代謝症候群案例說明 Kuo-Chin Huang MD, PhD Associate Professor

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1 代謝症候群案例說明 Kuo-Chin Huang MD, PhD Associate Professor
Department of Family Medicine National Taiwan University Hospital

2 Metabolic Syndrome Grundy SM. Nat Rev Drug Discov 2006 Apr;5(4):

3 Metabolic Syndrome Colon cancer ↑1.62 for proximal lesions
Grundy SM. Nat Rev Drug Discov Apr;5(4):

4 代謝症候群與心血管疾病及死亡率 Am J Med Oct;119: 812-9

5 台灣成年人代謝症候群與死亡率 Huang KC Obesity 2008 Mar;16(3):684-9.

6 台灣老年人代謝症候群與死亡率 CVD mortality All-cause mortality
Huang KC, et al. Eur J Clin Invest 2008; 38 (7): 469–475

7 Circulation 2005;112: Lancet Sep 24;366(9491):

8 Circulation 2005;112:

9 台灣代謝症候群的定義(>=3個) 腹部肥胖：腰圍男性>=90 公分，女性>=80公分
血壓過高：收縮壓>=130 mmHg and/or 舒張壓>=85mm Hg或是高血藥物治療中 空腹血糖過高：空腹血糖值>=100 mg/dL或是糖尿病治療中 三酸甘油脂過高：TG >=150 mg/dL 高密度脂蛋白膽固醇過低：low HDL-C 男性 <40mg/dL, 女性 <50mg/dL 國健局 2006

10 Limitations of BMI: The Y-Y Paradox
Yajnik & Yudkin, Lancet 2004 10

11 成人腰圍測量方法 國民健康局, Taiwan 除去腰部覆蓋衣物，輕鬆站立，雙手自然下垂。
以皮尺繞過腰部，調整高度使能通過左右兩側腸骨上緣至肋骨下緣之中間點(如圖)，同時注意皮尺與地面保持水平，並緊貼而不擠壓皮膚。 維持正常呼吸，於吐氣結束時，量取腰圍。

12 Prevalence of abdominal obesity by region or country
腹部肥胖之盛行率 Prevalence of abdominal obesity by region or country Men (%) Women (%) Total (%) US1 36.9 55.1 46.0 South Europe2 33.2 43.8 38.5 South Korea3 21.0 42.4 32.5 Australia4 26.8 34.1 30.5 South Africa5 9.2 42.0 27.3 North Europe2 22.8 25.9 24.4 Taiwan6 28.3 28.7 28.5 Abdominal obesity has reached epidemic proportions worldwide Surveys in various countries suggest a high prevalence of abdominal obesity, using criteria similar to those used for the metabolic syndrome by NCEP ATP III. Adapted from NHANES database (19992000). 1. Ford ES et al, 2003; 2 Haftenberger M et al, 2002; 3. Kim MH et al 2004; 4. Cameron AJ et al, 2003; 5. Puoane T et al, 2002; 6. Hwang LC et al, 2006 Ford ES et al. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: findings from the National Health and Nutrition Examination Survey, 1999 to Circulation 2003: 107(17):2185-9 Haftenberger M et al. Overweight, obesity and fat distribution in 50-to-64 year old participants in the European Prospective Investigation into Cancer Nutrition (EPIC). Public Health Nutr 2002;5(6B): Kim MH et al. Prevalence of the metabolic syndrome and its association with cardiovascular diseases in Korea. J Korean Med Sci 2004;19(2): Cameron AJ et al. Overweight and obesity in Australia: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Med J Aust 2003;178(9): Puoane T et al. Obesity in South Africa: the South African demographic and health survey. Obes Res 2002;10(10):

13 評估心血管疾病風險：Framingham 10年風險指數
代謝症候群之防制策略 成人健檢或其他健康檢查資料 篩選高危險群 符合診斷標準 量腰圍、量血壓、空腹抽血 確立診斷為代謝症候群 評估心血管疾病風險：Framingham 10年風險指數 處理 國健局 2006

