代謝症候群之 定義、生理機轉及流行病 學 國立成功大學醫學院 家庭醫學科副教授 楊宜青醫師
「代謝症候群」 n是指一群與新陳代謝症狀有關的 特徵，容易在同一個人身上出現( 危險因素聚集) n這些人將來得到糖尿病及心臟血 管疾病的機會也較大。
代謝症候群的緣起 思ㄚ…. 想ㄚ…. 起… Reaven
Reaven, 1988, Stanford, USA n n n Hyperinsulinemia Impaired Glucose Tolerance Hypertension Triglyceride ↑ HDL↓ Banting lecture Reaven GM. Role of insulin resistance in human disease. Diabetes 1988; 37: 1595 -607 Insulin Resistance: the Metabolic Syndrome X 1999 1 st ed by Gerald M. Reaven (Editor), Ami Laws (Editor)
Kylin E, 1923, Germany 1923 n The first man recognized clustering of some metabolic abnormalities. n The hypertension-hyperglycemiahyperuricemia syndrome Zentralblatt fuer Innere Medizin 1923; 44: 105 -27 1923 Other: n Vague J: Presse Med 1947; 30: 339 -40(upper body obesity) n Haller H, Hanefeld M: Lipidstoffwechelstorungen 1975: 254 -64 n (Term metabolic syndrome) n Hanefeld M, Leohardt W: Dtsch Gesundheitwes 1981; 36: 545 -51
Terms associated with Metabolic Syndrome n Metabolic Syndrome (Hanefeld & Leonhardt, 1981) n (Metabolic) Syndrome X (Reaven, 1988) n Deadly Quartet (Kaplan, 1989) n Multiple Metabolic Syndrome (Hjermann, Os & Nordby, 1992) n Insulin Resistance Syndrome (De. Fronzo & Ferrannini, 1991; Haffner et al. 1992 ) n Insulin Resistance-dyslipidemia syndrome (Despres, 1993) n Chronic cardiovascular risk factor clustering syndrome (Zimmet et al, 1994) n Dysmetabolic Syndrome (Groop L, ) n Cardiovascular Dysmetabolic syndrome (1998)
Incongruent Taxonomy Based on: n Disease manifestation or Phenotypes n Etiologic Conceptualization n Purpose
correlation coefficients M F
Phenotypic Correlations among Components Metabolic Syndrome WHR SBP 2小時 血糖 DBP BMI HOMA-IR microalbuminuria TG HDL Yang YC et al: Diabetes Research and Clinical practice 2007
Metabolic Syndrome WHO criteria WHR > 0. 85 (F) > 0. 9 (M) BM I > 30 (1998, 1999) HDL < 35 (F) < 39 (M) TG ≧ 150 DM, IGT, NGT with IR 2/4 BP > 160/90(1998) > 140/90(1999) Diabet Med 15: 539– 553, 1998 AER > 20 ug/min ACR > 20 mg/g > 30(1999) 1999: From: http: //www. staff. ncl. ac. uk/philip. home/who_dmg. pdf
Kaplan-Meier estimates of CHD death during an 18 -year follow-up DM=CHD Prior myocardial infarction (MI) prior evidence of CHD. with the status of diabetes in men (n = 1, 219), in women (n = 1, 213), and in all (n = 2, 432). Diabetes Care 28: 2901 -2907, 2005
IGT and Macrovascular Complications IGT as defined by the WHO guidelines (2 h-OGTT) is a risk marker for macrovascular complications. 2 known diabetes Hazard ratio 1. 75 IGT 1. 5 IFG 1. 25 1 CVD CHD Stroke All causes DECODE (Diabetes Epidemiology Collaborative analysis of Diagnostic criteria in Europe) Adapted from: DECODE study group: Arch Intern Med 161: 397 - 404, 2001.
