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台灣版健康飲食評量指標(Alternate Healthy Eating Index

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台灣版健康飲食評量指標(Alternate Healthy Eating Index 臺北醫學大學 保健營養學系碩士論文 Master Thesis School of Nutrition and Health Sciences Taipei Medical University 台灣版健康飲食評量指標(Alternate Healthy Eating Index for Taiwan, AHEI-T)與第 2 型糖尿病之人體測量值、血糖、 血壓及血清脂質相關性探討 Association between Alternate Healthy Eating Index for Taiwan (AHEI-T) and anthropometry, blood sugar, blood pressure and serum lipid profile among type 2 diabetes mellitus patients 研究生：李永成 撰 (Weng-Seng Lei) 指導教授：楊淑惠 博士 (Shwu-Huey Sherry Yang Ph.D) 中華民國九十九年六月 June 2010 摘要 根據行政院衛生署於 2009 年公布的「2008 國人十大死因」資料 顯示，糖尿病位居於第五位，而其併發症如：心血管疾病、腦血管疾 病及腎臟疾病則分別位居於第二、三和十位。研究指出良好的飲食習 慣可以降低第 2 型糖尿病患者併發症的發生，飲食指標是一種評估飲 食品質的工具，替代健康飲食指標（Alternate Healthy Eating Index, AHEI）是其中一種評估工具，其與慢性疾病的發生之間存在著顯著 的負相關，本研究參考台灣每日飲食指南提出台灣版健康飲食評量指 標（Alternate Healthy Eating Index for Taiwan, AHEI-T）並用於評估第 2 型糖尿病之飲食。研究目的：針對第 2 型糖尿病患者，利用 AHEI-T 評估飲食品質，並探討 AHEI-T 與其人體測量值、血糖及血脂控制 良好之相關性。實驗設計與方法：本研究為一追蹤研究(Follow-up study)，受試者為 20 歲以上之第 2 型糖尿病患者，排除罹患肝硬化、 腎衰竭及癌症之患者。研究收集受試者的人體測量學資料、血糖值、 血壓值及血脂質值。利用 24 小時飲食回憶法進行收集飲食資料，以 台灣版健康飲食評量指標評估飲食。結果：實驗基準期共招募 196 位 第 2 型糖尿病患者，平均年齡為 62.1 ± 11.2 歲，每日熱量攝取為 1387 ± 463 大卡。受試者平均 AHEI-T 分數為 45.5 ± 10.2。經邏輯氏迴歸 分析發現， AHEI-T 只與餐後血糖控制良好的比率間具有顯著的正 I 相關。餐後血糖達到良好控制的百分比經年齡、性別及熱量校正的勝 算比得，AHEI-T 分數的最高分位較最低分位，OR 為 3.38，顯示 AHEI-T 分數較高的第 2 型糖尿病患者有較高的 PC-sugar 達標率。 追蹤到第 6 個月後剩下 113 位受試者完成 24 小時飲食回憶法，比較 受試者前後飲食差異、AHEI-T 及 AHEI 分數均沒有顯著變化，利用 基準期的 AHEI-T 分數之中位數（AHEI-T 分數：47.0）區分出 AHEI-T 高分組（AHEI-T 分數 ≥ 47.0）及 AHEI-T 低分組（AHEI-T 分數 < 47.0），比較組別間受試者人體測量值、血糖、血壓及血脂質值之變 化則得，AHEI-T 高分組較 AHEI-T 低分組於餐後血糖、三酸甘油酯、 高密度脂蛋白膽固醇、三酸甘油酯與高密度脂蛋白膽固醇比及低密度 脂蛋白膽固醇與高密度脂蛋白膽固醇比均有顯著改善的情形。結論： 針對第 2 型糖尿病患者的研究顯示：利用 AHEI-T 評估其飲食， AHEI-T 與餐後血糖達到良好控制的比率具有顯著正相關。而 3 個月 及 6 個月的追蹤實驗則證實 AHEI-T 分數較高的受試者於餐後血糖及 血脂質皆有改善。 