14 代謝症候群申請支付標準流程圖

15 編號 診療項目 支付點數 P3701C 代謝症候群收案管理照護費 註：1.本項目已包含診察費，故不得另行申報。 2.建議診察及照護項目詳附表1。 3.完成「代謝症候群照護」方案記錄表(一)、(二)，詳附表2及附表3。 4.須完成個案登錄資料。 5.每一病患於同一院所限申報1次。 400 P3702C 代謝症候群評估管理照護費 註：1.本項目已含診察費及09004C三酸甘油酯、09005C血液及體液葡萄糖及09043C高密度脂蛋白膽固醇等3項檢驗費用，故不得另行申報。 2.建議診察及照護項目詳附表4。 3.須完成「代謝症候群照護」方案記錄表(二)追蹤欄。 4.須提供健康管理建議如附表5。 5.須完成個案登錄資料。 6.每一病患於同一院所限申報1次。 800 P3703C 高密度脂蛋白膽固醇檢查費 (1)須優先篩檢保險對象之腹部肥胖、血糖、三酸甘油酯及血壓等四項危險因子，如其中三項已符合收案條件者，應直接收案並於完成相關照護後，申請P 3701C及P 3702C (收案滿180日，且完成追蹤及評估事項)費用，不得申報本項費用。 (2)如上開四項危險因子僅二項符合收案條件，惟一年內曾做過HDL生化檢查且符合男性＜ 40 mg/dl；女性＜50mg/dl條件者，應直接採用該項生化檢查值作為收案條件，並申報P 3701C及P 3702C (收案滿180日，且完成追蹤及評估事項)費用，惟不得另行申報本項費用。 (3)如上開四項危險因子僅二項符合收案條件，且一年內曾做過HDL生化檢查，惟其不符合男性＜ 40 mg/dl；女性＜50mg/dl條件者，不得申報本項費用，亦不得申報P 3701C及P 3702C費用。 (4)如上開四項危險因子僅二項符合收案條件，且未曾做過HDL生化檢查，則得進行本項檢查並申報本項費用，如其結果符合男性＜40 mg/dl；女性＜50mg/dl條件者，得再申報P 3701C及P 3702C (收案滿180日，且完成追蹤及評估事項)費用。 (5)如上開四項危險因子僅二項符合收案條件，但一年前曾做過HDL生化檢查且其符合男性＜40 mg/dl；女性＜50mg/dl條件者，可再進行本項檢查並申報本項費用，如其結果符合男性＜40 mg/dl；女性＜50mg/dl條件者，則得再申報P 3701C及P 3702C (收案滿180日，且完成追蹤及評估事項)費用。 (6)如上開四項危險因子僅二項符合收案條件，但一年前曾做過HDL生化檢查，惟其不符合男性＜40 mg/dl；女性＜50mg/dl條件者，可再進行本項檢查並申報本項費用，如其結果符合男性＜40 mg/dl；女性＜50mg/dl條件者，則得再申報P 3701C及P 3702C (收案滿180日，且完成追蹤及評估事項)費用。 200

16 表一 不同性別與年齡層的代謝症候群之盛行率(N=124,513)
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 10.1 30.8 50.1 22.4 男 16.6 33.6 41.8 26.0 女 4.2 28.6 60.0 19.1

17 表二 有無腹部肥胖在不同性別與年齡層的代謝症候群之盛行率(N=124,513)
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 腹部肥胖 58.3 68.8 79.6 68.5 正常 5.0 16.1 26.0 10.6 男 66.1 73.6 79.2 72.1 9.2 20.1 23.7 14.5 女 43.1 65.6 79.9 65.4 1.7 12.7 30.7 7.1

18 表三 有無血壓高在不同性別與年齡層的代謝症候群之盛行率(N=124,513)
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 血壓高 35.7 54.0 60.9 50.6 正常 4.7 12.9 19.2 8.1 男 39.7 55.2 52.9 49.4 16.2 15.6 11.4 女 25.1 53.0 69.4 52.0 2.1 10.2 25.2 5.5

19 表四 同時有腹部肥胖與血壓高在不同性別與年齡層的代謝症候群之盛行率
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 86.4 85.3 86.9 85.8 男 86.6 87.5 87.4 87.2 女 85.7 83.8 84.7

20 表五 有無肥胖(BMI>=27kg/m2)在不同性別與年齡層的代謝症候群之盛行率
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 肥胖 52.4 67.8 81.2 64.2 正常 6.0 23.3 43.4 16.1 男 55.7 71.3 80.8 65.1 10.4 25.8 35.4 19.0 女 43.2 64.8 81.4 63.0 2.4 21.3 54.0 13.6

