Transcript Body Mass index (BMI)

Obesity
C 組柯媛薰 陳佳欣 紀怡如 林冠伶 林宛萱
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Body Mass index (BMI) and
Guidelines for Weight classes
Metric Conversion Formula Using Kilograms and
Meters
BMI= Weight in Kilograms
Height in meters2
Nonmetric Conversion Formula Using Pounds and
Inches
BMI= Weight in Pounds × 703
Height in inches2
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成人肥胖定義
身體質量指數(BMI)
(kg/m2)
體重過輕
BMI ＜ 18.5
正常範圍
18.5≦BMI＜24
異常範圍
過重：24≦BMI＜27
輕度肥胖：27≦BMI＜
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中度肥胖：30≦BMI＜
35
重度肥胖：BMI≧35
腰圍
(cm)
男性：≧90公
分
女性：≧80公
分
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Epidemiology
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Etiology and pathophysiology
• There are many possible causes for obesity such as
genetic predisposition, disturbances of hunger and
satiety centers in the brain, endocrine
abnormalities, environmental and cultural
influences, socioeconomic status, medical
conditions such as hypothyroidism, medications
that stimulate appetite, and inactivity.
• Obese individuals tend to have more restrained
eating (dieting with chronic caloric restriction) and
lower levels of activity compared with persons with
normal weight.
• This behavior can lead to lowered basal metabolic
rates, less energy expenditure, and increased
weight gain secondary to periodic overeating and
binge eating.
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• Normally when a person has eaten an adequate
amount of food, neurotransmitters or peptides in
the brain signal the satiety centers in the
hypothalamus and there is a reduced desire to eat.
• When the “starving” person begins to eat, the
brain neurotransmitters (e.g.,serotonin) that
normally turn off appetite may fail to work; thus,
the person eats excessive amounts of food.
• Individuals with mental illness are especially prone
to development of medical conditions including
obesity. Psychotropic medications including
chlorpromazine, clozapine, and olanzapine cause
significant weight gain.
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危險因子：
• 抽菸
• 高血壓
• 低密度脂蛋白膽固≧160mg/dl
• 高密度脂蛋白膽固醇＜40mg/dl
• 三酸甘油脂≧200 mg/dl
• 空腹血糖不良(110mg/dl≦空腹血糖＜126mg/dl)
• 早發性冠狀動脈硬化心臟病之家族史
• 男性≧45歲，女性≧55歲
合併症：
• 高血壓
• 血脂異常
• 糖尿病
• 冠心症
• 睡眠呼吸中斷症
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Antipsychotic-induced Weight Gain: A comprehensive Research Synthesis Am J Psychiatry 1999; 156: 16861696
Among the newer agents, clozapine appears to have the greatest
potential to induce weight gain, and ziprasidone the least.
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Strategies for Management of
Drug-Induced Weight Gain
• Monitor patients who are predisposed to
overweight and obesity when new therapy is
initiated
• Avoid drugs that commonly cause weight gain ≥7%
of baseline weight in predisposed individuals
• When therapy cannot be switched to an alternative
agent for therapeutic reasons, patients to reduce
their energy intake and increase daily exercise
• Use the lowest possible dose; if weight gain occurs,
consider lowering the dose and/or combining with
another agent known to be weight neutral or cause
weight loss
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Strategies for Management of
Drug-Induced Weight Gain
• Consider starting adjunctive therapy with weight
loss agent, such as sibutramine or orlistat, where
appropriate
• Counsel patients that the drug may cause weight
gain, as this may adversely affect their adherence
• Develop a plan with the patient of what to do if
weight gain occurs, how much weight gain to
expect, when to intervene, and what the
intervention will be
• Consider weight gain as an adverse effect to be
taken into account when designing a therapeutic
regimen
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Drug therapy of
obesity
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Weight Loss Medication
1. Reduce energy intake( appetite
suppressant)
2. Increase energy
expenditure( increase metabolism)
3. Reduce absorption of nutrients and
fat
4. Stimulate fat mobilization
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Amphetamines
• Amphetamines
- appetite-suppressant effectin in the
1950s and 1960s
- mechanism :increase in norepinephrine
and dopamine release form nerve
terminals, leading to an activation of
the hypothalamic feeding center
ultimately suppressing appetite
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Amphetamines
• Amphetamines
-下市原因:because of their euphoric
properties amd risks of drug abuse
-目前是 schedule 2 controlled agent
- 停藥後會產生的症狀:rebound binge
eating,
Weight gain, lethargy, and depression.