關鍵詞：飲食指標、替代健康飲食指標、台灣版健康飲食評量指標、 第 2 型糖尿病 II Abstract According to the 2008 top ten leading death in Taiwan which reported by Department of Health, Executive Yuan. R.O.C. Diabetes was the fifth and its complications as heart disease, cerebrovascular disease and kidney disease were second, third and tenth respectively. A good dietary habit might reduce onset of complications in type 2 diabetes patients. Diet index is a tool to assess diet quality. Alternate Healthy Eating Index (AHEI) is one of them and had been found associated to the incidence of chronic disease negatively. We provided Alternate Healthy Eating Index for Taiwan (AHEI-T) according to the Taiwan daily dietary guidelines to assess dietary of type 2 DM patients. Aim: To investigate the association between AHEI-T and good control of glycemic and lipid profile among type 2 DM patients. Study design: This was a cross-sectional and follow-up study. Participants were type 2 DM patients with over 20 years old. The following data were collected including: Anthropometric data, glycemic, blood pressure and lipid profile. Dietary data were collected used 24h dietary recall. AHEI-T was analyzed after that. Values are expressed as N, percentage or Mean ± SD. SAS 9.1 was used to perform data analysis, correlation test, regression, odds ratio and two-way repeated measures ANOVA were used, when p < 0.05 was considered as significant. Result: There were totally 196 type 2 DM patients involved. They were 62.1 ± 11.2 years old and daily intake was 1387 ± 463 kcal. For AHEI-T score, they got 45.5 ± 10.2 and found it was positively associated to the good control of PC-sugar after logistic regression analysis. AHEI-T score was then divided into quartiles for III calculating odds ratio. We found that good control of PC-sugar was found positively associated to AHEI-T score (Q4 vs Q1) under age, sex and energy adjusted model with an odds ratio = 3.38. It showed the higher AHEI-T score, the higher rate of good control in PC-sugar. Finally, there were 113 paticipants finished 24h dietary recall after 6 months