臺灣博碩士論文加值系統

近二十年來，肥胖在世界各地的盛行率逐年增加，是目前公共衛生關切的重要課題，肥胖不但增加了致死率及罹病率，還會降低生活品質。肥胖的研究近幾年來，受到相當的重視，本論文主要由三個關於肥胖領域的研究整理而成，包括腹部肥胖的評估、減肥課程成效評估及國人使用減肥葯物的流行病學調查等。
腹部內臟脂肪越多發生心血管疾病和代謝性疾病的機會就越大，例如第二型糖尿病和高血壓等，磁振造影檢查是目前評估內臟脂肪最常用的方法，但是如何由腹部磁振照影的影像推估內臟脂肪體積，是一件費力、耗時的工作；本研究嘗試使用全自動電腦運算的方式，計算出內臟脂肪和皮下脂肪的體積，計算結果與使用人工計算的方式比較，相關性相當高（r值大於0.99），平均誤差小於3%，同時因為不需人力介入，因此再現性很高，可應用於大量公共衛生用途。
其次，目前國內醫療院所普遍開設減肥門診/減重班，而現行減重計畫，計畫參與者須在院方指定的時間到院，經由門診/飲食營養諮詢課程/有氧運動課程之系列性的行程實施配合，來執行此減重計畫；本研究藉助遠距醫療來交換相隔兩地之病患的醫療臨床資料及專家意見，以克服空間及時間的障礙。應用遠距醫療的概念，以及遠距學習計劃的設計與實施，配合減重計畫的療程，希望能夠證明網路減重班的成效，並藉此了解設置網路減重班的架構及限制條件。幫助一般民眾達到控制體重的成效，進而維持健康的身體及生活。實驗主要針對受測因子包含體重、BMI、體脂肪率、腰圍、臀圍等五項進行比較。三個月後，發現網路減重班的確能夠達到成效，而相關系統的設置均利用現行的資訊技術及視訊會議軟體，建置成本及技術門檻均屬相當普及的層次，有利於未來之改善及推展。
此外，於民國九十三年7月到九十四年6月進行另一項橫斷式調查，希望瞭解台灣民眾在尋求專業減肥之前使用減肥藥物的情形，經由隨機分層抽樣的方法，選取十八家專業減肥醫院或診所，並由這些門診挑選18歲以上的受訪者共1,060位，其中女性791位、男性269位，每位受訪者皆填寫完成一份問卷。統計發現這些受訪者使用減肥藥物的盛行率是50.8%，其中女性高於男性（53.6%比42.4%）。1,060位受訪者中，17.1% 曾經使用過orlistat、21.1%使用過sibutramine、18.3%使用過雞尾酒減肥療法或未經證實的減肥藥，此外23.6%受訪者指出在減肥期間合併使用中藥減肥、22.4%合併補充減肥健康食品。邏輯式回歸分析發現，女性、年齡介於18-24歲、BMI大於35、同時合併使用減肥中藥/健康食品的受訪者使用減肥藥物的機會較高。總而言之，台灣成年民眾在尋求專業減肥之前，使用減肥藥物的情形相當普遍，尤其是女性、超重和那些同時合併使用中藥及健康食品減肥的民眾；此外，相關單位對於未經證實的減肥藥物使用情形必須進一步了解。

Obesity is a major public health problem all over the world. Obesity is considered as a chronic disease with high morbidity and mortality. Thus studies that are focus on assessment and prevention for obesity are urgently needed. This dissertation is composed of three obesity-related studies, including assessment of visceral fat, Internet-based weight loss program and anti-obesity drug use survey in Taiwan.
Substantial evidence suggests that the volume and distribution of visceral abdominal adipose tissue (VAAT) plays a critical role in the pathogenesis of the metabolic syndrome. A high level of VAAT has been linked to cardiovascular and metabolic diseases, such as type 2 diabetes mellitus. The accurate measurement of the volumes of VAAT and total abdominal adipose tissue is often critical in metabolism and obesity-related researches and clinical applications. However, measuring the fat quantity and distribution in the abdomen by MRI is generally laborious. We propose a fully automated method that allows abdominal fat distribution to be analyzed in a short time without any user intervention. The results show that this method is accurate to within a few percent, as compared with manual analysis, in the assessment of subcutaneous and visceral abdominal fat. The percentage root mean squared errors of the method for SAAT and VAAT ranged from 1.0% and 2.7% for the four sequences. It took approximately 7 and 15 min to complete the 15-slice volume estimation of the three adipose tissue classes using automated and manual methods, respectively. The results demonstrate that the proposed method is robust and accurate. Although the separation of SAAT and VAAT is not always perfect, this method could be really helpful in dealing with large amounts of data, such as in epidemiological studies.
Secondary, in order to test the feasibility of administering a weight loss program through the Internet, a pre-post test design was used to compare changes in body weight, metabolic variables and attendance rate. Nine subjects lost an average 5.9 kg (6.0% of body weight, p < 0.001) over the course of the program. Total cholesterol level, AST and ALT were significantly decreased. Eight participants filled out the questionnaire after intervention. Overall, responders were satisfied with the protocol and considered the Internet weight loss program helpful to them. One technical problem was that Internet traffic jams could obstruct the stream of signal and lower the quality of audio and video. In summary, a weight loss program via the Internet with videoconferencing was feasible for obese Taiwanese, but further studies are needed using larger numbers of subjects.
The third study, between July 2004 and June 2005, a cross-sectional study was performed to determine the prevalence and patterns of anti-obesity medicine use among subjects seeking obesity treatment in Taiwan. Eighteen obesity outpatient clinics were selected via a random stratified sampling method and 1,060 first-visit clients (791 females and 269 males) aged above 18 years were enrolled and then completed a self-administered questionnaire. The prevalence of anti-obesity medicine use was 50.8%; more females than male used anti-obesity medicines (53.6% vs. 42.4%). Of the 1,060 subjects, 17.1% had used orlistat, 21.1% had taken sibutramine, and 18.3% had utilized unproven drugs such as cocktail therapy and other anti-obesity drugs. Furthermore, 23.6% and 22.4% of subjects indicated that they concurrently used Chinese herbal preparations and dietary supplements, respectively. Logistic regression analyses demonstrated that the odds ratio (OR) for anti-obesity medicine use was substantially higher in females (OR, 1.9; 95% CI, 1.3–2.6), those aged 18–24 years (OR, 1.6; 95% CI, 1.0–2.6), those with a body mass index (BMI) >35 kg/m2 (OR, 3.4; 95% CI, 2.1–5.7) and respondents concurrently using Chinese herbal preparations (OR, 1.7; 95% CI, 1.2–2.4) and dietary supplements (OR, 2.2; 95% CI, 1.6–3.1). In conclusion, the prevalence of anti-obesity drugs use is high among Taiwanese adults before they seek obesity treatment. Young, obese females, and those who had taken Chinese herbal preparations/dietary supplements had a high likelihood to report using anti-obesity medicines. Use of unproven weight-loss drugs is common and warrants further investigation.