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Sympathomimetics
•
-
Ephedrine
Found in ephedra and ma huang
mechanism : increase energy expenditure
In 1997,FDA recommended limitations on
ephedrine-containing dietary supplement due
to many adverse effects( Ex: stroke,
seizure, and death)
- In 2004 April, FDA has prohibited the sale
of dietary supplement containing ephedrine
alkaloids ( ephedra)
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Sympathomimetics
• Phenylpropanolamine (PPA)
- mechanism :stimulate norepinephrine
and dopamine release in the
hypothalamic feeding center
- 在2000年主動下市
- 下市原因:because PPA may increase
risk of hemorrhagic stroke in women
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Serotonin-releasing
agents
• Fenfluramine
- mechanism : stimulate serotonin
release into neuronal synapses to
increase serotonin activity.
- Fenfluramine+phentermine( fen-phen)
had similar weight loss as
monotheraphy but combination
resulted in fewer cardiovascular and
CNS adverse effects.
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Serotonin-releasing
agents
• Fenfluramine
- in 1997, Fenfluramine were removed
from United States market.
- 下市原因: because Fenfluramine may
result in valvular heart disease and
primary pulmonary hypertension.
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Serotonin/Norepinephrine
Reuptake Inhibitors
• Sibutramine (Meridia® (USA), Reductil®
(other countries) ) 諾美婷
- mechanism :
(1) inhibit the reuptake of serotonin and
norepinephrine and, to a less extent
dopamine ,therefore increase concentration
of these neurotransmitters in the brain.
This promotes a sense of satiety and thus
decrease appetite.
(2)Increase metabolic rate in brown adipose
(thermogenesis to increase glucose
utilization.)
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Sibutramine ( Meridia ®)
諾美婷
• Adverse effect: headache, decrease
appetite, dry month, constipation,
insomnia
• Other less common side effect:
sweating,
excitation, irritability, dizziness,
increases in blood pressure and heart
rate( dose-related)
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Sibutramine ( Meridia ®)
諾美婷
• 藥動學
-absorption: well absorption
-metabolism: has high first-pass liver
metabolism to produce two active
metabolites, both with long
elimination half-lives of 14 to 16
hours.
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Sibutramine ( Meridia ®)
諾美婷
• 藥動學
• drug –drug interaction:
- drugs that inhibit liver
enzymes(CYP450 3A4), such as
ketoconazole and erythromycin
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Sibutramine ( Meridia ®)
諾美婷
• 用法用量
- Initial dose is 10 mg once daily with
or without food typcally in the
morning and the dose can be incresed
to 15mg once daily if needed. A 5mg
dose is available for patient who do
not tolerate the recommended
starting dose.
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®)
Sibutramine ( Meridia
諾美婷
• 下列病人不建議使用Sibutramine:
patients with heart disease,
congestive failure, conduction
disorders (arrhythmias), stroke
• 下列病人禁用Sibutramine:patients
taking certain CNS medications that
increse levels of norepinephrine or
serotonin ( e.g: MAOIs) and other
centrally acting appetite
suppressaNTS.
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®)
Sibutramine ( Meridia
諾美婷
• In a multicenter
dose-ranging trial,
1047 patients were randomly assigned
to receive placebo or 1, 5, 10, 15, 20,
or 30 mg of sibutramine daily for six
months There was a clear dose
response; the placebo group lost 1
percent of their initial body weight,
whereas the subjects in the 30-mg
sibutramine per day group lost 9.5
percent
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Sibutramine ( Meridia) 諾美婷
2.Continuous V.S Intermittent
• In a 48-week trial 1001 obese adults were
randomly assigned to receive sibutramine (15
mg/day) continuously or intermittently
(weeks 1 to 12, 19 to 30, 37 to 48, with
placebo during other weeks) as compared with
continuous placebo. Weight loss was similar
in both sibutramine groups, and significantly
more than in the placebo group. Safety
profiles were similar in both sibutramine
groups
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Sibutramine ( Meridia ®) 諾美婷
3. Sibutramine should always be combined with lifestyle
modification.