Problems before you see them
Metabolic Syndrome WHO criteria WHR > 0. 85 (F) > 0. 9 (M) BM I > 30 (1998, 1999) HDL < 35 (F) < 39 (M) TG ≧ 150 DM, IGT, NGT with IR 2/4 BP > 160/90(1998) > 140/90(1999) Diabet Med 15: 539– 553, 1998 AER > 20 ug/min ACR > 20 mg/g > 30(1999) 1999: From: http: //www. staff. ncl. ac. uk/philip. home/who_dmg. pdf
代謝症候群 2001 NCKUFM Metabolic Syndrome NCEP ATP III criteria YCY WC >102 90 cm(M) 88 80 cm(F) Modified TG > 150 mg/d. L BP > 130/85 HDL < 40 (M) < 50 (F) AC >110 mg/d. L
Abdominal Obesity: Risk Factor for Type 2 Diabetes Incidence of Type 2 diabetes is more related to abdominal fat accumulation than overweight 1967 1981 15. 2 13. 5 -year incidence of Type 2 DM (%) 9. 1 12. 5 9. 1 2. 9 0. 5 BMI tertiles 0. 5 ip /H ist s a W rtile te 792 54 -yr-old men selected by year of birth (1913) residence in Goteborg, Sweden Adapted from Ohlson et al. , Diabetes (1985) 34: 1055 -1058
Abdominal Obesity: Coronary Heart Disease 44, 702 women aged 40 to 65 Incidence rate per 100 000 person-years Follow-up of 8 years 128 83 110 106 The Nurses’ Health Study 97 89 77 55 46 High (81. 8 -<139. 7) Middle (73. 7 -<81. 8) te h ) rt gi cm st ( Low (38. 1 -<73. 7) High (25. 2 -<48. 8) Middle (22. 2 -<25. 2) Low (12. 2 -<22. 2) W ai BMI tertiles (kg/m 2) From Rexrode KM et al. , JAMA (1998) 280: 1843 -1848 es l rti
8 -year incidence of metabolic syndrome % Abdominal Obesity: Predicts the Metabolic Syndrome (NCEP-ATPIII) (2／ 4) 33 116/347 20 27/132 20 17/86 10 107/1072 >30 <30 >102 cm (men) >88 cm (women) <102 cm (men) <88 cm (women) Body Mass Index (kg/m 2) 628 non-Hispanic whites and 1340 Mexican Americans, ages 25 to 64 years, from the second cohort of the San Antonio Heart Study Han TS t al. Obes Res 2002; 10: 923 -31. . W ai st rc ci
YCY NCKUFM Waist Circumference: A Vital Sign
代謝症候群 2005 NCKUFM 世 Metabolic Syndrome IDF criteria 界 糖 尿 YCY 病 聯 盟 TG > 150 mg/d. L HDL < 40 (M) < 50 (F) Abdominal Obesity BP > 130/85 AC > 110 mg/d. L
YCY 代謝症候群 2005 NCKUFM Metabolic Syndrome revised NCEP ATP 3 criteria AHA / NHLBI WC > 90 cm(M) 80 cm(F) Modified TG > 150 mg/d. L BP > 130/85 HDL < 40 (M) < 50 (F) AC >100 mg/d. L 2006
不同代謝症候群定義比較 WHO(1998) 0. 必要核心異常 1. (腹部)肥胖：腰圍 (WC) 腰臀圍(WHR) EGIR(1999) 胰島素阻抗性 Insulin resistance WHR: M>0. 9/F>0. 85 BMI>30 (台灣 27) WC: M>94/F>80 IFG twice &DM(－ ) NCEP(2001) (2005)(2006) AACE(2003) IDF(2005) － * 腹部肥胖 (AOb) WC: M>102/F>88 (台灣+BMI> 27) BMI≧ 25 WC: M>102/F>88 WC M>90/F>80 ≧ 110(ATP 3) ≧ 100(AHA 2006) IFG(≧ 110)+IGT Exclude DM ≧ 110 Abdominal Obesity 2. 血糖異常或用藥 空腹血糖(FG)(mg/d. L) DM, IGT, HOMAIR (highest 25%) 3. 血壓異常或用藥 (SBP/DBP)(mm. Hg) ≧ 140/90 ≧ 130/85 4. 血脂異常 1(High TG) TG(mg/d. L) TG ≧ 150 Or ≧ 180 ≧ 150 5. 血脂異常 2(Low HDLc) HDL-c(mg/d. L) HDL: M<35 F<40 M&F<40 or treated M<40 F<50 － 家族史： 第二型糖尿病，高 血壓，心血管疾病， 過去病史：血壓, 心血管疾病, 多囊性卵巢症, 黑色棘皮症, NAFLD, 靜態生活，年齡>40， 種族有致糖尿病與心血管疾 病傾向 DM, IGT － 6. 其他 微白蛋白尿 ACR＞ 30 mg/g UAER＞ 20 ug/min Fasting hyperinsulinemia (highest 25%) －
