楊偉勛臺灣大學:臨床醫學研究所江瑞坤Chiang, Jui-KunJui-KunChiang2010-05-102018-07-062010-05-102018-07-062008U0001-0411200821522000http://ntur.lib.ntu.edu.tw//handle/246246/181644世界上隨著經濟的發展，肥胖已成為一個世界性的警訊，新陳代謝症候群也盛行於各國家，新陳代謝症候群與心血管中風有著密切的關係。不同的飲食型態可能影響體內代謝發炎狀況，因此素食者可能有較低的代謝疾病及心血管疾病風險、較好的胰島素敏感性、較好的血管內皮功能。島素抗性是指胰島素的生理作用有缺陷，臨床表現有血脂異常、高血壓、葡萄糖不耐、或第二型糖尿病、高尿酸血症或痛風等。脂肪細胞分泌多種荷爾蒙，很多基因可在脂肪細胞內表達，如瘦素(leptin)、脂締素(adiponectin)，近來已將脂肪細胞視為一種內分泌器官。脂締素是脂肪細胞分泌的荷爾蒙，在過重的人身上可見較低的脂締素。脂締素是一個重要的新陳代謝症候群的指標。脂締素有增加胰島素敏感的作用及避免動脈粥狀變化的保護作用，可抑制單核球黏至內皮細胞及脂質的堆積，並且經由抑制腫瘤壞死因子α而有抗發炎作用，低的血中脂締素與內皮細胞功能不良、心血管疾病、糖尿病、高血壓有關。本研究嘗試著驗證著成人女性素食者與非素食者各項身體因子與血液中生化因子，尤其是胰島素抗性、脂締素、活動量的關聯性。究方法與進行步驟：為一橫斷式關聯性研究。象: 以大林慈濟醫院參與健康檢查的健康人，經解說後簽署同意書後進行，本研究經研究倫理委員會通過後進行： (1)定義: 研究定義素食者為蛋奶素或全素且維持一年以上者，非素食者定義為不合乎本研究定義素食者。 (2)問卷表格，如附件包括背景資料、身高、血壓、運動習慣等。 (3)配合受檢過程經八小時禁食後，進行高級體檢並登錄檢查結果，另配合體檢抽血留下3cc血液檢體，依研究檢驗步驟方法冷凍待收集完成，統一進行本實驗欲研究之因子檢測胰島素、脂締素。果與討論：共收案素食組397位，非素食組400位，整體年齡平均為55.10歲，標準差為8.81歲，比較素食組56.47 ± 8.88歲與非素食組53.71 ± 8.56歲的年紀，素食者年紀稍大，平均數差為2.76歲(p < 0.001)。在身高、體重、身體質量指數方面，素食者皆比較小。腰圍比較，素食組72.90 ± 6.88公分平均比非素食者74.61 ± 7.83公分小1.71公分(p = 0.003)。空腹血糖比較上，發現素食組89.78 ± 15.94mg/dL平均比非素食組91.48 ± 16.20mg/dL小1.70mg/dL (p = 0.007)。在總膽固醇、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇，素食組平均皆比非素食組小。三酸甘油酯比較，兩組(素食組108.18 ± 68.15 mg/dL，非素食組102.16 ± 59.22 mg/dL)無差異(p = 0.121)。以腹部肥胖（腰圍大於或等於80公分）變項，取年紀、收縮壓、空腹血糖、三酸甘油酯、停經與否、每天每公斤活動仟卡數、素食與否做多因子邏輯斯迴歸，素食對非素食為顯著因子，素食者有較低的腹部肥胖機會（勝算比估計值0.412，95%信賴區間為0.274-0.62，p < 0.0001）。以糖尿病為依變項，對年紀、收縮壓、身體質量指數、三酸甘油酯、高密度脂蛋白膽固醇、停經與否、活動量、及素食與否做多因子邏輯斯迴歸分析，發現素食是一個顯著因子，素食組對非素食組有較低的糖尿病機會（勝算比估計值0.473，95%信賴區間為0.233-0.962，p = 0.0389）。對新陳代謝症候群台灣標準為依變項，取年紀、停經與否、及素食、素食年數、睡眠時間、每天活動仟卡數做邏輯斯迴歸，可得素食對非素食為顯著因子，素食者有較低的風險（勝算比估計值0.368，95%信賴區間為0.191-0.708，p = 0.0028）。以胰島素抗性（HOMA-IR）當成依變項，取年紀、收縮壓、腰圍、高密度脂蛋白膽固醇、三酸甘油酯、停經與否、素食、每天活動仟卡數作多因子線性迴歸分析，結果發現素食組顯著比非素食組低（β = -0.3548，p = 0.001）。以脂締素為依變項做多因子線性迴歸分析，發現素食（p = 0.3801）不是顯著因子。使用運動當量換算出一週的總活動量，其關於胰島素抗性的關係，在調整年紀、收縮壓、腰圍、總膽固醇、三酸甘油酯、停經、素食情形下，仍與胰島素抗性呈顯著負相關（β = -0.144，p = 0.0086），運動可以改善胰島素抗性。進一步分析素食年數對於胰島素抗性的關係，發現在11年內有顯著降低胰島素抗性的效果。論：素食對於健康的影響是廣泛性的，除了有較低的血糖、血脂、較低的肥胖糖尿病發生機會，並且是胰島素抗性獨立顯著因子，素食者有較低的胰島素抗性，素食者對於脂締素的關係則是可能透過影響其他身體因子如減少腰圍發生機會等，而有較好的關聯性。總活動量是胰島素抗性的獨立影響因子，兩者呈負相關，而活動量與脂締素並未有直接顯著關係。進一步的研究，要考慮性別是否有不同的效益，及長期追蹤素食對於身體的影響。Obesity is a global warning sign after the development of world economics. High prevalence rate of metabolic syndrome has been noted in the most countries. The different lifestyle may influence the inflammatory status of the body. Vegetarians may have the lower risk of metabolic and cardiovascular diseases, better insulin sensitivity, improved endothelium cells function.nsulin resistance is a physiological defect of insulin function. The clinical manifestation is associated with dyslipidemia, type 2 diabetes, hypertension, gout etc. The fat cells can secret several hormones and several genes can be expressed in the fat cells., such as leptin, adiponectin.diponectin, an adipose-derived plasma protein, has been well established as an important biomarker for metabolic syndrome. Plasma concentration of adiponectin was found to be lower in overweight or obese subjects. Adiponectin is associated with inproved insulin sensitivity and has the function of atherosclerosis prevention, inhibits the adhesion of manocytes to the endothelium cells and the accumulation of lipids, and has the potential of anti-inflammation by the inhibition of α-tumor necrosis factor. Low adiponectin level is associated with the endothelium dysfunction, cardiovascular disease, diabetes and carotid artery atherosclerosis. The aim of this cross sectional study is aimed to explore the effect