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 楊宜青醫師

「代謝症候群」 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 ) 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 Hyperinsulinemia Impaired Glucose Tolerance Hypertension Triglyceride ↑ HDL↓ Banting lecture Reaven GM. Role of insulin resistance in human disease. Diabetes 1988; 37: Insulin Resistance: the Metabolic Syndrome X st ed by Gerald M. Reaven (Editor), Ami Laws (Editor)

1923 Kylin E, 1923, Germany The first man recognized clustering of some metabolic abnormalities. The hypertension-hyperglycemia- hyperuricemia syndrome 1923 Zentralblatt fuer Innere Medizin 1923;44: Other: 1947 Vague J: Presse Med 1947 ;30:339-40(upper body obesity) 1975 Haller H, Hanefeld M: Lipidstoffwechelstorungen 1975 : (Term metabolic syndrome) 1981 Hanefeld M, Leohardt W: Dtsch Gesundheitwes 1981 ;36:545-51

Terms associated with Metabolic Syndrome Metabolic Syndrome (Hanefeld & Leonhardt, 1981) (Metabolic) Syndrome X (Reaven, 1988) Deadly Quartet (Kaplan, 1989) Multiple Metabolic Syndrome (Hjermann, Os & Nordby, 1992) Insulin Resistance Syndrome (DeFronzo & Ferrannini, 1991; Haffner et al.1992 ) Insulin Resistance-dyslipidemia syndrome (Despres, 1993) Chronic cardiovascular risk factor clustering syndrome (Zimmet et al, 1994) Dysmetabolic Syndrome (Groop L,) Cardiovascular Dysmetabolic syndrome (1998)

Incongruent Taxonomy Based on: Disease manifestation or Phenotypes Etiologic Conceptualization Purpose

Factor Analysis ( 因素分析 ) A mathematical technique by which a large number of correlated variables can be reduced to fewer “factors” that represent distinct attributes that account for a large proportion of the variance in the original variables. Factor Extraction  to estimate the numbers of factors Factor Rotation  to determine constituents of each factor in terms of the original variables Exploratory vs Confirmatory FA

correlation coefficients F M

Modeling the Structure of the MS Confirmatory factor analysis

Phenotypic Correlations among Components Metabolic Syndrome Yang YC et al: Diabetes Research and Clinical practice 2007 SBPDBP BMI WHR HOMA-IR 2 小時 血糖 TG HDL microalbuminuria

Metabolic Syndrome WHO criteria (1998,1999) DM, IGT, NGT with IR WHR > 0.85 (F) > 0.9 ( M ) BM I > 30 HDL < 35 (F) < 39 ( M ) TG ≧ 150 BP > 160/90 (1998) > 140/90 (1999) AER > 20 ug/min ACR > 20 mg/g > 30 (1999) Diabet Med 15: 539–553, :From: 2/4

prior evidence of CHD. Kaplan-Meier estimates of CHD death during an 18-year follow-up Prior myocardial infarction (MI) Diabetes Care 28: , 2005 with the status of diabetes in men (n = 1,219), in women (n = 1,213), and in all (n = 2,432). DM=CHD

IGT and Macrovascular Complications CVDCHDStrokeAll causes Hazard ratio known diabetes IGT IFG Adapted from: DECODE study group: Arch Intern Med 161: , IGT as defined by the WHO guidelines (2h-OGTT) is a risk marker for macrovascular complications. DECODE (Diabetes Epidemiology Collaborative analysis of Diagnostic criteria in Europe)

Problems before you see them

Metabolic Syndrome WHO criteria (1998,1999) DM, IGT, NGT with IR WHR > 0.85 (F) > 0.9 ( M ) BM I > 30 HDL < 35 (F) < 39 ( M ) TG ≧ 150 BP > 160/90 (1998) > 140/90 (1999) AER > 20 ug/min ACR > 20 mg/g > 30 (1999) Diabet Med 15: 539–553, :From: 2/4