follow-up. There were no significant differenet in dietary data, AHEI-T score and AHEI score between baseline and 6 months. We separated paticipants into 2 groups (High AHEI-T score: AHEI-T score ≥ 47.0; Low AHEI-T score: AHEI-T score < 47.0) according to the median of AHEI-T score (AHEI-T score = 47.0) found in the baseline of this study in order to compared difference in anthropometric, glycemic, blood pressure and lipid profile between baseline, 3 months and 6 months follow-up. High AHEI-T score group was found improved in PC-sugar, TG, HDL-C, TG/HDL-C and LDL-C/HDL-C compared to Low AHEI-T score group during 6 months of follow-up. Conclusion: For the type 2 diabetes patients, baseline data showed AHEI-T score was positively associated to good control of PC-sugar; 3 and 6 months follow-up study found High AHEI-T score group had improved in glycemic and lipid profile compared to Low AHEI-T score group. Keywords: diet index, Alternate Healthy Eating Index, Alternate Healthy Eating Index for Taiwan, Type 2 diabetes mellitus IV 致謝 來台灣唸書，是因為受了大哥永恒的影響，而攻讀營養則是高中 時的突發奇想，當初只想到為身邊的眾人盡一分力，幫助大家過一個 健康美滿的人生，因為我高興看到大家快樂的樣子，大家的微笑變成 了我動力的來源。 我常常想，要不是大學二年級遇上了我一生中最重要的好老 師 – 楊淑惠老師，我的人生又會怎樣？楊老師不同於別的老師，她 讓學生有發揮的空間，但不忘叮嚀學生要勤奮努力，不斷的進步，無 時無刻提醒著我＂沒有最好，只有更好＂的做事態度。在老師身上， 我不但學到了實驗的技巧，更重要的是邏輯思考的能力，她要求學生 要先思考問題後尋求答案，要培養出獨立思考的能力，這無疑是投身 社會最重要的一種特質。還有更多……這一切一切使我不懼投身社會 工作，因為我已經準備好了！老師，謝謝你！ 另外，還有一位老師需要特別感謝，那就是鄭心嫻老師，坦白說 碩士二年我一直覺得自己很委屈，明明是準備的很充分，卻每次都被 重重的擊倒，有好幾次想過要放棄，卻又不甘心的爬起來，過程雖然 十分艱苦，但卻練就了一種不屈不撓的精神。這一切都得歸功於鄭老 師的地獄式訓練！老師，謝謝你！ 也謝謝我的口試委員曾明淑老師，依循著曾老師的獨特見解，讓 V 論文內容得以在思考完整的情況下開始，並嚴緊的考慮數據中的干擾 因子，這都大大增加了實驗結果的可信性。 感謝過程中幫助我的各位，特別感謝盧義發教授願意提供反式脂 肪酸的資料作分析用途；感謝施純光老師於 Meeting 時的提問及建 議，讓我可以提早發現問題並尋求解決之道；感謝北醫附設醫院黃千 鈴醫師及家婕護士於收案時的配合並提供實驗討論的方向；感謝大 Meeting 時大家提供多方面的建議，璻薇學姐、素珍學姐、佳蓉、明 萱、小可，謝謝你們的指教，十分感恩；感謝實驗室中的眾人，佩瑜 學姐、宛禎、斯涵、菊、曉慧及大學部的學弟妹，乙玄、士超、雅琪、 湘君、子嫻、家俊，謝謝您們的幫助以及對於實驗室的付出。 感謝在實驗室陪伴我每週七天的嘉文學長，曾問過你，為什麼週 末還要來實驗室，你說，實驗室就像是自己家裏一樣，應有儘有，更 重要的是有 study 的氣氛，若留在家裏則只會渾渾噩噩，無所事事。 