• A組.Receive Sibutramine alone(15 mg/day)
• B組. lifestyle modification counseling alone (30 group
sessions lasting 90 minutes each
• C組. sibutramine plus lifestyle modification counseling (30
group sessions lasting 90 minutes each)
• D組.sibutramine plus brief lifestyle modification counseling
(eight visits of 10 to 15 minutes each with primary care
provider),結果:,
• All subjects were prescribed a diet of 1200 to 1500 kcal
per day and the same exercise regimen.
Weight loss
A組
B組
C組
D組
5.0 ± 7.4 kg
6.7 ± 7.9 kg
12.1 ± 9.8 kg 7.5 ± 8.0 kg
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Lipase Inhibitor
• Orlistat( Xenical) 羅氏鮮
- mechanism : reduce dietary fat absorption by
inhibiting GI (stomach and pancreas) lipase activity
by binding to and inactivating the enzyme.
- 用法用量:
- 120mg three times daily, during (or up to 1 hour
after) each main meal containing fat.If a meal
occasionally is missed or contains no fat, the dose
may be omitted. Dosages exceeding 120 mg three
times daily do not provide additional benfit.
- Orlistat has additive effects when combined with
lipid( cholesterol)-lowering agents such as
pravastatin. Thus the dose can be reduced.
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Orlistat( Xenical) 羅氏鮮
- beneficial effects :
1.the therapeutic activity of Orlistat takes place in
the stomach and intestine and effects are as soon
as 24-48 hours after dosing
2.Orlistat has no CNS effects and has no systemic
absorption. Less than 1 % of an oral dose of
Orlistat is absorbed.
3. Orlistat has very few clinically significant drugdrug interaction with commonly prescribed
medications.
4.Orlistat can reduce the risk of weight regain after
prior weight loss.
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Orlistat( Xenical) 羅氏鮮
• Most common adverse effects:
fatty/oily stools(31%), increased
defecation(20%), losse stool, oily
spotting(18%), headache(6%),flatus
with discharge, fecal urgency, fecal
incontinence, bloating, and cramping
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Orlistat( Xenical) 羅氏鮮
•
1.
注意事項:
Orlistat may reduce the absorption of
fat-soluble vitamins(A,D,E,K) and
patients should take a multivitamins that
contains these vitamins.Supplement should
be taken once a day at least 2 hours
before or after the administration of
Orlistat.
2. Orlistat may interfere with vit.k
absorption and potentiate the bleeding
effects of warfarins.
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In the two-year weight maintenance trial in obese patients, orlistat
120 mg (three times/day), taken with an appropriate diet, resulted
in clinically significant weight loss and reduced weight regain when
compared to placebo
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Phentermine
• Phentermine
- mechanism :
Stimulate the release of norepinephrine or inhibit
its reuptake bysynaptic granules
- drugs are only FDA approved for the short-term
treatment of obesity , which is widely interpreted
as up to 12 week
• Side effect: Hypertension, Palpitations,
Tachyarrhythmia , Constipation, Diarrhea, Nausea,
Dizziness, Headache, Insomnia, Tremor, Dysphoric
mood, Nervousness, Psychotic disorder,
Restlessness ,Impotence,
- 用法用量:Short-term: 15-37.5 mg orally once daily
before breakfast or 1-2 hr after breakfast
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Phentermine
• The efficacy of Phentermine was
demonstrated in a 36-week trial which
found that both continuous and
intermittent administration led to
more weight loss than placebo. Weight
loss slowed during the drug-free
periods in the intermittently-treated
patients, but accelerated when
treatment was resumed
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Diethylpropion
• Diethylpropion
- mechanism :
Stimulate the release of norepinephrine or inhibit
its reuptake bysynaptic granules
- Side effect:Finding of increased blood pressure
(Mild), Palpitations - rapid (Mild) ,
Urticaria ,Constipation, Nausea, Stomach cramps,
Vomiting, Xerostomia, Central nervous system
stimulation, Dizziness, Headache, Insomnia,
Pain,Blurred vision, Mydriasis
- 用法用量:
<1>Adjunct: controlled release, 75 mg ORALLY daily,
take midmorning
<2>immediate release, 25 mg ORALLY 3 times a day, 1
hr before meals
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Diethylpropion
- Diethylpropion is Schedule IV drugs,
a regulatory classification suggesting
potential for abuse, although the
actual potential is low.