of vegetarian lifestyle, physical activity and clinical outcomes on concentration of plasma adiponectin, and insulin resistance among vegetarians and omnivores of the female adults in Taiwan. ethods: Those healthy adults that take part of Health Physical Exam are our possible study group. Informed consent will be given before enrollment .This study was approved by the IRB of the Buddhist Dalin Tzu Chi General Hospital.. Definition of vegetarians: those who practiced ovo-lacto-vegetarian diet or vegan for more than one year.. Questionnaires are including the demographic data, which including 7-day physical activity and exercise. . Blood was collected for routine physical exam and the data will be recorded for analysis. Another 10cc blood will be collected for adiponectin and insulin assay after informed consent. esults: Totally 397 female vegetarians (VEG) and 400 female non-vegetarians (non-VEG), with a mean age of 55.10 (S.D.: 8.81) years old, were enrolled in our study. The year of VEG are 10.23±7.22. The age of VEG was significantly older than the non-VEG by 2.76 years (p < 0.001). There were no significant difference between the VEG and non-VEG group among systolic blood pressure (p = 0.566), diastolic blood pressure (p = 0.747), heart rate (p = 0.6547), triglyceride (p = 0.121) and the prevalence of diabetes (p = 0.235) and hypertension (p = 0.747). The VEG has better metabolic parameters than the non-VEG among the variables of body height ( mean difference = -0.81cm, p = 0.039), body weight [ mean difference (VEG minus non-VEG) = -2.12kg, p < 0.001],BMI ( mean difference = -0.67kg/m^2, p = 0.015), waist circumference ( mean difference = -1.71cm, p = 0.003), glucose AC ( mean difference = -1.70mg/dL, p = 0.007), total cholesterol ( mean difference = -16.45 mg/dL, p <0.001), high density lipoprotein-cholesterol ( mean difference = -3.86 mg/dL, p < 0.001), low density lipoprotein-cholesterol ( mean difference = -12.83 mg/dL, p < 0.001). Using multivariate logistic regression, the VEG (vs. non-VEG) is an independent factor for central obesity (OR: 0.412, 95%CI: 0.274-0.62, p < 0.0001) for central obesity after adjusting for the variables of age , systolic blood pressure, glucose AC, triglyceride (TG), menopause statue, activity score. Using logistic regression analysis with an adjustment for age, systolice blood pressure, body mass index, triglyceride, high density lipoprotein-cholesterol (HDL-C), menopause status, activity score, the VEG (vs. non-VEG) has a lower probability of diabetes, with an odds ratio of 0.473, 95%CI: 0.233-0.962, p = 0.0389). Using logistic regression analysis with an adjustment for age, menopause status, years of vegetarian diet, sleep hours, activity score, the VEG (vs. non-VEG) has a lower probability of Taiwan modified metabolic syndrome, with an odds ratio of 0.368, 95% CI: 0.191-0.708, p = 0.0028. For the insulin resistance, multivariate linear regression analysis showed that VEG (vs. non-VEG, β = -0.3548, p = 0.001) were significant independent factors when controlling for the variables of age, systolic blood pressure, waist, HDL-C, TG, menopause status, and activity score. Using multivariate linear regression analysis for adiponectin, VEG (vs. non-VEG, p = 0.3801) was not a significant factor. Daily activity is negative associated with insulin resistance（β = -0.144，p = 0.0086）after adjusting age, systolic blood pressure, waist, total cholesterol, TG, menopause status, vegetarian status. Moreover, the effect of VEG was most contributed by the cases of years of vegetarian diet