NCKUFM YCY TG > 150 mg/dL HDL < 40 (M) < 50 (F) BP > 130/85 AC >110 mg/dL WC >102  90 cm(M) 88  80 cm(F) Modified Metabolic Syndrome NCEP ATP III criteria 代謝症候群 2001

Abdominal Obesity: Risk Factor for Type 2 Diabetes Waist/Hip tertiles BMI tertiles Adapted from Ohlson et al., Diabetes (1985) 34: Incidence of Type 2 diabetes is more related to abdominal fat accumulation than overweight year incidence of Type 2 DM (%) yr-old men selected by year of birth (1913) residence in Goteborg, Sweden 1967  1981

From Rexrode KM et al., JAMA (1998) 280: High (25.2-<48.8) Middle (22.2-<25.2) Low (12.2-<22.2) Low (38.1-<73.7) Middle (73.7-<81.8) High (81.8-<139.7) BMI tertiles (kg/m 2 ) Waist girth tertiles (cm) Incidence rate per person-years Follow-up of 8 years Abdominal Obesity: Coronary Heart Disease The Nurses’ Health Study 44,702 women aged 40 to 65

Abdominal Obesity: Predicts the Metabolic Syndrome (NCEP-ATPIII) (2 ／ 4) >30<30 <102 cm (men) <88 cm (women) >102 cm (men) >88 cm (women) Waist circ. Body Mass Index (kg/m 2 ) 8 -year incidence of metabolic syndrome % Han TS t al. Obes Res 2002;10: / / / / non-Hispanic whites and 1340 Mexican Americans, ages 25 to 64 years, from the second cohort of the San Antonio Heart Study

NCKUFM YCY Waist Circumference: A Vital Sign

NCKUFM YCY Metabolic Syndrome IDF criteria Abdominal Obesity TG > 150 mg/dL HDL < 40 (M) < 50 (F) BP > 130/85 AC > 110 mg/dL 代謝症候群 2005

NCKUFM YCY TG > 150 mg/dL HDL < 40 (M) < 50 (F) BP > 130/85 AC > 100 mg/dL WC > 90 cm(M) 80 cm(F) Modified Metabolic Syndrome revised NCEP ATP3 criteria 代謝症候群 2005 AHA / NHLBI 2006

不同代謝症候群定義比較 WHO(1998)EGIR(1999) NCEP(2001) (2005)(2006) AACE(2003)IDF(2005) 0. 必要核心異常 胰島素阻抗性 Insulin resistance － * 腹部肥胖 (AOb) Abdominal Obesity 1. ( 腹部 ) 肥胖：腰圍 (WC) 腰臀圍 (WHR) WHR:M>0.9/F>0.85 BMI>30 ( 台灣 27) WC: M>94/F>80 WC: M>102/F>88 ( 台灣 +BMI> 27) BMI ≧ 25 WC: M>102/F>88 WC M>90/F>80 2. 血糖異常或用藥 空腹血糖 (FG)(mg/dL) DM, IGT, HOMA- IR (highest 25%) IFG twice &DM( － ) Fasting hyperinsulinemia (highest 25%) ≧ 110(ATP3) ≧ 100(AHA2006) IFG( ≧ 110 )+IGT Exclude DM ≧ 血壓異常或用藥 (SBP/DBP)(mmHg) ≧ 140/90 ≧ 130/85 4. 血脂異常 1(High TG) TG(mg/dL) TG ≧ 150 Or ≧ 180 ≧ 血脂異常 2(Low HDL-c) HDL-c(mg/dL) HDL: M<35 F<40 M&F<40 or treated M<40 F<50 M<40 F<50 M<40 F<50 6. 其他 微白蛋白尿 ACR ＞ 30mg/g UAER ＞ 20ug/min －－ 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 － 備註 IR + 2/43/5 胰島素阻抗依臨床診斷 不做項目數別診斷依據 AOb+ 2/4