台灣代謝症候群之臨床診斷準則 (Taiwan 2006 Oct) 危 險 因 子 異 常 值 腹部肥胖(central obesity) 腰圍: 男性 ≧ 90 cm 女性 ≧ 80 cm 血壓(BP)上升 SBP ≧ 130 mm. Hg / DBP ≧ 85 mm. Hg 高密度酯蛋白膽固醇(HDL-C)過低 男性 <40 mg/dl 女性 <50 mg/dl 空腹血糖值(Fasting glucose)上升 FG ≧ 100 mg/dl 三酸甘油酯(Triglyceride)上升 TG ≧ 150 mg/dl 診斷標準： 5 個危險因子個數大於等於 3 個 備註：上項危險因子中「血壓上升」、「空腹血糖值上升」之判定，包括依醫師處方使用降血壓或降血糖 等藥品(中、草藥除外)，血壓或血糖之檢驗值正常者。
New ICD-9 -CM Code for Dysmetabolic Syndrome X n AACE's request for a new ICD-9 -CM code describing Dysmetabolic Syndrome X has been approved by the Centers for Disease Control. The new code, 277. 7, is available for use as of October 1, 2001. n Dysmetabolic Syndrome denotes a constellation of metabolic abnormalities in serum or plasma insulin/glucose level ratios, lipids (TG, LDL-C subtypes and/or HDL-C), uric acid levels, coagulation factor imbalances and vascular physiology. Diagnostic criteria and operational definition developed by the American Association of Clinical Endocrinologists
Prevalence Of The Metabolic Syndrome According To ATP III Definition Age range 45 -49 20 -75 30 -79 32+ 30 -79 50 -69 25+ 21+ 25+ 30 -64 *Obesity criteria adjusted to waist circumference appropriate for an Indian population
Men 18% Age-specific Prevalence of the Metabolic Syndrome Women 13% Hwang LC et al: J Formos Med Assoc 2006; 105(8): 626 -35 Tw. SHHH 2002(台灣三高調查)
Age-sex specific prevalence of Metabolic Syndrome in Tainan, 1996 WHO (M: 25. 7, F: 16. 1, T: 20. 6 [18. 3%]) IDF (M: 19. 2; F: 16. 6; T: 17. 9[16. 1%]) ATP III-AP (M: 21. 3, F: 17. 1, T: 19. 1 [17. 0%]) AHA (M: 26. 4, F: 21. 3, T: 23. 7 [21. 5%])
n=3629 The incidence rate of DM was 7. 8% (M: 9. 8%; F: 6. 3%) MS was 24. 2% (M: 23. 4%; F: 24. 7%)
Metabolic syndrome as a risk factor for CHD and stroke: An 11 -year prospective cohort in Taiwan community Chien KL, Hsu HC, Sung FC, Su TC, Chen MF, Lee YT National Taiwan University, Taiwan Chien KL et al: Atherosclerosis 2006 sep
Prevalence of MS components (bar) Incidence rates of CHD and stroke (line) CHD M F Stroke The X-axis shows the number of MS components in baseline. Chien KL et al: Atherosclerosis 2006; Sep
Kaplan–Meir curves of 11 -yr free from CHD events by status of Met. S at study entry (left) by Met. S numbers at study entry (right). Chien KL et al: Atherosclerosis 2006; Sep(簡國龍)