- drugs are only FDA approved for the
short-term treatment of obesity ,
which is widely interpreted as up to
12 week
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中草藥減肥
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減肥藥分類
•
•
•
•
瀉劑
利尿劑
食慾抑制劑
膨漲劑
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瀉劑
• 特色瀉藥被視為減肥產品是因為有人相信他
能增加腸道蠕動，減少卡路里吸收。但
是美國ＦＤＡ指出，瀉藥引發的拉肚子，
並不能減少卡路里的吸收，因為瀉藥不
作用在吸收卡路里的小腸，而是在腸的
尾端結腸。
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瀉劑
• 副作用瀉藥副作用包括嘔吐及腸胃痙攣；過度
依賴則會造成便秘，腸功能不良；嚴重
時則會發生暈厥、脫水、電解質不平衡
死亡。一旦停用，胃腸肌肉會無法運作。
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瀉藥
• 番瀉葉具輕瀉效果，常被添加在減肥茶、減肥
食品中，醫師提醒消費者，曾有人疑似喝出猛
爆性肝炎、換肝，也有人疑似喝到嚴重神經病
變，從手腳麻痺到陷入全身癱瘓，半年後死亡。
曾有一名國二女生飲用含「番瀉葉」成分的泰
國減肥茶，引發「猛爆性肝炎」。番瀉葉含有
毒性，國外也有長期飲用導致肝功能指數異常
的例子。根據衛生署規定，番瀉葉一天食用不
能超過12mg，但只有少數減肥茶合乎標準，像
這名國二女生喝的泰國減肥茶，番瀉葉成分竟
高達450mg，每天當水喝，極有可能導致腎臟
病變。
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瀉藥
•
•
•
•
Senna(番瀉葉)
Anthraquinone Glycoside
Fam. Fabaceae
主要成分Sennoside A and B
(為Aloe-Emodin+Rhein之二合苷質)
• 用途緩瀉劑
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利尿劑
• 特色脫水，造成體重暫時下降，但是並非減
少脂肪，停止服用後體重就會回升。
• 副作用嘔吐、暈眩、虛弱、血壓下降、引發糖
尿病，破壞腎功能。
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利尿劑
• 一般人都以為中藥較溫和較無害，但事實上近
年來最近新聞報導國外有報告指出一些因服用
減肥藥而導致腎衰竭之病例，被懷疑是與其所
含之馬兜鈴酸成分有關。含有馬兜鈴酸的中藥
材有馬兜鈴科的馬兜鈴、廣防己、關木通，青
木香、春木香、天仙藤。發現服用馬兜鈴酸病
人臨床上表現出貧血、多尿與腎功能快速惡化，
通常在短期內發展成為尿毒症。在1990至
1992年間，比利時有上百名婦女長期服用含
廣防己的減肥藥以後，迅速惡化成末期腎病。
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利尿劑
• 比利時研究人員Jean-Louis Vanherweghen等，
於1993年The Lancet上發表：一群年輕女性
因服用含有中藥的減肥藥而引起腎臟纖維化，
很快的變成尿毒症，而需要洗腎或換腎。
• 隔年1994年他們發現，標示的粉防己的中藥─
（Stephania tetrandra）被以廣防
（Aristolochia fangchi）替代，而廣防己含
的馬兜鈴酸Aristolochic acid（A.A）是元凶，
它不但有腎毒性且致癌。遂稱這些吃了含廣防
己的而有腎臟纖維化的病，為「中藥腎病
─Chinese herb nephropathy 」。
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食慾抑制劑