所以接下來的 1 年我們都在實驗室出雙入對，害得大家以為我們有超 友誼的關係，每天還得忙著澄清，辛苦你了，感謝你這 1 年的陪伴， 讓我有勇氣一直走下去！ 感謝在澳門默默給予我支持的家人，尤其是媽媽，我終於可以學 成歸來，好好的在妳身邊盡孝了！ VI 內容目次 頁碼 摘要 I 英文摘要 III 致謝 V 內容目次 VII 附表目次 X 附圖目次 XIII 附錄目次 XIV 第一章 緒論 1 第二章 文獻回顧 2 第一節 糖尿病的盛行率 2 第二節 糖尿病 2 第三節 糖尿病的併發症 3 第四節 糖尿病的治療 5 第五節 糖尿病的飲食建議 6 第六節 飲食指標 9 第七節 HEI、AHEI 及 AHEI-T 10 第八節 飲食調查法 19 VII 內容目次（續） 頁碼 第三章 研究目的 23 第四章 材料與方法 24 第一節 研究設計 24 第二節 受試者條件、研究流程及收案流程 25 第三節 研究方法 28 第四節 統計分析 40 第五章 結果 41 第一節 資料收集 41 第二節 24 小時飲食回憶法的效度分析 41 第三節 受試者基本資料 44 第四節 比較 AHEI-T 與 AHEI 52 第五節 AHEI-T 與受試者資料的相關性分析 56 第六節 AHEI-T 分數四分位的迴歸分析 61 第七節 根據 ADA 對於血糖、血壓及血脂質的建議達標 率之迴歸分析及多因子調整後的勝算比 65 第八節 比較受試者資料在基準期與 3 個月及 6 個月的資 料 70 VIII 內容目次（續） 頁碼 第六章 討論 81 第一節 24 小時飲食回憶法的效度分析 81 第二節 血糖值、血壓值及血脂值 82 第三節 AHEI-T 與 AHEI 的比較 84 第四節 AHEI-T 與血糖值、血壓值及血脂值 86 第五節 研究限制 89 第六節 研究優勢 90 第七章 結論及建議 91 第八章 參考文獻 92 第一節 中文文獻 92 第二節 英文文獻 94 第九章 附錄 103 IX 附表目次 頁碼 表 1. HEI 與 AHEI 之項目組成和計分方式 14 表 2. AHEI-T 及 AHEI 其內容及評分方式 18 表 3. AHEI-T 與對於第 2 型糖尿病的飲食建議內容 20 表 4. 24 小時飲食回憶法與 3 天飲食記錄其熱量、巨量營養 素、食物類別、膳食纖維、反式脂肪酸的斯皮爾曼等 級相關分析 42 表 5. 24 小時飲食回憶法與 3 天飲食記錄其熱量、巨量營養 素、食物類別、膳食纖維及反式脂肪酸三分位中的 一致性檢定 (n = 76) 44 表 6. 受試者的基礎資料及人體測量值 47 表 7. 受試者的飲食資料分析 47 表 8. 受試者的 AHEI-T 分數、其項目及計分標準 49 表 9. 受試者的血糖、血壓及血脂，以及根據 ADA 的建議 判斷為控制 良好的百分比 50 表 10. 比較 AHEI-T 與 AHEI 分數上的差異 55 表 11. AHEI-T 及 AHEI 與飲食資料的相關性分析 57 X 附表目次（續） 頁碼 表 12. AHEI-T 分數與受試者基礎資料及人體測量值的斯皮爾 曼等級 相關分析 59 表 13. AHEI-T 分數與飲食資料及 AHEI 的斯皮爾曼等級相 關分析 59 表 14. AHEI-T 分數與血糖、血壓及血脂的斯皮爾曼等級相 關分析 60 表 15. AHEI-T 分數與符合 ADA 建議達到良好控制的血糖 、血壓及血脂百分率的斯皮爾曼等級相關分析 60 表 16. 利用 AHEI-T 分數作四分位後，受試者的基礎資料及 人體測量值 62 表 17. 利用 AHEI-T 分數作四分位後，受試者的飲食資料 63 表 18. 利用 AHEI-T 分數作四分位後，受試者的血糖值、血 壓值及血脂值 64 表 19. 利用 AHEI-T 分數作四分位後，根據 ADA 建議下血糖 達到良好控制的各分位間勝算比的分析 67 表 20. 利用 AHEI-T 分數作四分位後，根據 ADA 建議下血壓 達到良好控制的各分位間勝算比的分析 68 XI 附表目次（續） 頁碼 表 21. 利用 AHEI-T 分數作四分位後，根據 ADA 建議下血脂 達到良好控制的各分位間勝算比的分析 69 表 22. 受試者運動量及 24 小時飲食回憶法內容的基準期與 6 個月後的數據之比較 (n = 113) 71 表 23. 基準期及六個月後的 AHEI-T 及 AHEI 分數及其組成 項目的比較 73 表 24. 比較 AHEI-T 高分組與 AHEI-T 低分組其活動量及人體 測量值於基準期、三個月及六個月的追蹤期間的變化 78 表 25. 