中文摘要 1
Abstract 3
第一章 緒論 5
第二章 文獻探討 7
第一節 肥胖與健康之關係 7
第二節 肥胖症之診斷 7
第三節 肥胖症之治療 11
第三章 腹部肥胖與內臟脂肪的評估 18
第一節 研究目的 18
第二節 材料與方法 20
第三節 結果 25
第四節 討論 28
第五節 結論 29
第四章 以網際網路減重的成效評估 30
第一節 研究目的 30
第二節 材料與方法 32
第三節 結果 38
第四節 討論 41
第五節 結論 42
第五章 減肥藥物之藥物流行病學調查 44
第一節 相關文獻探討 44
第二節 研究目的 50
第三節 材料與方法 52
第四節 結果 54
第五節 討論 63
第六章 總結與建議 66
第一節 結論 66
第二節 建議 67
第七章 誌謝 68
參考文獻 69


附錄

附錄ㄧ 成人肥胖治療流程
附錄二 國人使用減肥葯物之流行病學調查問卷
附錄三 學位考試報告檔案
附錄四 Liou TH, Chan WP, Pan LC, Lin PW, Chou P, and Chen CH. Fully automated assessment of large-scale visceral and subcutaneous abdominal adipose tissue by magnetic resonance imaging. Int J Obes 2006;30:844-52
附錄五 Liou TH, Chen CH, Hsu CY, Chou P and Chiu HW. A pilot study of videoconferencing for an Internet-based weight loss programme for obese adults in Taiwan. J Telemed Telecare. 2006;12(7):370-3
附錄六 Liou TH, Wu CH, Chien HC, Lin WY, Lee WJ and Chou P. Anti-obesity medicine use among patients before seeking professional obesity treatment in Taiwan. Asia Pac J Clin Nutr. 2007 (in press)
附錄七 後記

表 目 錄
表一 世界衛生組織之定義 8
表二 世界衛生組織亞太地區和台灣肥胖之定義BMI(KG/M2) 9
表三 評估腹部脂肪方法的優缺點比較 11
表四 歷年來使用腹部磁振造影評估內臟脂肪的研究 19
表五 脂肪組織體積的推測值和誤差值 26
表六 網路減重課程設定的條件 34
表七 依據「LEARN」課程改編之十二週營養課程內容 37
表八 網路減重課程前後受試者身體體位測量及生化檢查的改變（N=9） 39
表九 受試者針對網路減重課程的問卷結果 (N = 8) 40
表十、美國食品藥物管理局公告禁止之減肥藥物 44
表十一 美國食品藥物管理局核准之減肥藥物 47
表十二 市面上常見宣稱具有減肥效果的非處方用藥和健康食品 49
表十三 受訪者基本資料 55
表十四 受訪者於一年內之減肥藥物使用率（百分比） 56
表十五 受訪者人口學分佈與減肥藥使用率（百分比）之關係 57
表十六 多項式邏輯回歸模式 59
表十七 受訪者減肥動機分析 60
表十八 各種減肥藥物與藥物不良反應之關係，以勝算比 (95%信賴區間)表示 61

圖 目 錄

圖一 如何計算腹部內臟及皮下脂肪的流程圖 21
圖二 以全自動計算方式分析腹部脂肪的方法 23
圖三 人工分辨皮下脂肪與內臟脂肪的方法 24
圖四 BLANT-ALTMAN圖 27
圖五 網路減重課程系統 33
圖六 網路減重課程基礎架構 35
圖七 BMI22記錄系統網站功能 36

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