• 興奮劑，例如麻黃，被當做食慾抑制劑，
也就是所謂的厭食劑。
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膨脹劑
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甲殼素
Chitosan
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•
http://www.kjemi.uio.no/Polymerkjemi/Research/Chitosan.htm
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• 幾丁質（chitin）及甲殼素（幾丁胺醣，chitosan）都是
提煉自海洋生物體中的纖維質，其中幾丁質是一種多醣類
（糖分子的聚合鏈），自然地形成在昆蟲、甲殼類生物的
外殼；例如蝦蟹及蝦類、甲蟲、蝗蟲等昆蟲的殼中；以及
花枝、貝類等軟體動物的器官、外皮；香菇、酵母等菌類
的細胞壁中。幾丁質的化學性質，類似於植物纖維，它能
應用於製造各種物質，其中包括了甲殼素。其製造過程就
是將幾丁質與化學溶液共煮，就可得到之。甲殼素有著比
幾丁質更溶於水的優點。
• 甲殼素用途多廣，可使用在醫藥（成人病、肥胖、血壓下
降）、醫療（人工皮膚、縫合線、人工血管、隱形眼鏡）、
健康食品、化妝品（美肌、育毛）、公害處理、農業（殺
蟲劑）、漁業（養魚飼料）、食物鮮度保持、纖維等。
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• 甲殼素是一種含有幾丁質和幾丁聚醣的機能性食品。其本
身所帶的正負電離子能包覆食物中帶負電的油脂，調節生
理機能，幫助消化。
• 需在用餐前約半小時內食用甲殼素，使其能分佈在消化
道，等待食物的降臨。
• 食用時，需搭配約300cc的開水，否則可能造成腸道的阻
塞，甚至有排便不順的現象。
• 服用甲殼素期間，不要同時服用魚油，否則兩者的效果均
會受影響。
• 三餐連續服用甲殼素者，不要超過兩個月，否則會造成脂
溶性維生素缺乏，若能適時補充綜合維他命，則能改善之。
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• 幾丁質真正的脂肪吸收量約為本身體積的六到八倍
• 一般市面上含幾丁質的減肥食品，多半劑量為一粒500毫
克，如果以每粒可吸收七倍的脂肪來計算，約可減少3.5
公克的油脂吸收量，大約31.5大卡
• 每餐餐前都吃個2錠，大約能吸收約7公克的油脂（相當於
63大卡，約等於兩大匙冰淇淋中所含的脂肪量）。
• 幾丁質不只會吸收食物中油脂，也會吸收一些與人體健康
有關係的脂溶性維生素及必須脂肪酸，結果可能因維生素
D缺乏而使鈣質的吸收不良，進而造成骨質疏鬆症；也可
能因必須脂肪酸的濃度不足而使皮膚粗糙
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纖維素
Cellulose
纖維素是減肥者的最佳輔助食品
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•
http://www.l-spioneers.org/hschool/teachers/pitts/bio/un7/old/un3/
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• 纖維素是指植物中不能被人體消化吸收的食物成份。對人
體有好幾種重要的功能。纖維素分為可溶性和非可溶性兩
種：
• 可溶性纖維－－例如蘋果、燕麥麩和綠花椰菜裡面的果膠
及植物膠，可以延緩食物通過小腸的速度。許多研究都表
明，可溶性纖維能降低膽固醇
• 非可溶性纖維－－存在於芹菜、小麥麩、菜豆及斑豆等食
物當中，會加速食物通過小腸的時間，不僅能幫助預防便
秘及消化疾病（如憩室形成），還可預防發生結腸癌、肺
癌、乳腺癌和子宮頸癌等等。研究表示 ，在以纖維素為主
食的地區（如非洲），比起在纖維素攝取量低的國家（如
美國） ，人們患腸癌的機率要低很多 。
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• 增加糞便的體積、重量與含水量，不致便秘