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 mmHg / DBP ≧ 85 mmHg 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 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。 等藥品 ( 中、草藥除外 ) ，血壓或血糖之檢驗值正常者。 台灣代謝症候群之臨床診斷準則 (Taiwan 2006 Oct) 診斷標準： 5 個危險因子個數大於等於 3 個

New ICD-9-CM Code for Dysmetabolic Syndrome X 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, 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 *Obesity criteria adjusted to waist circumference appropriate for an Indian population

Men Women Hwang LC et al: J Formos Med Assoc 2006;105(8): % 13% TwSHHH2002( 台灣三高調查 ) Age-specific Prevalence of the Metabolic Syndrome

Age-sex specific prevalence of Metabolic Syndrome in Tainan, 1996 WHO WHO (M:25.7, F:16.1,T:20.6 [18.3 %]) IDF IDF (M:19.2;F:16.6;T:17.9[ 16.1%]) AHA AHA (M:26.4, F:21.3, T:23.7 [21.5%]) ATP III-AP ATP III-AP (M:21.3, F:17.1, T:19.1 [17.0%])

The incidence rate of DM was 7.8% (M:9.8%; F:6.3%) MS was 24.2% (M: 23.4%; F:24.7%) n=3629

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) The X -axis shows the number of MS components in baseline. Chien KL et al: Atherosclerosis 2006;Sep M F CHD Stroke

Kaplan–Meir curves of 11-yr free from CHD events by status of MetS at study entry (left) by MetS numbers at study entry (right). Chien KL et al: Atherosclerosis 2006;Sep( 簡國龍 )

Chen HJ. et al. Stroke 2006;37: Kaplan-Meier Ischemic Stroke-free Survival curves by MS-GOB status (Taiwan) MS(+) ／ OB(+) MS(+) ／ OB( － ) MS( － ) ／ OB(+) MS( － ) ／ OB( － ) MS is defined by AHA/NHLBI 2005 Asian WC cut points (M90/F80) GOB, BMI 27 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 Circulation. 2003;108: X 1 modified NCEP definition with BMI in place of WC Baseline assessments in the West of Scotland Coronary Prevention Study were available for 6447 men to predict CHD risk and for 5974 men to predict incident diabetes over 4.9 years of follow-up. WOSCOPS

Kaplan-Meier curves for new-onset DM in men with 0, 1, 2, 3, or 4 characteristics of the MS at baseline Circulation. 2003;108: X 1 modified NCEP definition with BMI in place of WC Baseline assessments in the West of Scotland Coronary Prevention Study were available for 6447 men to predict CHD risk and for 5974 men to predict incident diabetes over 4.9 years of follow-up. WOSCOPS

Association of MS and CVD  Modified def Original def RR: 1.74 Ford ES: Risk for all cause mortality, CVD, DM associated with MS. Diabetes Care 2005 July

Association of DM and MS Ford ES: Risk for all cause mortality, CVD, DM associated with MS. Diabetes Care 2005 July 3x

Prevalence of Metabolic Syndrome NGTIGTDM 10~15% 50% 80% Isomaa B: Diabetes Care 2001;24:683 The Risk of CAD & CVA ↑3 x

NCKUFM YCY NCKU-FM-YCY 台灣地區主要死因排行 死亡原因 死亡人數 每十萬人口死亡率 % 順位所有死因 129, 惡性腫瘤 35, 惡性腫瘤 35, 腦血管疾病 12, 腦血管疾病 12, 心臟疾病 11, 心臟疾病 11, 糖尿病 10, 糖尿病 10, 高血壓 1, 高血壓 1, 三高相關 27.75

NCKUFM YCY 依據 92 年十大死因統計資料 與代謝症候群相關疾病 腦血管疾病 腦血管疾病 心臟疾病 心臟疾病 糖尿病 糖尿病 腎病變 腎病變 高血壓.. 等 高血壓.. 等 之標準化死亡率總計 (134.4/10 6 ) 之標準化死亡率總計 (134.4/10 6 ) 已超過 惡性腫瘤 (124.9/10 6 ) 已超過 惡性腫瘤 (124.9/10 6 )

