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研究生:盧卡思
研究生(外文):Adi Lukas Kurniawan
論文名稱:台灣中老年人飲食模式與腎臟功能障礙之關聯:2008年至2010年的橫斷研究
論文名稱(外文):Dietary patterns in relation with impaired kidney function outcomes amongmiddle-aged and elderly in Taiwan: A cross-sectional study from 2008 to2010
指導教授:趙振瑞趙振瑞引用關係
指導教授(外文):Jane C-J Chao
口試委員:徐建業劉沁瑜黃士懿白其卉
口試委員(外文):Chien-Yeh HsuChinyu LiuShih-Yi HuangChyi-Huey Bai
口試日期:2020-06-22
學位類別:博士
校院名稱:臺北醫學大學
系所名稱:保健營養學研究所
學門:醫藥衛生學門
學類:營養學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:英文
論文頁數:125
中文關鍵詞:飲食模式腎功能睾丸激素心血管疾病危險因素血脂異常貧血主成分分析回歸回歸
外文關鍵詞:dietary patternkidney functiontestosteronecardiovascular risk factorsdyslipidemiaanemiaprincipal component analysisreduced rank regression
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Objective: Chronic Kidney Disease (CKD), characterized by impaired kidney function, affects over 1.5 million individuals in Taiwan. Low testosterone levels, cardiovascular disease (CVD), dyslipidemia, anemia, and low-grade inflammation are commonly found in impaired kidney function CKD subjects. Since diet plays an important role in the development of the outcomes of CKD aforementioned, our study was designed to investigate the association of dietary patterns with testosterone levels, cardiovascular risk factors, dyslipidemia, anemia, and the severity of impaired kidney function in middle-aged and older adults in Taiwan.
Methods: 41,128 participants aged more than 40 years old with an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2 and positive urinary protein were recruited from Mei Jau Health Institute between 2008 and 2010. The dietary patterns were identified using principal component analysis (PCA) and reduced rank regression (RRR) method was used to determine the kidney function-, inflammatory-, and metabolic syndrome (MetS) - related dietary pattern. A multivariable linear regression analysis was used to identify the association between dietary patterns derived by PCA with testosterone levels and kidney function biomarkers. While, a multivariable logistic regression analysis was used to identify the association between dietary pattern derived by RRR with the severity of impaired kidney function, cardiovascular risk factors, dyslipidemia, anemia, and MetS components.
Results: Males with higher tertile of fried-processed dietary pattern score was associated with decreased testosterone levels by 0.8 nmol/L (95% CI: -1.40, -0.16), reduced testosterone-to-TG (T/TG) ratio by 1.8 units (95% CI: -2.99, -0.53), and increased risk of moderate/severe decline in kidney function (eGFR < 60 mL/min/1.73 m2) by 1.35 (95% CI: 1.15, 1.58). The kidney function-related dietary pattern characterized by frequent intakes of preserved or processed food, meats and organ meats, rice and flour products, and low intakes of fruit, dark-colored vegetables, bread, and legumes or beans. In both genders, high adherence of dietary score was correlated with 2.07 times (95% CI 1.89–2.27) risk of obese weight status, 10 to 31% risk of cardiovascular risk, and 1.15 times (95% CI 1.02–1.29) risk of moderately or severely impaired kidney function. The higher adherence of inflammatory dietary pattern (low intakes of seafood, grains, vegetables, and fruit but frequent intakes of meats, eggs, preserved or processed food, and sweet drinks) was associated with increased 21% risk of dyslipidemia in males and increased 35% - 47% risk of anemia in both genders. There was an association between high consumption of inflammatory dietary pattern with reducing eGFR (males and females; β = -0.85 and -0.53, p < 0.05 respectively) and increased CRP level and/or neutrophil-to-lymphocyte (N/L) ratio in both genders. Moreover, compared with PCA method, RRR shows stronger statistical associations with MetS.
Conclusion: Our findings suggest that high intakes of processed and animal foods and low intake of seafood and plant foods predict the risk for developing hypogonadism, cardiovascular disease, dyslipidemia, anemia, and rapid kidney function decline.