• 延緩飯後血糖上升之速度
• 降低血管硬化
• 減少膽固醇吸收
• 增加飽足感，因此不致多吃，有助於體重的控制
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• 錠狀或膠囊狀食品，比較方便。
• 在攝取這些纖維素補充品時，要飯前服用
• 同時喝下一杯約300cc的開水
• 並間格約15分鐘以後再攝食
• 值得注意的是，對於患有胃炎或胃潰瘍的人，並不適合空
腹時服用纖維錠，尤其是富含非水溶性纖維的產品，對於
胃腸較敏感的人，不妨可以選用含完全水溶性纖維的產品。
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• 每餐飯前可先攝取約3到5公克的纖維素
• 纖維素有益人體健康，但是，每天攝取超過30公克時，卻
可能影響許多營養素如鈣質、鐵質及藥物的吸收，這點可
是想要以纖維素來輔助減肥的人，不得不小心的。
73
藤黃果
HCA
74
75
• 藤黃果（Garcinia Cambogia）是來自印度的一種類似柑
橘的果實，藤黃果中萃取出來的HCA成分，可以阻止碳水
化合物轉化為脂肪，還能夠促進脂肪燃燒，排除體內多餘
的脂肪，用餐前30分鐘攝取 HCA，可以達到最佳功效。
此外，HCA還具有增加飽足感，達到降低食慾及減少飢餓
感的效果
• 服用這一類產品,如果沒有配合飲食與運動, 而放心大吃大
喝, 效果也是不可能發生的
• HCA是一種天然提取物,目前尚無報告顯示它有毒性或副
作用
76
• 籐黃果HCA的作用原理,就是在人體的葡萄糖轉為脂肪時,
抑制其中一個ATP Citrate lyase的酵素,使脂肪酸無法合
成, 並且抑制糖解(glycolysis)作用的進行,因此,減少體內能
量的吸收
• 通常,這類產品如果單純以HCA來減少熱量吸收,效果並不
會十分顯注,而且是屬於一種溫合性的產品,需耐心地服用
才會有效果,因此,通常產品會搭配一些具有燃脂效果的Lcarnitine, 與提高胰島素利用度的chromium元素, 才會加
強效用, 因為L-carnitine(肉酸)會增加粒腺體對於脂肪酸
的利用,具有燃脂功效, 褡配HCA使用效果極佳,而
chromium元素(鉻), 則可以增加糖類的利用, 加速三酸甘
油脂的代謝,並降低血脂濃度, 在國外銷售的產品,多半是這
種三合一的產品
77
減肥菜中毒
台中榮民總醫院
林增記醫師
78
•
http://www.shop.sunshine-seeds.de/
79
• 減肥菜，為大戟科植物，在馬來西亞，印尼等地已經有很
長的食用歷史，根據馬來西亞的文獻報告，減肥菜除了含
有中等的熱量，另含有蛋白質、脂肪、鈣、鐵、胡蘿蔔素
和維生素 C等成份，是頗富營養價值的作物。
• 在台灣，減肥菜被稱為“守宮木”“剪肥菜”“樹仔
菜”“越南
菜”“沙巴菜”等等；最初被進口在餐廳當作上等之菜餚，
民
國83年開始被推廣成“具有神奇減肥效果”的“健康食
品”，
人們將它拿來治療肥胖、高血壓、痛風及婦科疾病，吸引
了許多人購買食用。銷售者建議每人每天食用量為四台
兩，但食用者可能為達速效或半信半疑而增減量；有些人
每天食用、有些人幾天才食用一次。減肥菜的大量引進，
80
以健康食品販賣，卻始料未及地造成了不少中毒之事件。
• 減肥菜中毒的案例第一個發生在民國83年8月23日。一位
55歲女性在食用減肥菜40多天後因失眠，食慾不振，和
呼 吸困難而求醫。
• 在醫院作心電圖時發現病人有心律不整的現象。由於對減
肥菜的了解不多，當時無法確認是否為食用減肥菜引起之
中毒。
• 直到民國84年6月至 8月間，全省各地突然出現多起疑似
因食用減肥菜而中毒的報告。受害者大多為年輕肥胖的女
性，因呼吸困難而求醫，但卻無法以一般呼吸系統的疾病
來診斷。經詳細追問受害者的病史，發現所有的病人都曾
食用過減肥菜。為了進一步地了解中毒事件的前因和後果，
榮總毒藥物諮詢中心以回朔法將民國84年8月25日以前通
報進來的44個案例，以電話訪問的方式收集受害者的流行
病學資料。其中有3個病人因為有氣喘的病史而不納入我
們的研究中。
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由這41個案例所得到的資料顯示，減肥菜之食用，平
