body mass and BMI）before and after three-month intervention，dietary intake（carbohydrate，fat，protein and energy），energy metabolism index〔resting energy expenditure（REE），predicted resting energy expenditure（PREE），percentage of PREE（PREE%），respiratory quotient（RQ），carbohydrate oxidation rate（CHO%），fat oxidation rate（FAT%） and protein oxidation rate（PRO%）〕，glucose metabolism index〔glycosylated hemoglobin（HbA1c），fasting blood glucose （FBG） and fasting insulin （FINS）〕，insulin resistance index（HOMA-IR），islet B cell function index （FBCI） and liver function index （ALT，AST，TBIL，TP，ALB，PALB，CHE and PTA） were compared between two groups.Results　There was no significant difference in body mass，BMI，carbohydrate intake，fat intake，protein intake and energy intake between the two groups at baseline and three months after intervention（P>0.05）．There was no significant difference in REE，PREE and PREE% between the two groups after three-month intervention（P> 0.05）．RQ and CHO% in the intervention group were higher than those in the non-intervention group after three-month intervention，while FAT and PRO% were lower（P<0.05）．RQ and CHO% after three-month intervention in intervention group were higher than those at baseline in the same group，while FAT and PRO% were lower（P<0.05）．HbA1c，FBG，FINS and HOMA-IR in intervention group were lower than those in non-intervention group at 3 months after intervention（P<0.05）．There was no significant difference in FBCI between the two groups at 3 months after intervention （P> 0.05）．HbA1c，FBG，FINS and HOMA-IR in the intervention group at 3 months after intervention were lower than those in the same group at baseline（P<0.05）．TP，ALB and PALB in the intervention group at 3 months after intervention were higher than those in the same group at baseline（P<0.05）．Conclusion　Before going to bed，200 kcal of food with low-glycemic index and high-carbohydrate can improve nutritional metabolism and blood sugar control in patients with hepatitis B cirrhosis and DM，reduce insulin resistance and prevent hypoglycemia caused by disorders of glucose metabolism.

Key words: Liver cirrhosis, Hepatitis B, Diabetes mellitus, Late-evening snack, Energy metabolism, Insulin resistance

摘要： 背景　肝硬化合并糖尿病患者很多存在蛋白质-能量营养不良症和糖代谢紊乱，由于患者肝糖原储备差和胰岛素抵抗，易发生晨起低血糖。既往研究发现睡前加餐（LES）能够缩短患者饥饿时间，降低肝硬化患者自身脂肪和蛋白质的氧化分解供能，预防次晨低血糖，但是否适用于肝硬化合并糖尿病人群值得探讨。目的　探究200 kcal LES对乙肝肝硬化合并糖尿病患者能量代谢、糖代谢的影响。方法　选取2015-01-01至2017-12-30于首都医科大学附属北京佑安医院肝病重症医学科住院的符合研究标准的乙肝肝硬化合并糖尿病患者25例，依据随机数字表法分为低升糖指数、高碳水化合物LES管理组（干预组，n=13）和肝硬化糖尿病饮食组（非干预组，n=12）。患者均继续使用抗病毒、护肝、降糖治疗。非干预组维持肝硬化糖尿病3餐饮食；干预组患者将传统3餐改为4餐，3餐各减少67 kcal（每餐减少16.7 g碳水化合物）食物，放在睡前1 h进行加餐。比较两组患者基线人口学资料（性别、年龄），基线和干预结束3个月人体测量学资料（体质量、BMI）、饮食摄入情况（碳水化合物、脂肪、蛋白质、能量）、能量代谢指标〔静息能量消耗（REE）、预计静息能量消耗（PREE）、REE占PREE百分比（PREE%）、呼吸商（RQ）、碳水化合物氧化率（CHO%）、脂肪氧化率（FAT%）、蛋白质氧化率（PRO%）〕、糖代谢指标〔糖化血红蛋白（HbA1c）、空腹血糖（FBG）、空腹胰岛素（FINS）〕、胰岛素抵抗指数（HOMA-IR）、胰岛B细胞功能指数（FBCI）、肝功能指标〔丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、总胆红素（TBIL）、总蛋白（TP）、白蛋白（ALB）、前白蛋白（PALB）、胆碱酯酶（CHE）、凝血酶原活动度（PTA）〕。结果　两组患者基线和干预结束3个月体质量、BMI、碳水化合物摄入量、脂肪摄入量、蛋白质摄入量、能量摄入量比较，差异无统计学意义（P>0.05）。两组患者干预结束3个月REE、PREE、PREE%比较，差异无统计学意义（P>0.05）；干预组患者干预结束3个月RQ、CHO%高于非干预组，FAT%、PRO%低于非干预组（P<0.05）。干预组患者干预结束3个月RQ、CHO%高于同组基线，FAT%、PRO%低于同组基线（P<0.05）。干预组患者干预结束3个月HbA1c、FBG、FINS、HOMA-IR低于非干预组（P<0.05）；两组患者干预结束3个月FBCI比较，差异无统计学意义（P>0.05）。干预组干预结束3个月HbA1c、FBG、FINS、HOMA-IR低于同组基线（P<0.05）。干预组患者干预结束3个月TP、ALB、PALB高于同组基线（P<0.05）。结论　睡前给予200 kcal低升糖指数、高碳水化合物的食物，能够改善乙肝肝硬化合并糖尿病患者的营养代谢状况及血糖控制情况，降低胰岛素抵抗，预防糖代谢紊乱可能引发的低血糖。

关键词: 肝硬化, 乙型肝炎, 糖尿病, 睡前加餐, 能量代谢, 胰岛素抵抗