Kaplan-Meier Ischemic Stroke-free Survival curves by MS-GOB status (Taiwan) Chen HJ. et al. Stroke 2006; 37: 1060 -1064 MS(－)／OB(－) MS(－)／OB(+) MS is defined by AHA/NHLBI 2005 Asian WC cut points (M 90/F 80) GOB, BMI 27 MS(+)／OB(－) MS(+)／OB(+) from 3453 adults (≧ 20 yrs) in the CVD Risk Factor Two-Township Study were linked to insurance claim and death certificate records. During 10. 4 years of follow-up, 132 persons developed IS 2005 NCEP definition stronger than 2001 definition (Prof. Pan WH潘文涵)
Kaplan-Meier curves for CVD events in men with 0, 1, 2, 3, or 4 characteristics of the MS at baseline 3. 7 X 1 modified NCEP definition with BMI in place of WC Baseline assessments in the West of Scotland Coronary Prevention Study WOSCOPS were available for 6447 men to predict CHD risk and for 5974 men to predict incident diabetes over 4. 9 years of follow-up. Circulation. 2003; 108: 414
Kaplan-Meier curves for new-onset DM in men with 0, 1, 2, 3, or 4 characteristics of the MS at baseline 24. 5 X 1 modified NCEP definition with BMI in place of WC Baseline assessments in the West of Scotland Coronary Prevention Study WOSCOPS were available for 6447 men to predict CHD risk and for 5974 men to predict incident diabetes over 4. 9 years of follow-up. Circulation. 2003; 108: 414
Association of MS and CVD Ford ES: Risk for all cause mortality, CVD, DM associated with MS. Diabetes Care 2005 July RR: 1. 74 o. Modified def n Original def
Association of DM and MS Ford ES: Risk for all cause mortality, CVD, DM associated with MS. Diabetes Care 2005 July 3 x
Prevalence of Metabolic Syndrome The Risk of CAD & CVA ↑ 3 x 10~15% NGT 50% IGT 80% DM Isomaa B: Diabetes Care 2001; 24: 683
NCKUFM YCY 台灣地區主要死因排行-2003 死亡原因 順位 所有死因 死亡人數 129, 878 每十萬人口死亡率 575. 63100. 00 1 惡性腫瘤 2 腦血管疾病 12, 40454. 98 9. 55 3 心臟疾病 11, 78352. 23 9. 07 4 糖尿病 10, 01344. 38 7. 71 10 高血壓 1, 844 8. 17 1. 42 三高相關 35, 201156. 0127. 10 27. 75 NCKU-FM-YCY-960615 %
NCKUFM YCY 92年國人代謝症候群相關疾病醫療費用 項目 糖尿病 高血壓 心臟病 腦中風 小計 癌症 佔率(給付總計) 代謝症候群／癌症 就診人數 門診費用( 住院費用( (萬) 億點數) 合計 (億點數) 98. 6 95. 0 18. 2 113. 2 211. 2 129. 3 4. 0 133. 3 119. 5 57. 6 86. 1 143. 7 45. 5 51. 8 55. 0 106. 8 474. 8 333. 7 163. 3 497 31. 7 93. 0 127. 6 220. 6 23. 1% 17. 3% 13. 61% 15. 9% 3. 59 1. 28 2. 25 NCKU-FM-YCY-960615 資料來源：衛生署 92年全民健康保險醫療統計年報
冰山美女 看面相 有沒有代謝症候群?
An estimated 300 million people around the world are obese (BMI>30). u one in 10 children is overweight, a total of 155 million. u Around 30 -45 million obese - accounting for 2 -3% of u the world’s children aged 5 -17. A further 22 million younger children under fives.