21 表六 同時有肥胖(BMI>=27kg/m2)與血壓高在不同性別與年齡層的代謝症候群之盛行率
20-39歲(%) 40-64歲(%) >=65歲(%) >=20歲(%) 全部 77.9 82.4 87.7 82.2 男 77.3 84.5 88.7 82.5 女 80.6 80.7 87.0 82.0

22 40-55歲

23 40-55歲

24 不同情況下代謝症候群絕對風險之比較 Despres et al. Nature 2006; 444: 881-7

25 代謝症候群之防制策略(續) 處理 定期追蹤、積極處理 預防心血管疾病及糖尿病 A. 減重 B. 增加體力活動 C. 健康飲食 D. 戒菸
血脂異常 必要時藥物治療，詳見 BHP/do/chinese/home 2. 血壓異常 必要時藥物治療，詳見 BHP/do/chinese/home 3. 血糖異常 必要時藥物治療，詳見 BHP/do/chinese/home 定期追蹤、積極處理 預防心血管疾病及糖尿病 國健局 2006

26 治療式生活形態改變(TLC)之施行步驟 第1次就診 開始TLC 第2次回診 第3次回診 評估達到 治療目標否 第N次回診 評估與監測 ……
6週 6週 每3-6個月 若無 1.評估 2.設立治療目標（TLC目標 及血壓、血脂、血糖 控制目標） 3.鼓勵適度體力運動 4.強調健康飲食 5.轉介給營養師 1.評估及討論 2.補強第1次就診後之缺失 3.轉介給營養師 1.評估及討論 2.再加強TLC 3.考慮使用藥物 國健局 2006

27 Patient Profile: Ron G. BP 140/94 mmHg, BMI 28 kg/m2, WC 41"
TC: 230 LDL: 138 HDL: 36 TG: 280 mg/dL Fasting glucose: 114 mg/dL (prediabetes) Family history of T2DM with complications No clinically evident disease, but clearly at risk for CVD, T2DM What is the best treatment for Ron G. within the new treatment paradigm? Blood pressure (BP) = 140/94 mmHg Body mass index (BMI) = 28 kg/m2 Waist circumference (WC) = 41" Total cholesterol (TC): 230 Low-density lipoprotein (LDL) cholesterol = 138 High-density lipoprotein (HDL) cholesterol = 36 Triglycerides (TG) = 280 Fasting glucose = 114 (prediabetes) Family history of type 2 diabetes mellitus (T2DM) with complications No clinically evident disease, but clearly at risk for cardiovascular disease (CVD) and T2DM What is the best treatment for Ron G. within the new treatment paradigm? Data from Prof Jillian Meyer in USA

28 Comprehensive Management for Disease Prevention
Current Treatment Paradigm Treatment AO ± pre-HTN, dyslipidemia HTN, ↑LDL, ↑TG + ↓HDL, IFG, AO CVD/T2DM Delay/prevent? This conceptual slide shows an evolution in the treatment paradigm for risk-factor management in cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Under the current paradigm, treatment of individual risk factors is sometimes initiated in later stages of risk-factor progression after therapeutic lifestyle changes have not worked, or in patients with established CVD or T2DM. In contrast, under a new treatment paradigm, a comprehensive treatment approach to cardiometabolic risk—implemented early—could help to delay or prevent disease progression. Treatment New Treatment Paradigm Data from Prof Jillian Meyer in USA

29 Metabolic Syndrome- a lifestyle disease with genetic predisposition

30 Etiological categories for the metabolic syndrome
Obesity and abnormalities of adipose tissue Insulin resistance A constellation of independent factors (eg, molecules of hepatic, vascular and immunological origin) that mediate specific components of the metabolic syndrome (FFA, Cortisol, Estrogen, Leptin, Adiponectin, Resistin, IGF-1, IL-6, TNF-A, PAI-1) Carlson LA. Clinician’s Manual on the Metabolic Syndrome

31 Medications for this patient
Blood pressure: 148/ 89 mmHg Diuretics Beta blocker ACE-Inhibitors AT1-blockers .... Impaired fasting glucose: AC sugar: 111 mg/dl 2-h OGTT: 180 mg/dl Metformin Acarbose TZD´s LDL-Cholesterol: 140 mg/dl Statin HDL-Cholesterol: 32 mg/dl Niacin Central obesity: 128 cm Diet, Exercise Orlistat, Sibutramine Triglycerides: 288 mg/dl Fibrates Data from Prof. Matthias Blüher in Germany