below 11 years. n conclusion, vegetarian lifestyle is good for health. The vegetarians have lower glucose, total cholesterol, HDL-C, LDL-C, waist circumference, and lower probability of obesity and diabetes. The vegetarian is an independent significant factor of insulin resistance and has lower insulin resistance. The association between smaller waist circumference, and lower probability of diabetes with vegetarian lifestyle may result into higher adiponectin level. The physical activity is an independent risk factor for insulin resistance. The higher physical activity score, the lower insulin resistance. There is no direct association between physical activity score with adiponectin. Further prospective follow up studies are still necessary for more investigation about the gender effect and the long term impact of vegetarian lifestyle on the health.口試審定書---------------------------------------------------------------------------------------i誌------------------------------------------------------------------------------------------------ii錄-----------------------------------------------------------------------------------------------iii目錄---------------------------------------------------------------------------------------------v 目錄--------------------------------------------------------------------------------------------vi文摘要---------------------------------------------------------------------------------------viii 文摘要-----------------------------------------------------------------------------------------xi一章 緒言-------------------------------------------------------------------------------------1 二章 文獻回顧-------------------------------------------------------------------------------3一節 肥胖及新陳代謝症候群-------------------------------------------------------3 第二節 血脂肪----------------------------------------------------------------------------5 第三節 胰島素抗性----------------------------------------------------------------------7 第四節 脂締素（adiponectin）-------------------------------------------------------10 第五節 代謝當量評估------------------------------------------------------------------12 第六節 飲食型態與疾病---------------------------------------------------------------14三章 實驗方法與進行步驟---------------------------------------------------------------20 第一節 研究方法------------------------------------------------------------------------20 第二節 脂締素檢測---------------------------------------------------------------------21 第三節 胰島素檢測---------------------------------------------------------------------24 第四節 停經定義------------------------------------------------------------------------25 第五節 統計方法------------------------------------------------------------------------26四章 結果------------------------------------------------------------------------------------28一節 描述性結果---------------------------------------------------------------------28二節 以素食年數為自變項做單因子分析---------------------------------------31三節 以胰島素抗性為依變項做單因子相關性分析---------------------------32四節 以脂締素為依變項做單因子相關性分析---------------------------------33五節 對共病症做多因子分析------------------------------------------------------33六節 對新陳代謝症候群做多因子邏輯斯迴歸分析---------------------------39七節 對胰島素抗性做多因子迴歸分析------------------------------------------40 第八節 對脂締素做多因子迴歸分析------------------------------------------------41 第九節 關於肝炎的影響---------------------------------------------------------------42 第十節 不平衡選擇的檢定------------------------------------------------------------42 第十一節 素食年數對於胰島素抗性的影響---------------------------------------43五章 討論------------------------------------------------------------------------------------45一節 