101年「員工健康促進系列」 活動 家庭醫學部 潘湘如醫師

本院參與行政院衛生署國民健康局 「健康促進醫院」補助計畫， 員工健康減重計畫101年需達成減重 2,500公斤

國民健康局100年補助3萬元 本院舉辦「100年體重控制」共減輕257.6公斤

家庭醫學部及社區健康中心舉辦系列活動 「問卷調查」 「員工健康講座」 「有氧律動」 「蓮潭健走」 「101減重競賽」

問卷調查

員工健康講座 公務人員終身學習時數

有氧律動 5月22日至起11月9日止 每週二、五 下午5:40 ~ 6:30 於醫療大樓大廳，免費參加

蓮潭健走 與社區合辦，事先報名者可獲參加獎一份。 完成健走者除可參加當日摸彩活動外，本院同仁另外抽獎6份，並於院務會議時請院長頒發。

「101減重競賽」 參與減重競賽者於3月20日「健康講座」時完成減重前體重登錄，參加者可獲參加獎一份。 每月第4週星期四下午均可至家醫科門診59診測量體重/體脂。 於11月底測量減重後體重，減重公斤數最多前10名提供獎品鼓勵

肥胖與癌症 高雄榮總家庭醫學部 潘湘如醫師

The WHO : 2.3 billion people will be overweight and 700 million will be obese by 2015

全世界共同的問題 持續升高的肥胖盛行率

我國成人過重或肥胖比率達44.1﹪ 其中男性比率為50.8% 女性比率為50.8% 兒童每4個就有一個為重或肥胖

2000年亞太肥胖組織共識 女性 男性 腰圍 >80 公分 腰圍 >90 公分 cm Slide 5: Waistline circumference is a surrogate marker of visceral fat Waistline circumference, perhaps the simplest of all measurements, provides an accurate assessment of visceral fat mass which has been shown to be a key indicator of risk factors for major cardiovascular disease. A waistline circumference >88 cm in women and >102 cm in men reflects a significantly increased risk of developing many of the co-morbidities associated with obesity. Xenical Slide Kit August 1998 Section 1 5 5 21

Obesity comorbidity 身體過多的脂肪加速血管硬化、 增加冠心病、糖尿病、 代謝症候群機會增加， 但較不為人注意的是罹癌風險增加

肥胖與第2型糖尿病患者的關聯性 危險指數 Body mass index (kg/m2) 100 93.2 75 54.0 50 40.3 27.6 25 15.8 8.1 2.9 4.3 5.0 1.0 <22 22- 22.9 23- 23.9 24- 24.9 25- 26.9 27- 28.9 29- 30.9 31- 32.9 33- 34.9 35+ Body mass index (kg/m2) Adapted from Colditz et al. Ann Intern Med 1995; 122: 481-6 25 25

糖尿病 神經病變 血管病變 腎功能 癌症

診斷糖尿病後折壽年數 NEJM 2011 Mar 3; Vol. 364 (9), pp. 829-41

肥胖 癌症 糖尿病

致癌危險因子

Risk Factors: major modifiable lung, larynx, oral cavity, esophagus 30% Tobacco use Unhealthy diet Infectious agents Ultraviolet radiation Physical inactivity 18% Tobacco use Tobacco use is the main cause of cancers of the lung, larynx, oral cavity, and esophagus, and a major cause of bladder and pancreas cancers. Unhealthy diet Up to 30% of cancers in developed countries may be related to poor nutrition. Diets high in saturated fats and low in fruits and vegetables increase the risk of cancers of the breast, colon, prostate, and esophagus. Infectious agents Infectious agents account for 18% of cancers worldwide. Human papillomavirus, hepatitis B virus, and Helicobacter pylori bacterium account for the largest number of cancers due to infections. Ultraviolet radiation Sunlight is the major source of UV radiation, which causes several types of skin cancer, the most common malignancy in humans. Physical inactivity A sedentary lifestyle increases the risk of colon cancer, and may increase the risk for other types of cancer. Its effects are closely related to an individual’s nutrition.

體能活動與罹患大腸癌機會成反比

Possible protective effect Reduction in circulating levels of insulin, hormones, and other growth factors Impact on prostaglandin leveles Improved immune function Possible protective effect : reduction in circulating levels of insulin, hormones, and other growth factors; impact on prostaglandin levels; improved immune function, and altered bile acid metabolism [42-44]. Physical activity during certain periods of life, such as adolescence, may offer additional protection against disease. The optimal duration, intensity, and frequency of physical activity that may afford cancer protection is unknown.

Occupational exposures Environmental pollution Other modifiable Increased by concurrent smoking Lung Alcohol use Occupational exposures Socioeconomic status Environmental pollution Obesity Food contaminants Ionizing radiation Alcohol use Heavy alcohol use causes cancers of the oral cavity, esophagus, liver, and upper respiratory tract. The cancer risk is greatly increased by concurrent smoking. Alcohol use also increases the risk of breast cancer. Occupational exposures Certain substances encountered at work are carcinogens, including asbestos, arsenic, benzene, silica, and second-hand tobacco smoke. Lung cancer is the most common occupational cancer. Socioeconomic status Some cancers occur more often in people with a higher socioeconomic status (SES); others are more common in lower-SES populations. SES is most likely a marker for lifestyle and other risk factors described in this section. Environmental pollution Pollution of air, water, and soil account for between 1% and 4% of all cancers in developed nations. Obesity Obesity is an important risk factor for endometrial, kidney, gallbladder, and breast cancers. Food contaminants Certain food contaminants are carcinogenic, including those that occur naturally (e.g. aflatoxins) and those that are manufactured (e.g. pesticides.) Ionizing radiation For most, the greatest exposure to ionizing radiation comes from medical X-rays. But we are all exposed to small amounts of naturally occurring radiation. 1~4% Aflatoxins pesticides