比較 AHEI-T 高分組與 AHEI-T 低分組其血糖值及血壓 值於基準期、三個月及六個月的追蹤期間的變化 79 表 26. 比較 AHEI-T 高分組與低分組之血脂值於基準期、三個 月及六個月的追蹤期間的變化 80 XII 附圖目次 頁碼 圖 1. 研究設計 24 圖 2. 研究流程 27 圖 3. 收案流程 28 圖 4. 第 2 型糖尿病患者其糖化血色素的分佈 (n = 196) 51 圖 5. 以性別區分的 AHEI-T 及 AHEI 的分數分佈 53 XIII 附錄目次 頁碼 附錄 1. ADA 在 2008 年提出對於糖尿病的飲食建議 103 附錄 2. 中華民國糖尿病衛教學會（Taiwanese Association of Diabetes Educators, TADE）提出的健康飲食金字塔 106 附錄 3. 中華民國糖尿病衛教學會（Taiwanese Association of Diabetes Educators, TADE）提出的健康飲食原則 107 附錄 4. 人體試驗同意書 108 附錄 5. 運動量表 109 附錄 6. 台灣常見食品營養圖鑑 110 附錄 7. 標準容量器具 110 附錄 8. 收案及 24 小時飲食回憶法記錄單 111 附錄 9. 追蹤及 24 小時飲食回憶法記錄單 112 附錄 10. 3 天飲食記錄本 113 附錄 11. 3 天飲食記錄範例 114 附錄 12. 酒精含量（份） 114 附錄 13. 全部變項的常態性檢定 115 附錄 14. AHEI-T 及 AHEI 中各變項的常態性檢定 116 附錄 15. 基礎值及第 6 個月的飲食資料常態性檢定 117 XIV 附錄目次（續） 頁碼 附錄 16. 基礎值及第 6 個月的 AHEI-T 及 AHEI 中各變項 的常態性檢定 118 附錄 17. 低昇糖指數（Glycemic index）飲食金字塔 119 XV 第一章 緒論 根據行政院衛生署於 2009 年公布的「2008 國人十大死因」資料 顯示，糖尿病位居於第五位，而與其相關的併發症如：心血管疾病、 腦血管疾病及腎臟疾病則分別位居於第二、三和十位（行政院衛生 署，2009）。Funnell（1992）指出，良好的飲食控制可降低≧ 50%第 2 型糖尿病患者發生併發症的機率（Funnell et al., 1992）。 飲食指標是一種整合大量營養資訊所形成的單一有效指標 （Kennedy et al., 1995），藉由指標將營養資訊量化並以分數呈現，提 供評估者（臨床營養工作者）做快速的整體飲食品質評估（Hu, 2002）。關於飲食指標的研究大部份都是針對健康飲食（McCullough et al., 2002）與健康的維持（McNaughton et al., 2008）作探討，很少有 研究討論以飲食指標評估糖尿病患者的飲食品質與其健康的相關性 （Fung et al., 2007）。因此本次的研究動機為擬利用替代健康飲食指 標（Alternate Healthy Eating Index for Taiwan, AHEI-T）評估第 2 型糖 尿病患者的飲食，並探討 AHEI-T 對於糖尿病患之健康狀況（人體測 量值、血糖、血壓及血脂質）的關係。 1 第二章 文獻回顧 第一節 糖尿病的盛行率 2001年，Zimmet 等推估2010年全球糖尿病的盛行率將會由2000 年的1.58億上升至2.21億，增加達46%，其中以亞洲地區的成長速度 最 快，預 計 在 2010年將會由2000年的0.85億上升至1.32億，增加達53% （Zimmet et al., 2001）。我國行政院衛生署在2005-2008年間的國民營 養健康狀況變遷調查研究指出糖尿病在台灣的盛行率，男性約 11.6%；女性約8.4%；平約達9.2%，比2003年國民健康局的三高﹙高 血糖、高血脂與高血壓﹚調查﹙國民健康局，2003﹚上升約3%（行 政院衛生署，2009）。 第二節 糖尿病 美國糖尿病協會（American Diabetes Assocaition, ADA）提出糖尿 病是一種慢性疾病，需要持續的醫療照護來預防急性或慢性併發症的 發生（ADA, 2009）。糖尿病的發生是由於缺乏胰島素的分泌或細胞 對於胰島素的敏感性不良，促使細胞對於葡萄糖的利用下降，最後導 致高血糖、高血脂高血壓及蛋白質代謝異常等症狀（Franz, 2004）。 一、糖尿病的診斷標準為（ADA, 2009）： 1.空腹≥ 8 小時後血糖值≥ 126 mg/dL。 2 2.任一時間血糖值≥
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