均每日食用的數量為131公克，平均食用日數為35天，
平均累積用量則為4100公克。在食用減肥菜時，不論
是產地不同、使用方式不同、食用部位不同、冷藏與
否、過濾與否，添加不同物品，都有中毒的狀況出現，
這有可能是減肥菜本身的成份所引起的毒性。呼吸困
難是中毒者出現的主要癥候，在食用減肥菜期間或停
止服食減肥菜後的一段時間都有可能發生。根據12例
病患肺功能測試的結果，發現她們都是以阻塞性肺部
病變來表現。其他臨床症狀尚有開始時感覺睡不著、
食慾不振或興奮，但是不論停吃減肥菜與否，這些症
狀大部份會消失。有些病人還會有發疹或心律不整的
臨床症狀。但最令中毒者長期困擾的還是呼吸困難的
阻塞性肺部病變。
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然而，減肥菜在馬來西亞等地已經有多年的使用歷史，
卻未曾有過類似的中毒報告，而在台灣卻引起許多中
毒的事件。
是甚麼原因造成這種差異呢？我們推測其原因可能是
個人代謝因素、HLA typing之不同、誤食有毒亞種、
劑量效應以及減肥菜之未知有毒成份。
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減肥手術
84
何種情況適合並應該考慮減肥
手術？
• 依健保局的標準，應符合下列五項條件；但體重超過
理想體重85%以上，未超過理想體重100%以上者，如
已符合一至四條件，並因肥胖引起具有明確之身心障
礙，經相關科醫師鑑證實者得以施行。
• 飲食控制在半年以上。(需有醫療紀錄)
• 精神狀態健全，經由精神科專科醫師會診認定無異常。
• 無其他因代謝性疾病或內分泌疾病所引起的病態肥胖。
(需內分泌專科醫師認定)
• 年齡在55歲以下。
• 超過理想體重100%以上。
85
* 理想體重的算法
• 男生 : [身高(公分)-80] x 0.7
• 女生 : [身高(公分)-70] x 0.6
86
手術治療
目前有兩種常用的手術方法：
• A 垂直加帶胃隔間術
• B胃改道術
87
垂直加帶胃隔間術
• 將胃隔成兩個互通的房間，其中連接食道的小房間，
只能 容納30~50ml的食物，因此容易有飽足感。此法
適合習慣大吃大喝者，類似強迫節食。但若意志不堅
者，術後仍以 高熱量液體食物，如奶昔、冰淇淋、起
士濃湯等滿足口慾，則效果大打折扣。此法安全性高，
所以為許多外科醫師採用。
88
胃改道術
• 將胃賁門部(約30ml不到的容積)和其他胃部完全分隔，
並連接一段空腸至此胃賁門部。此法不僅容易有飽食
感，而且當病人攝取高熱量液體食物時，會因為滲透
壓變化過大，而造成腹痛、盜汗等不適症狀。是目前
已知最有效的方法。不過，此法的併發症較高，且長
期會缺乏鐵質及維生素B12，需定時補充。
89
減肥手術後的
預期效果如何？
• 手術後1至2年內，可以減少超出理想體重部分的
50~60%，另一種算法，術後1至2年內，可以下降10
個BMI值。。更重要的是，約有90%肥胖合併的糖尿
病病況可以減至輕微；約有2/3的病患在術後4年內高
血壓可以回復至正常值。
90
Behavior therapy
91
Behavior therapy
• Behavioral treatment of obesity has
become a standard part of most
treatment programs in the last 30
years.
• The current evidence suggests that
behavioral therapy, in addition to
exercise and diet, produces weight
loss of approximately 10% over 4
months to 1 year
92
• Behavior therapy should be included
in any weight loss program to
facilitate changes in eating and
activity behaviors needed for
successful weight loss.