NCKUFM YCY NCKU-FM-YCY 項目 就診人數 ( 萬 ) 門診費用 ( 億點數 ) 住院費用 ( 億點數 ) 合計 ( 億點數 ) 糖尿病 高血壓 心臟病 腦中風 小計 癌症 佔率 ( 給付總計 ) 23.1%17.3%13.61%15.9% 代謝症候群／癌症 資料來源：衛生署 92 年全民健康保險醫療統計年報 92 年國人代謝症候群相關疾病醫療費用

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).  one in 10 children is overweight, a total of 155 million.  Around million obese - accounting for 2-3% of the world ’ s children aged  A further 22 million younger children under fives.

Global Prevalence of Obesity in Adult Males % Obese 0-9.9% % % % % ≥30% Self Reported data North America USA 31% Mexico 19% Canada (self report) 17% Guyana 14% Bahamas 14% 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% South East Asia & Pacific Region Nauru 80% Tonga 47% Cook Island 41% French Polynesia 36% Samoa 33% Eastern Mediterranean Lebanon 36% Qatar 35% Jordan 33% Kuwait 28% Saudi Arabia 26% European Region Croatia 31% Cyprus 27% Czech Republic 25% Albania (urban) 23% England 23% With examples of the top 5 Countries in each Region 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 TaskForce, London –January 2007

Global Prevalence of Obesity in Adult Females South East Asia & Pacific Region Nauru 78% Tonga 70% Samoa 63% Niue 46% French Polynesia 44% Africa Seychelles 28% South Africa 28% Ghana 20% Mauritania 19% Cameroon (urban) 14% South Central America Panama 36% Paraguay 36% Peru (urban) 23% Chile (urban) 23% Dominican Republic 18% North America USA 33% Barbados 31% Mexico 29% St Lucia 28% Bahamas 28% Eastern Mediterranean Jordan 60% Qatar 45% Saudi Arabia 44% Palestine 43% Lebanon 38% European Region Albania 36% Malta 35% Turkey 29% Slovakia 28% Czech Republic 26% % Obese 0-9.9% % % % % ≥30% Self Reported data With examples of the top 5 Countries in each Region 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 TaskForce, London –January 2007

Age-specific prevalence of overweight, obesity and abdominal obesity in men, Taiwan, 2002 Hwang LC et al: J Formos Med Assoc 2006;105(8): TwSHHH2002( 台灣三高調查 ) 2815 OW30.5 OB19.2 COB28.3 OW+OB50%

Age-specific prevalence of overweight, obesity and abdominal obesity in women, Taiwan, 2002 Hwang LC et al: J Formos Med Assoc 2006;105(8): TwSHHH2002( 台灣三高調查 ) 3131 OW21.3 OB13.4 COB28.7 OW+OB35%

Obesity as a disease

Pathogenesis of Metabolic syndrome 2 major, interacting causes Obesity and abnormal body fat distribution disorders of adipose tissue. Endogenous metabolic susceptibility  Insulin resistance 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? 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: ATP III criteria Specificities: >90% Sensitivities: between 20 and 50% ATP III+ 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 There is no biological basis for the diagnostic algorithm The syndrome is a relatively poor predictor of future DM or CVD The whole is not greater than the sum of the parts There is no scientific evidence that the syndrome has clinical utility. 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 ) 發明疾病的人 現代醫療產業如何賣掉我們的健康 醫學快速企業化、商品化、世俗化的時代 另類角度深刻省思 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

Requiescat of Metabolic Syndrome Reaven GM 2005 Metabolic syndrome Reaven GM: The MS: requiescat in pace. Clin Chem 2005;51:931-8 白髮送黑髮 ? 小伙子 安息祈禱文

Confusion Confusion about Metabolic Syndrome Is it an artificial, mathematical concept that simply recasts old known risk factors into a new disease entity? Does the clustering indeed reflect a single pathophysiology that can be a target for therapeutic decisions? Does Tx of the MS differ from the Tx of its individual components? Can the MS offer advantages over existing models for the predictions of CV events? Should the MS simply be declared dead? Reaven GM: The MS: requiescat in pace. Clin Chem 2005;51:931-8 特異性夠敏感性不足 舊酒裝新瓶 Detect IR ? 更佳預測指標 ?