Objective: Chronic Kidney Disease (CKD), characterized by impaired kidney function, affects over 1.5 million individuals in Taiwan. Low testosterone levels, cardiovascular disease (CVD), dyslipidemia, anemia, and low-grade inflammation are commonly found in impaired kidney function CKD subjects. Since diet plays an important role in the development of the outcomes of CKD aforementioned, our study was designed to investigate the association of dietary patterns with testosterone levels, cardiovascular risk factors, dyslipidemia, anemia, and the severity of impaired kidney function in middle-aged and older adults in Taiwan.
Methods: 41,128 participants aged more than 40 years old with an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2 and positive urinary protein were recruited from Mei Jau Health Institute between 2008 and 2010. The dietary patterns were identified using principal component analysis (PCA) and reduced rank regression (RRR) method was used to determine the kidney function-, inflammatory-, and metabolic syndrome (MetS) - related dietary pattern. A multivariable linear regression analysis was used to identify the association between dietary patterns derived by PCA with testosterone levels and kidney function biomarkers. While, a multivariable logistic regression analysis was used to identify the association between dietary pattern derived by RRR with the severity of impaired kidney function, cardiovascular risk factors, dyslipidemia, anemia, and MetS components.
Results: Males with higher tertile of fried-processed dietary pattern score was associated with decreased testosterone levels by 0.8 nmol/L (95% CI: -1.40, -0.16), reduced testosterone-to-TG (T/TG) ratio by 1.8 units (95% CI: -2.99, -0.53), and increased risk of moderate/severe decline in kidney function (eGFR < 60 mL/min/1.73 m2) by 1.35 (95% CI: 1.15, 1.58). The kidney function-related dietary pattern characterized by frequent intakes of preserved or processed food, meats and organ meats, rice and flour products, and low intakes of fruit, dark-colored vegetables, bread, and legumes or beans. In both genders, high adherence of dietary score was correlated with 2.07 times (95% CI 1.89–2.27) risk of obese weight status, 10 to 31% risk of cardiovascular risk, and 1.15 times (95% CI 1.02–1.29) risk of moderately or severely impaired kidney function. The higher adherence of inflammatory dietary pattern (low intakes of seafood, grains, vegetables, and fruit but frequent intakes of meats, eggs, preserved or processed food, and sweet drinks) was associated with increased 21% risk of dyslipidemia in males and increased 35% - 47% risk of anemia in both genders. There was an association between high consumption of inflammatory dietary pattern with reducing eGFR (males and females; β = -0.85 and -0.53, p < 0.05 respectively) and increased CRP level and/or neutrophil-to-lymphocyte (N/L) ratio in both genders. Moreover, compared with PCA method, RRR shows stronger statistical associations with MetS.
Conclusion: Our findings suggest that high intakes of processed and animal foods and low intake of seafood and plant foods predict the risk for developing hypogonadism, cardiovascular disease, dyslipidemia, anemia, and rapid kidney function decline.
Contents
Abstract i
Acknowledgment ii
Contents iii
Figure Contents v
Table Contents vi
List of Abbreviations vii
Chapter 1. Introduction and Purposes 1
Chapter 2. Literature Review 4
2.1 Overview of Chronic Kidney Disease (CKD) 4
2.1.1 Epidemiology of CKD 4
2.1.2 Risk factors and outcomes of CKD 5
2.1.3 CKD development, progression, and diagnosis 12
2.2 Dietary patterns and CKD 16
2.2.1 Dietary patterns identification methods 16
2.2.2 Diet and impaired kidney function 21
2.3 Overview of testosterone 23
2.3.1 Hormonal regulation of testosterone 23
2.3.2 Association between testosterone and CKD 24
2.4 Overview of anemia 27
2.4.1 Anemia in relation with CKD 27
Chapter 3. Methods 30
3.1 Data source 30
3.2 Study subjects 30
3.3 Clinical and biochemical data 31
3.4 Dietary assessment and other covariates 34
3.5 Statistical analysis 35
Chapter 4. First Paper 40
4.1 Characteristic of the subjects 40
4.2 Dietary patterns 42
4.3 Testosterone and kidney function 44
4.4 Dietary patterns, testosterone levels, and severity of decreased kidney function 46
Chapter 5. Second Paper 50
5.1 Characteristics of the participants 50
5.2 Weight status and cardiovascular risk factors in relation to the severity of impaired kidney function 52