Global Prevalence of Obesity in Adult Males With examples of the top 5 Countries in each Region North America USA 31% Mexico 19% Canada (self report) 17% Guyana 14% Bahamas 14% % Obese 0 -9. 9% 10 -14. 9% 15 -19. 9% 20 -24. 9% 25 -29. 9% ≥ 30% Self Reported data European Region Croatia 31% Cyprus 27% Czech Republic 25% Albania (urban) 23% England 23% Eastern Mediterranean Lebanon 36% Qatar 35% Jordan 33% Kuwait 28% Saudi Arabia 26% South Central America Panama 28% Paraguay 23% Argentina (urban) 20% Uruguay (self report) 17% Dominican Republic 16% Africa South Africa 10% Seychelles 9% Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5% With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity Task. Force, London –January 2007 South East Asia & Pacific Region Nauru 80% Tonga 47% Cook Island 41% French Polynesia 36% Samoa 33%
Global Prevalence of Obesity in Adult Females With examples of the top 5 Countries in each Region North America USA 33% Barbados 31% Mexico 29% St Lucia 28% Bahamas 28% % Obese 0 -9. 9% 10 -14. 9% 15 -19. 9% 20 -24. 9% 25 -29. 9% ≥ 30% Self Reported data European Region Albania 36% Malta 35% Turkey 29% Slovakia 28% Czech Republic 26% Eastern Mediterranean Jordan 60% Qatar 45% Saudi Arabia 44% Palestine 43% Lebanon 38% South Central America Panama 36% Paraguay 36% Peru (urban) 23% Chile (urban) 23% Dominican Republic 18% Africa Seychelles 28% South Africa 28% Ghana 20% Mauritania 19% Cameroon (urban) 14% With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity Task. Force, London –January 2007 South East Asia & Pacific Region Nauru 78% Tonga 70% Samoa 63% Niue 46% French Polynesia 44%
Age-specific prevalence of overweight, obesity and abdominal obesity inmen, Taiwan, 2002 2815 OW+OB 50% COB 28. 3 OB 19. 2 OW 30. 5 Tw. SHHH 2002(台灣三高調查) Hwang LC et al: J Formos Med Assoc 2006; 105(8): 626 -35
Age-specific prevalence of overweight, obesity and abdominal obesity inwomen, Taiwan, 2002 3131 OW+OB 35% COB OB 28. 7 13. 4 OW 21. 3 Tw. SHHH 2002(台灣三高調查) Hwang LC et al: J Formos Med Assoc 2006; 105(8): 626 -35
Obesity as a disease
Pathogenesis of Metabolic syndrome 2 major, interacting causes n Obesity and abnormal body fat distribution disorders of adipose tissue. n Endogenous metabolic susceptibility Insulin resistance n A constellation of independent factors (e. g. molecules of hepatic, vascular, and immunologic origin) Contributors: aging , proinlfammatory state, hormonal change. Grundy SM et al: Circulation 2004; 109: 433 -8 Grundy SM: Am J Clin Nutr 2006 Aug 1248
代謝症候群是否可以幫忙在 臨床上找到胰島素阻抗者？ Critical evaluation of adult treatment panel III criteria in identifying insulin resistance with dyslipidemia Liao Y et al: Diabetes Care 2004; 27: 978 -83
How well do the emperor’s clothes fit? 國王的新衣是否合身? Critical evaluation of adult treatment panel III criteria in identifying insulin resistance with dyslipidemia Liao Y et al: Diabetes Care 2004; 27: 978 -83 ATP III+ ATP III criteria Specificities: >90% Sensitivities: between 20 and 50% ATP III －
The MS (Emperor) wears No clothes 國王根本沒有穿衣服! Richard Kahn (ADA): Diabetes Care 2006 July
The MS (Emperor) wears No clothes n There is no biological basisfor the diagnostic algorithm n The syndrome is a relativelypoor predictorof future DM or CVD n The whole is not greater than the sum of the parts n There is no scientific evidencethat the syndrome has clinical utility. n Labeling a person with MS can be very misleading to the Dr. and the Patient. Richard Kahn (ADA): Diabetes Care 2006 July
Die Krankheitserfinder Jorg Blech (尤格。布雷希) n發明疾病的人 現代醫療產業如何賣掉我們的健康 n 醫學快速企業化、商品化、世俗化的時代 n 另類角度深刻省思 n n 醫學已經進步到不再有人健康了 ~赫胥黎
The Metabolic Syndrome vs. the Insulin Resistance Syndrome? Different Names Different Concepts Different Goals Gerald Reaven: Endocrinal Metabl Clin N Am 2004; 33: 283
安息祈禱文 Requiescat of Metabolic Syndrome 17 -18小伙子 n sy c o dr e Reaven GM 2005 m i ol b a t Me Reaven GM: The MS: requiescat in pace. Clin Chem 2005; 51: 931 -8 白髮送黑髮?