32 Mr JP Now 64 year-old retired taxi driver
Type 2 diabetes mellitus since 1998, age 56 Diagnosed on screening at GP Fasting glucose 9.2 mmol/L (166 mg/dl) HbA1c 8.4% Total Cholesterol 6.1 mmol/L (236 mg/dl) BP 154/88 mm Hg Weight 94 kg BMI 32.4 Advised on ‘diabetic diet’ (patient description) Avoid sugar and fatty foods Data from Dr Finer in UK

33 Mr JP Feb 2000 HbA1c 9% Started on Metformin 500 mg bid Feb 2001
Continues on Metformin Cholesterol 6.2 mmol/L (240mg/dl): Simvastatin started Jan 2002 BP 156/92 mm Hg: Perindopril started Weight 98 kg, BMI 34 Oct 2002 HbA1c 8.5% Weight 101 kg, BMI 35 Data from Dr Finer in UK

34 Mr JP What should he do now? Accept current glycaemic control
Re-advise on diet and exercise Add 2nd hypoglycaemic drug Start insulin Data from Dr Finer in UK

35 Clinical Management of Metabolic Syndrome
Lifestyle risk factors Abdominal obesity (7-10% at year 1, BMI<25 kg/m2 finally), physical inactivity (30-60 min, 5-7 d/wk, RT 2d/wk), atherogenic diet (reduced saturated fat, trans fat, and cholesterol), smoking cessation Metabolic Risk Factors Atherogenic dyslipidemia (1st LDL-C, 2nd non-HDL-C, 3rd HDL-C) Elevated BP Elevated glucose Prothrombotic state Proinflammatory state Circulation 2005;112:

36 (1)代謝症候群之 腹部肥胖的治療

37 減重的效益 ~5% Weight Loss 5%-10% Weight Loss HbA1c Blood Pressure
Total Cholesterol HDL Cholesterol Triglycerides 1 1 2 2 3 3 3 3 4 Impact of weight loss on risk factors Weight losses of 5%-10% have been shown to have a significant impact on several aspects of the metabolic syndrome, including well-recognized risk factors for cardiovascular disease and diabetes. For example: Wing and colleagues at Brown University evaluated the effect of modest weight loss in 114 patients with type 2 diabetes. Those who lost 5% or more of their baseline weight showed statistically significant decreases in serum HbA1c levels [4]. The Trial of Antihypertensive Interventions and Management Study found that weight losses of 5% or more produced reductions in diastolic pressure that were equivalent to those produced by a single dose of antihypertensive medication [3]. Numerous studies have shown that weight losses of 5%-10% improve total cholesterol, LDL-to-HDL ratio, and the ratio of total-to-HDL cholesterol [1]. In one study, weight reduction of just 5.8% was associated with a 16% reduction in total cholesterol, an 18% increase in HDL cholesterol, and a 12% decrease in LDL cholesterol [1]. More recently, Ditschunheit and colleagues documented significant decreases in total cholesterol, triglycerides, and VLDL in obese patients with baseline hyperlipidemia who maintained a weight loss of 7.6% [2]. Blackburn G. Ob Res 1995;3(Suppl2):211S-216S. Ditschunheit HH, et al. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr 2002;56: Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: The effects of modest weight reduction. Ob Res 2000;8(3): Wing RR, et al. Long-term effects of modest weight loss in Type 2 diabetic patients. Arch Intern Med 1987;147: 1. Wing RR et al. Arch Intern Med. 1987;147: 2. Mertens IL, Van Gaal LF. Obes Res. 2000;8: 3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S. 4. Ditschunheit HH et al. Eur J Clin Nutr. 2002;56:

38 N Engl J Med 2002;346: 31% 58%

39 Intensive Lifestyle Intervention
The goal is to achieve and maintain a weight reduction of at least 7 % initial BW through a healthy low calorie, low-fat diet and physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification one-to-one basis during the first 24 weeks (flexible, culturally sensitive, and individualized) Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes. N Engl J Med 2002;346:

40 Development and Resolution of the Metabolic syndrome (53%)
38% 53% 23% 18% 47% 38% Development Resolution Ann Intern Med. 2005; 142(8):611-9.