Non-modifiable risk factors Aging Ethnicity or race Heredity Sex

96年國人十大死亡原因

癌症死亡 民國71年以來，癌症一直高居台灣死亡原因首位，95年國人因癌症死亡人數37,998 人，占所有死亡人數的 28.1 %，約 13.8 分鐘便有一位癌症病患過世。 癌症治癒成功率約只佔一半，80％的癌症末期患者有不等程度的身體症狀，以及心理、精神壓力。

Evaluation by the International Agency for Research on Cancer (IARC) 2002 sufficient evidence in humans for a cancer preventive effect of avoidance of weight gain based on epidemiologic studies of overweight and/or obese individuals compared to leaner individuals The main emphasis of research is on epidemiology, environmental carcinogenesis and research training. This emphasis reflects the generally accepted notion that 80% of all cancers are, directly or indirectly linked to environmental factors, and thus are preventable epidemiologic studies of over-weight and/or obese individuals compared to leaner individuals, not on studies of individuals who have lost weight.

Overall cancer deaths BMI > 40 kg/m2 vs (BMI 18.5 to 24.9) ♂ RR 1.5 (95% CI 1.1 - 2.0) ♀ RR 1.6 (95% CI 1.4 -1.9)

♀ ♂ In a prospective study of over one million men and women who never smoked and had no history of disease at enrollment and were followed for 14 years, all cause and cardiovascular mortality progressively increased at high body mass indices (BMI) and were highest in those who were heaviest (BMI 35). Data from Calle EE, Thun, MJ, Petrelli JM, et al, N Engl J Med 1999; 341:1097. N Engl J Med 1999; 341:1097

與肥胖相關的癌症 大腸直腸癌 乳癌 食道癌 腎臟癌 子宮內膜癌 胰臟癌 肝癌 淋巴癌 多發性骨髓瘤

肥胖者發生癌症機率 發生子宮內膜癌機率為非肥胖者之2-4倍 發生胃癌機率為非肥胖者之2倍 發生食道腺癌機率為非肥胖者之2倍 發生腎細胞癌機率為非肥胖者之2-4倍 停經後婦女乳癌機率為非肥胖者之1.5倍

糖尿病 罹癌風險高 致死率高

Abdominal or visceral adiposity is a risk factor for colorectal cancer independent of BMI Waist > 99.1cm : < 83.8cm : 2 fold elevated risk for colorectal cancer Moore LL, Bradlee ML, et al. BMI and waist circumference as predictors of lifetime colon cancer risk in Framingham Study adults. Int J Obes Relat Metab Disord 2004;28:559–67. 33]. Following adjustment for BMI, a large prospective study found a twofold elevated risk for colorectal cancer among men and women

Obesity-related carcinogenic pathways Chronic inflammation Insulin resistance Candidate genes

Macrophage accumulate Pro-inflammatory peptides secretion Adiposity Macrophage accumulate Pro-inflammatory peptides secretion DNA damage carciongenesis chemotactic signals Chronic Inflammation Macrophages accumulate in white adipose tissue is possibly in response to increasing levels of chemotactic signals from the adipocyte

patients with idiopathic inflammatory bowel disease, colorectal cancer incidence rates reaching 19% after 30 years habitual use of nonsteroidal anti-inflammatory drugs confers a 40–50% reduction in disease risk

肥胖與癌症發生的可能機轉 肥胖細胞發炎因子：影響正常細胞凋亡、細胞不斷增生腫瘤因此發生 以阿斯匹靈預防大腸腫瘤 肥胖者有較高的胰島素濃度及胰島素阻抗，胰島素除了促進醣類的代謝外，同樣也有促進DNA合成，刺激細胞分化和抑制細胞凋亡的功能。 第二型糖尿病人得大腸腫瘤的機會是非糖尿病人的三倍

乳癌 肥胖會增加血液女性荷爾蒙的濃度 肥胖會引起胰島素抗性( insulin resistence)， 使得血中胰島素增多，而隨著胰島素增加會使得雄睪固 酮(testosterone)血中濃度增加、性荷爾蒙結合蛋白降 低。

子宮內膜癌 子宮內膜癌和暴露女性荷爾蒙也有直接的關係。 未生育或是不孕者；本身曾罹患乳癌或卵巢癌；肥胖症；使用藥物Tamoxifen(泰莫西芬)者皆為子宮內膜癌發生之危險因子。 肥胖會導致胰島素抗性，另外也會使得脂肪細胞增加。故血清中的荷爾蒙如動情激素、雄性激素濃度也會上升，所以，肥胖可增加子宮內膜癌的發生。

大腸直腸癌 大腸直腸癌之危險因子包括本身或家族成員曾是罹患結直腸癌或腺癌性息肉者； 反覆性罹患大腸發炎。 常食用高脂肪食物；纖維蔬果攝取量低；運動量少； 抽煙；酗酒也是導致大腸直腸癌的原因。 肥胖引起大腸直腸癌之機轉，也和增加胰島素抗性有相關。另外，也因過多脂肪攝取會增加腸道內膽酸(bile acid)的分泌，膽酸在腸道細菌的作用下，會形成催化腫瘤成長的代謝物，加速大腸直腸癌的形成。

保健之道 低油飲食並減少動物性脂肪攝取 適當的運動減少體脂肪 保持標準體重