Confusion about Metabolic Syndrome n Is it an artificial, mathematical concept that simply recasts old known risk factors into a new disease entity? 舊酒裝新瓶 n Does the clustering indeed reflect a single pathophysiology that can be a target for therapeutic decisions? Detect IR ? 特異性夠敏感性不足 n Does Tx of the MS differ from the Tx of its individual components? 更佳預測指標? n Can the MS offer advantages over existing models for the predictions of CV events? n Should the MS simply be declared dead? Reaven GM: The MS: requiescat in pace. Clin Chem 2005; 51: 931 -8
Time for a Critical Appraisal Kahn R et al: Diabetes Care 2005; 28: 2289 -2304 ADA & EASD
論戰…. Endless War? n內分泌學家 n血脂學家 n糖尿病學家 n心臟學家 Gerald Reaven Scott Grundy
IRS MS Blaha M Elasy TA: Clinical Diabetes 2006; 24: 125
代謝症候群的病因、進展與後果 代謝易感因素(常以胰島素阻抗表現) 胰島素訊號傳遞缺陷、脂肪組織疾病、 身體活動不足、老化、藥物、 多重基因變異(個人、種族變異)、 吸菸、壓力等 身體脂肪 過多 代謝 易感性 代謝症候群 多項邊緣性 危險因子 吸菸 老化 ↑低密度脂 蛋白膽固醇 心血管疾病 及其併發症 ↑血壓 ↑血糖 ↓高密度脂蛋白膽固醇 ↑三酸甘油酯 前栓塞狀態 前發炎狀態 多項 危險因子 第二型 糖尿病 併發症 Adapted from Grundy SM: J Am Coll Cardiol 2006; J Clin Endocrinol Metab 2007
the liporegulatory system and lipid partitioning Copyright © 2003 The Endocrine Society Unger, R. H. Endocrinology 2003; 144: 5159 -5165
Lipid partitioning in diet-induced obesity Copyright © 2003 The Endocrine Society Unger, R. H. Endocrinology 2003; 144: 5159 -5165
J Clin Invest. 2006 January 4; 116(1): 33– 35.
proinflammatory cytokines/chemokines, adipokines, and angiogenic factors J Clin Invest. 2006 January 4; 116(1): 33– 35.