Time for a Critical Appraisal Kahn R et al: Diabetes Care 2005;28: ADA & EASD

論戰 ….Endless War? 內分泌學家 糖尿病學家 血脂學家 心臟學家 Gerald Reaven Scott Grundy

Blaha M Elasy TA: Clinical Diabetes 2006;24:125 IRS MS

代謝症候群的病因、進展與後果 代謝 易感性 多項邊緣性 危險因子 多項 危險因子 第二型 糖尿病 心血管疾病 及其併發症 併發症 代謝症候群 Adapted from Grundy SM: J Am Coll Cardiol 2006; J Clin Endocrinol Metab 2007 老化 吸菸 ↑ 低密度脂 蛋白膽固醇 ↑ 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 身體脂肪 過多 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 代謝易感因素 ( 常以胰島素阻抗表現 )

Copyright ©2003 The Endocrine Society Unger, R. H. Endocrinology 2003;144: the liporegulatory system and lipid partitioning

Copyright ©2003 The Endocrine Society Unger, R. H. Endocrinology 2003;144: Lipid partitioning in diet-induced obesity

J Clin Invest January 4; 116(1): 33–35.

proinflammatory cytokines/chemokines, adipokines, and angiogenic factors

脂質過多 - 異位脂肪模式 (The lipid overflow-- ectopic fat model) 正常脂肪 正 正熱量平衡 缺乏身體活動 高熱量食物 ↑ 脂肪 + 醣類攝取 皮下肥胖 功能健全脂肪組織 腹部肥胖 脂肪組織功能失調 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 脂質過多-異位脂肪分佈 ↑ 肌肉脂肪 ↑ 細胞內脂肪 ↑ 心臟表面脂肪 ↑ 肝臟脂肪 / 功能改變 正常代謝指標代謝指標改變 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 ↑ 游離脂肪酸 代謝改變 ↓ 脂締素 分泌改變  吸菸  不利遺傳型態  壓力適應不良  有利遺傳型態  動態生活 代謝異常易感性 胖

Photographs and Abdominal MRI before and after Liposuction Klein et al: NEJM 2004 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 wks

Kelley, D. E. et al. Am J Physiol Endocrinol Metab 278: E941-E 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)

脂肪分佈的區分 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 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 子宮內排程 世代間效應 出生體重過低 成長、代謝及 血管組織改變 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 腎臟腎絲球數量 貝他細胞功能 胰島素阻抗 高血壓腎臟病 肥胖 代謝症候群 Adapted from Hales: Br Med Bull 2001; Fernandez-Twein: Physiology Behavior 2006 營養過剩

肥胖的相關疾病 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 精神疾病 脂肪分佈

NCKUFM YCY Broad spectrum characteristics of MS Dyslipidemia Abdominal obesity Pre-HTN Pre-DM Lipid disorders HTN DM Stroke CHD PAD MEDICAL STRETEGIES HEALTH COST

結 語結 語結 語結 語 胰島素阻抗 肥胖 腹部肥胖 「胰島素阻抗」一直被認定是代謝症候群最根 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 「腹部肥胖」，更是促使這一連串代謝發炎變 化的最大推力。 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 高盛行增加中 高健康衝擊性 預防醫學角度 生活型態改變 應用行為醫學 生活環境相關 社區醫學思維 多層面跨領域 整合資源介入

NCKUFM YCY

NCKUFM YCY

感謝各位的聆聽與參與 敬請賜教 問題討論