41 XENical in the Prevention of Diabetes in Obese Subjects (XENDOS) Study
Diabetes Care 2004; 27:

42

43

44 N Engl J Med 2004;351:

45 N Engl J Med 2004;351:

46 N Engl J Med 2004;351:

47 減重手術降低重度肥胖病人的死亡率 29% N Engl J Med 2007;357:741-52 Background
Obesity is associated with increased mortality. Weight loss improves cardiovascular risk factors, but no prospective interventional studies have reported whether weight loss decreases overall mortality. In fact, many observational studies suggest that weight reduction is associated with increased mortality. Methods The prospective, controlled Swedish Obese Subjects study involved 4047 obese subjects. Of these subjects, 2010 underwent bariatric surgery (surgery group) and 2037 received conventional treatment (matched control group). We report on overall mortality during an average of 10.9 years of follow-up. At the time of the analysis (November 1, 2005), vital status was known for all but three subjects (follow-up rate, 99.9%). Results The average weight change in control subjects was less than ±2% during the period of up to 15 years during which weights were recorded. Maximum weight losses in the surgical subgroups were observed after 1 to 2 years: gastric bypass, 32%; verticalbanded gastroplasty, 25%; and banding, 20%. After 10 years, the weight losses from baseline were stabilized at 25%, 16%, and 14%, respectively. There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P = 0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P = 0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29). Conclusions Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality. N Engl J Med 2007;357:741-52

48 (2)代謝症候群之 血脂異常的治療

49 Intensive LDL lowering is recommended in ATP III report (2004)
High Risk CHD or CHD risk equivalents (10-yr risk >20%) Moderately High Risk ≥ 2 risk factors (10-yr risk 10-20%) Moderate Risk ≥ 2 risk factors (10-yr risk <10%) Lower Risk < 2 risk factors 190 - Target 160 mg/dL 160 - Target 130 mg/dL Target 130 mg/dL LDL-C level 130 - Target 100 mg/dL or optional 100 mg/dL Although overall mortality due to CVD remains high (nearly 1 million deaths yearly)1 and has decreased only slightly in the United States,1 the mortality rates have steadily decreased from 1979 to This can be explained because of population increase over this period. While the population grew, the actual number of CVD-related deaths remained virtually unchanged, only decreasing slightly. A more realistic picture emerges when the death rate per 100,000 population is calculated. This number steadily declined from 1979 to Nevertheless, CVD remains the leading cause of death, accounting for 38% of all deaths in the United States.2 References 1. National Institutes of Health. National Heart, Lung, and Blood Institute.Morbidity & Mortality, 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. National Institutes of Health, 2002. 2. American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Texas: American Heart Association; 2005. 台灣健保局治療目標 100 - or optional 70 mg/dL＊ 70 - ＊ Patient who had established CVD combine with acute coronary syndromes or multiple risk factors (esp. diabetes) or severe and poorly controlled risk factors (e.g., cigarette smoking) or metabolic syndrome (high TG, low HDL-C) Circulation. 2004;110:

50 Therapeutic Lifestyle Changes（TLC）for Dyslipidemia
　血中膽固醇或壞的膽固醇過高，可藉由改善以下的生活形態，來降低動脈粥樣硬化的危險： TLC飲食（TLC diet）： 少吃飽和脂肪 少吃膽固醇 多攝取水溶性纖維，例如：全穀類、豆莢、種子、蔬菜、水果 規律運動 維持理想體重

51 Very high risk patients…
CHD + at least one of the following conditions: Multiple risk factors (especially diabetes) Severe and poorly controlled risk factors (especially continued cigarette smoking) Multiple risk factors of the metabolic syndrome (especially high triglycerides > 200 mg/dl plus non-HDL-C > 130 mg/dl with low HDL-C < 40 mg/dl) Acute coronary syndrome Circulation. 2004;110:

52 Circulation 2004;110:

53 Classification of Serum Triglycerides
Normal <150 mg/dL Borderline high 150–199 mg/dL High 200–499 mg/dL Non-HDL-C is the secondary target Non-HDL cholesterol goal: LDL-C goal + 30 mg/dL Very high 500 mg/dL Goal of therapy: prevent acute pancreatitis Very low fat diets, Triglyceride-lowering drug (fibrate or nicotinic acid) NCEP ATP III. JAMA 2001;285:2486–97.