有關新陳代謝症候群---------------------------------------------------------46二節 有關胰島素抗性---------------------------------------------------------------50三節 有關脂締素---------------------------------------------------------------------51四節 有關停經、B、C型肝炎----------------------------------------------------52五節 運動當量------------------------------------------------------------------------54六節 結論------------------------------------------------------------------------------55六章 展望------------------------------------------------------------------------------------57考文獻----------------------------------------------------------------------------------------58錄一、問卷----------------------------------------------------------------------------------116錄二、研究倫理委員會同意書----------------------------------------------------------119 目 錄一、素食年數與人數分布圖---------------------------------------------------------------70二、以尿酸對素食年數做散佈圖及迴歸線---------------------------------------------71三、以高密度脂蛋白膽固醇對素食年數做散佈圖及迴歸線------------------------72四、以低密度脂蛋白膽固醇對素食年數做散佈圖及迴歸線------------------------73五、以胰島素抗性對(低密度脂蛋白膽固醇/高密度脂蛋白膽固醇比)做散佈圖及迴歸線-------------------------------------------------------------------------74六、以胰島素抗性對(三酸甘油酯/高密度脂蛋白膽固醇比)做散佈圖及迴歸線----------------------------------------------------------------------------------------75七、以胰島素抗性對脂締素(adioponectin)做散佈圖及迴歸線-------------------76八、以脂締素對年紀做散佈圖及迴歸線-----------------------------------------------77九、以脂締素對血色素做散佈圖及迴歸線--------------------------------------------78十、以複廣義相加模式分析素食年數對胰島素抗性的影響效果之loess平滑成分圖-------------------------------------------------------------------------------------------79 目 錄一、現有文獻關於素食與非素食者的研究結果-------------------------------------80二、全部女性基本資料與不同飲食習慣基本資料比較表--------------------------82三、以素食年數對做單因子相關性檢定-----------------------------------------------85四、以胰島素抗性為依變項做單因子相關性分析-----------------------------------87五、對脂締素做單因子相關性分析-----------------------------------------------------89六、以身體質量指數為依變項作多因子線性迴歸分析----------------------------91七、以肥胖（BM≧I25）為依變項做多因子邏輯斯迴歸分析--------------------92八、以腰圍為依變項作多因子線性迴歸分析-----------------------------------------93九、以腹部肥胖為依變項做多因子邏輯斯迴歸分析--------------------------------94十、以腹部肥胖（腰圍大於80公分）為依變項做逐步邏輯斯迴歸-------------95十一、以空腹血糖為依變項做多因子線性迴歸--------------------------------------96十二、以糖尿病為依變項做邏輯斯迴歸分析------------------------------------------97十三、以收縮壓為依變項做多因子線性迴歸-----------------------------------------98十四、以高血壓為依變項做邏輯斯迴歸分析-----------------------------------------99十五、以三酸甘油酯為依變項做線性迴歸分析-------------------------------------100十六、以三酸甘油酯為依變項做線性迴歸分析-------------------------------------101十七、以高三酸甘油酯（≧150mg/dL）為依變項做邏輯斯迴歸分析--------102十八、以低密度脂蛋白膽固醇為依變項做線性迴歸分析------------------------103十九、以異常低密度脂蛋白膽固醇為依變項做邏輯斯迴歸分析-----------104二十、以高密度脂蛋白膽固醇為依變項做線性迴歸分析-------------------------105二十一、以異常高密度脂蛋白膽固醇為依變項做邏輯斯迴歸分析---------106二十二、對新陳代謝症候群台灣標準做多因子邏輯斯迴歸分析----------------107二十三、對國際糖尿病聯盟新陳代謝症候群標準做多因子邏輯斯迴歸分析-108二十四、以胰島素抗性為依變項做多因子線性迴歸結果-------------------------109二十五、以高胰島素抗性為依變項做多因子邏輯斯迴歸結果------------------110二十六、以脂締素為依變項做多因子線性迴歸分析結果------------------------111二十七、以脂締素25百分位為依變項做邏輯斯迴歸分析（一）--------------112二十八、以脂締素25百分位為依變項做邏輯斯迴歸分析（二）--------------113二十九、以高胰島素抗性為基礎做不平衡選擇檢定-------------------------------114三十、以胰島素抗性為依變項將素食年數分組後做多因子迴歸分析----------115表一、美國國立心肺血液研究所代謝當量編碼系統主要活動分類------------121表二、常見活動的代謝當量簡易分類表----------------------------------------------122表三、縮寫中英文對照表----------------------------------------------------------------123application/pdf2220738 bytesapplication/pdfen-US素食胰島素抗性脂締素新陳代謝症候群代謝當量vegetarianinsulin resistanceadiponectinmetabolic syndromeMET[SDGs]SDG3http://ntur.lib.ntu.edu.tw/bitstream/246246/181644/1/ntu-97-P95421007-1.pdf