5.3 Dietary pattern in relation to weight status, cardiovascular risk factors, and the severity of impaired kidney function 53
Chapter 6. Third Paper 59
6.1 Characteristics of the study participants 59
6.2 Inflammatory-related dietary pattern and characteristics across quartiles of dietary pattern scores 61
6.3 Association of inflammatory-related dietary pattern with dyslipidemia, anemia, and kidney function markers 67
Chapter 7. Fourth Paper 73
7.1 Characteristics of the participants 73
7.2 Dietary patterns analysis 77
7.3 Association between dietary patterns and metabolic syndrome 78
Chapter 8. Discussion 85
Chapter 9. Conclusion 101
References 102
Supplementary 114



Figure Contents
Figure 1. Schematic diagram to summarize the purposes of the study 3
Figure 2. Pathophysiological interactions between kidney and heart in chronic kidney disease. 11
Figure 3. Prognosis of CKD by GFT and albuminuria categories. 16
Figure 4. Major gonadal pathways for testosterone biosynthesis 24
Figure 5. Schematic diagram of low testosterone levels in CKD 27
Figure 6. Schematic figure of the mechanism-underlying anemia in CKD 29
Figure 7. The kidney function-related dietary pattern derived from the RRR method. 39
Figure 8. The inflammatory-related dietary pattern derived from the RRR method. 39
Figure 9. Scheme of metabolic syndrome dietary pattern scores derived from the RRR method. 39
Figure 10. Multivariable logistic regression analysis for predicting the progression of mild to moderate/severe decreased kidney function, and proteinuria severity. 49
Figure 11. Radar chart of factor loadings of dietary pattern scores identified by RRR methods. 54
Figure 12. Radar chart of factor loadings of inflammatory-related dietary pattern identified by the RRR method. 62
Figure 13. Radar chart of Pearson’s correlation coefficients between food groups and two dietary patterns derived by principal component analysis (—) and reduced rank regression (---). 78
Figure 14. Schematic diagram to summarize the study results 85


Table Contents
Table 1. The relationship among categories for albuminuria and proteinuria 13
Table 2. GFR categories in CKD 15
Table 3. Strengths and limitations of approaches to measuring dietary patterns 20
Table 4. Studies of diet and effect on impaired kidney function 21
Table 5. Characteristics of the subjects across tertiles of eGFR, n = 21,376 a 40
Table 6. Factor loadings of three dietary patterns identified by principal component analysis a 43
Table 7. Multivariable linear regression analysis of independent variables affecting blood testosterone levels (nmol/L), n = 256 45
Table 8. Multivariable linear regression analysis of across tertiles of dietary pattern scores associated with blood testosterone and kidney function biomarkers a 47
Table 9. Characteristics of the participants across the severity of impaired kidney function 50
Table 10. Multivariable logistic regression of weight status and cardiovascular risk factors for moderately/severely impaired kidney function 52
Table 11. Characteristics of participants across tertiles of dietary pattern scores a 54
Table 12. The association of dietary pattern scores with weight status, cardiovascular risk factors, and the severity of impaired kidney function (n = 41,128) a 57
Table 13. Characteristics of the study participants (n = 41,128) a 59
Table 14. Characteristics of the participants by quartiles of dietary pattern score a 64
Table 15. Association between quartile of dietary pattern score with dyslipidemia 67
Table 16. Association between quartile of dietary pattern score with anemia 68
Table 17. Linear association between quartiles of dietary pattern score with anemia, lipid, inflammatory and kidney function biomarker 70
Table 18. Characteristics of the participants by MetS status (n = 25,569)* 74
Table 19. Association of dietary patterns derived by PCA or RRR with MetS across quartiles (Q) of dietary pattern scores* 80
Table 20. Association of dietary patterns derived by PCA with components of MetS across quartiles (Q) of dietary pattern scores* 81
Table 21. Association of dietary patterns derived by RRR with components of MetS across quartiles (Q) of dietary pattern scores* 83
Table 22. Studies of diet and effect on low testosterone levels 89
Table 23. Studies of diet and effect on kidney function, inflammation, weight status, and cardiovascular risk factors 91
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