54 Combination therapy Statin based Non-statin based Statin + ezetimibe
Statin + niacin Statin + resin Statin + fenofibrate, not gemfibrozil Statin + ezetimibe + fenofibrate Non-statin based Fibrate + ezetimibe Fibrate + niacin

55 (3)代謝症候群之 血糖過高的治療

56 Pathophysiology of T2DM
N Engl J Med 1996;334:777–83 Fortschr Med 1992;110:637–41. Macro- vascular disease Insulin sensitivity Insulin secretion Plasma glucose Micro- vascular disease Impaired glucose tolerance Hyperglycemia

57 Treatment of Elevated Fasting Glucose
In MetS patients with IFG ( or IGT if assessed), weight reduction and/or increased physical activity will delay or prevent the onset of DM Metformin, TZDs, acarbose will lower risk for DM in people with IFG or IGT Only acarbose reduces the risk of HTN and CV events in subjects with dysglycaemia (JAMA 2003) Circulation 2005;112:

58 (4)代謝症候群之 血壓過高的治療

59 Treatment of Elevated Blood Pressure
HTN without DM or CKD, the BP goal is < 140/90 mmHg HTN with DM or CKD, the BP goal is < 130/80 mmHg DASH (Dietary Approaches to Stop HTN) diet for mild elevations of BP ACEIs (ARBs if can’t tolerate ACEIs) as the first-line therapy for HTN in the MetS, especially when DM or CKD is present The role of diuretics? Circulation 2005;112:

60 Lifestyle Modification Recommendations
Hypertension. 2003;42:1206

61 DASH diet DASH （Dietary Approaches to Stop Hypertension）diet為高血壓保健飲食。
注意飲食的攝取，包括：飽和脂肪、膽固醇、脂肪，並特別強調蔬菜水果與低脂乳製品的攝取有助於降低血壓。 亦強調全穀類、魚肉、雞肉、堅果類、少紅肉、少單糖及少含糖飲料，富含鉀、鎂、鈣離子、蛋白質及纖維的食物。 原本並不是設計用來減重的一種飲食，但是因為此種飲食富含蔬菜類與水果類，藉由這二低熱量食物的攝取來取代其他高熱量食物，亦可控制體重。

62 如何遵循DASH飲食計畫(範例) 食物類別 一份 在DASH飲食中的重要性 五穀根莖類 蔬菜類 水果類 低脂乳製品 蛋豆魚肉類 堅果種子類
半片全麥土司 三湯匙燕麥片… 主要的熱量來源，且未精緻加工的五穀根莖類富含纖維 蔬菜類 一顆大蕃茄 半碗煮熟青菜 富含鉀、鎂與纖維 水果類 一個網球大小新鮮水果 低脂乳製品 240毫升牛奶 富含鈣與蛋白質 蛋豆魚肉類 1個蛋 1兩肉、半盒豆腐 富含蛋白質與鎂 堅果種子類 1/3杯堅果類 2湯匙種子 可提供熱量，富含鉀、鎂與纖維 油脂類 1茶匙油 可提供熱量、必需脂肪酸 糖 1湯匙糖或果醬

63 Beneficial effects of DASH on features of the metabolic syndrome
116 patients with metabolic syndrome 6 months of control diet, a weight-reducing diet, DASH diet with reduced calories/increased fruit, vegetables, low-fat dairy, whole grains..2400mg Na HDL-C (7/10mg/dl), TG (-18/14mg/dl), SBP (-12/11mmHg), DBP (-6/7mmHg), AC (-15/8mg/dl), WC (-7/5cm), Weight (-16/14kg) DASH diet can likely reduce most of the metabolic risks in both men and women Diabetes Care 2005; 28:

64 Other Conditions Prothrombotic state- low-dose aspirin for 2nd prevention; in 1st prevention, lowered the risk of stroke in women (N Engl J Med 2005; 352: ), reduction in the risk of myocardial infarction in men (N Engl J Med 1989; 321:129–35); DM/MetS Proinflammatory state- agents to treat other metabolic risk factors, like statins, nicotinic acid, fibrates, ACEIs, TZDs Circulation 2005;112:

65 Summary The metabolic syndrome is a clustering of amendable risk factors for CVD and diabetes The cornerstone of treatment is TLC, which stresses on a moderate reduction of body weight and waist circumference Multifaceted drug treatment is indicated when TLC is not enough

66 謝謝聆聽，敬請指教！ 丹麥-最快樂的國家《禮記》中的大同世界，在丹麥實現 丹麥人富裕，人均國民所得三萬四千六百美元，全球國家中排名第七。
平均月薪合新台幣十八萬元，是台灣的四．七倍，即便送報生都能拿到月薪新台幣十幾萬元。這是一個幾乎沒有窮人的國家。 謝謝聆聽，敬請指教！