脂質過多-異位脂肪模式(The lipid overflow--ectopic fat model) 正常脂肪 高熱量食物 缺乏身體活動 ↑脂肪+醣類攝取 正熱量平衡 Ø有利遺傳型態 Ø動態生活 皮下肥胖 功能健全脂肪組織 無異位脂肪囤積 低肌肉脂肪 低心臟表面脂肪 低肝臟脂肪/正常功能 胖 正 常 神 經 內 分 泌 系 列 指 標 代謝異常易感性 Ø 吸菸 Ø 不利遺傳型態 Ø 壓力適應不良 腹部肥胖 脂肪組織功能失調 異 常 神 ↑游離脂肪酸 ↓脂締素 經 分泌改變 內 代謝改變 分 泌 脂質過多-異位脂肪分佈 系 列 ↑肌肉脂肪↑細胞內脂肪 指 ↑心臟表面脂肪 標 ↑肝臟脂肪/功能改變 正常代謝指標改變 無代謝症候群特徵 出現代謝症候群特徵 Adapted from Despres JP: Nature 2006: 881 -7, Despres JP: Annual of Med 2006; 52 -63
Photographs and Abdominal MRI before and after Liposuction Total 15 obese subjects (8 Non DM, 7 DM); 9 -10 kg SVT(30 -40%) Klein et al: NEJM 2004
Absence of an effect of Liposuction on insulin action and Risk Factors for CHD 10 -12 wks Klein et al: NEJM 2004
Visceral Adipose Tissue (VAT) (large arrowheads) (retroperitoneal compartment) vs. (intraperitoneal compartment) Subcutaneous Adipose Tissue (SAT) Deep (open arrows) vs. superficial (closed arrows ) The fascia (small arrowhead) Kelley, D. E. et al. Am J Physiol Endocrinol Metab 278: E 941 -E 948 2000
脂肪分佈的區分 n 腹部內臟脂肪組織分成： – 進入全身循環的「後腹腔區塊」 (retroperitoneal compartment) – 流入門脈循環的「腹膜內區塊」 (intraperitoneal compartment) ~Gary A: JCEM 2004 n 腹部皮下脂肪組織分成： – 與胰島素阻抗較無關的「表淺區塊」 (superficial compartment) – 與胰島素阻抗較有關的「深部區塊」 (deep compartment) ~Kelley DE et al: Am J Physiol Endocrinol Metab 2000
儉約基因表現型假說 The Thrifty Phenotype Hypothesis 母親壓力、感染、 營養不足、胎盤功能不良 吸菸、飲酒 世代間效應 子宮內排程 貝他細胞功能 代謝症候群 胰島素阻抗 肥胖 營養過剩 高血壓腎臟病 減少胰臟貝他細胞 肌肉肝臟脂肪組織 下視丘腦下腺軸 神經內分泌系統 出生體重過低 成長、代謝及 血管組織改變 腎臟腎絲球數量 Adapted from Hales: Br Med Bull 2001; Fernandez-Twein: Physiology Behavior 2006
肥胖的相關疾病 精神疾病 脂肪分佈 高血壓 葡萄糖耐性異常 血脂代謝異常 女性：卵巢癌、乳癌、 子宮內膜癌 男性：大腸癌、前列腺癌
NCKUFM YCY Broad spectrum characteristics of MS Dyslipidemia Lipid disorders Stroke CHD Abdominal obesity HTN PAD DM Pre-HTN Pre-DM MEDICAL STRETEGIES HEALTH COST
結語 n 「胰島素阻抗」一直被認定是代謝症候群最根 胰島素阻抗 本的病態生理機制，串連許多與代謝症候群及 其相關危險因子的變化，而「肥胖」，尤其是 肥胖 「腹部肥胖」，更是促使這一連串代謝發炎變 腹部肥胖 化的最大推力。 n 如果代謝症候群的根本原因是環境因素(肥胖 及不活動的生活型態)，那治療的重點就是要 減少肥胖及增加體能活動，如果代謝症候群的 根本潛在原因是胰島素阻抗，那就需透過行為 改變及藥物介入來改善胰島素阻抗。
代謝症候群是基層照顧醫師的舞台 n 高盛行增加中 n 高健康衝擊性 n 預防醫學角度 n 生活型態改變 n 應用行為醫學 n 生活環境相關 n 社區醫學思維 n 多層面跨領域 n 整合資源介入
YCY NCKUFM
YCY NCKUFM
感謝各位的聆聽與參與 敬請賜教 問題討論
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