93
• The goal of this approach is to help
patients modify their eating habits,
increase their physical activity, and
become more conscious of both of
these activities, thereby helping
them make healthier choices
94
• There are several stages in this
process.
• This approach recognizes that body
weight is affected by factors other
than behavior. These factors include
genetic, metabolic, and hormonal
influences
95
• Behavioral treatments for obesity
can be broken into three components:
(1) self-monitoring (2) stimulus control
(3) exercise (4) cognitive
restructuring
96
Self-monitoring
• Patients keep detailed records of
their food intake, physical activity,
and weight throughout treatment.
• with this information, they try to
reduce hidden sources of fat and
sugar from their diet and thus
decrease energy intake by
approximately 500 to 1000 kcal/day.
97
Stimulus control
• teach patients to control cues
associated with inappropriate eating
• these techniques are avoiding highrisk venues, such as fast-food
restaurants, all-you-can-eat buffets,
convenience stores, and certain aisles
of the grocery store
98
Physical activity
• The addition of 30 to 60 minutes of
physical activity, 3 times a week, to a
behavioral weight loss program
increases weight loss by an average
of 2 kg, a modest amount considering
the effort involved
99
Cognitive restructuring
• teaches patients to identify,
challenge, and correct the irrational
thoughts that frequently undermine
weight control efforts
• fall into one of three categories: (1)
the impossibility of weight control (in
view of previous failures) (2)
unrealistic eating and weight loss
goals (3) self-criticism in response to
overeating or gaining weight
100
• Behavioral factors are central in
explaining the recent increase in the
prevalence of obesity across the
industrialized world.
• Combined behavioral and
pharmacologic approaches to obesity
may provide better long-term
outcomes than those now available
for this serious disorder
101
CONCLUSION
102
DRUGS
• Amphetamines
• Sympathomimetics - Ephedrine、
Phenylpropanolamine (PPA)
• Serotonin-releasing agents – Fenfluramine
• Serotonin/Norepinephrine Reuptake
Inhibitors - Sibutramine (Meridia® (USA),
Reductil® (other countries) ) 諾美婷
• Lipase Inhibitor - Orlistat( Xenical) 羅氏鮮
• Phentermine
• Diethylpropion
103
HERBS
• 瀉劑 - Senna、Anthraquinone
Glycoside
• 利尿劑
• 食慾抑制劑
• 膨漲劑
104
HEALTHY FOODS
• Chitosan
• Cellulose
• Garcinia Cambogia
• 減肥菜
105
SURGERY
• Gastric partitioning -調節矽膠束胃帶
adjustable silicon gastric banding
[ lapa band®束胃帶]、垂直加帶胃隔間
術 vertical banded gastroplasty
• Gastric bypass
106
成人肥胖治療流程
個案評估
5.
1.
BMI≧24或腰圍
≧90公分(男)
，≧80公分(女
)
7.
1. 是否BMI≧27，或
2.是否BMI≧24或腰圍≧90
公分(男)，≧80公分(女)
，且有合併症或兩個以上
心血管疾病危險因子
是
是
1.
2.
3.
4.
12
.
飲食控制
運動指導
生活習慣修正
危險因子控制
BMI≧35並已有因
肥胖引起之合併
症，可考慮外科
手術治療
3-6個月
13
.
8.
否
是否達
到減重
目標
是
2.
過去兩年
每3-6個月評估腰圍
及BMI，並
持續進行：
1. 飲食控制
2. 運動指導
3. 生活習慣修正
4. 危險因子控制
否
內是否曾
經BMI≧24
9.
是否有兩
個以上合
併症
否
否
是
否
是
3.
4.
給予維持體
重衛教，並
每年評估腰
圍及BMI
6.
建議維持體
重，每3-6個
月評估腰圍
及BMI
1. 飲食控制
2. 運動指導
3. 生活習慣修正
10
.
是
11
.
評估失敗
因素是否
能改善
否
危險因子：
1. 抽菸
2. 高血壓
3. 低密度脂蛋白膽固≧160mg/dl
4. 高密度脂蛋白膽固醇＜40mg/dl
5. 三酸甘油脂≧200 mg/dl
6. 空腹血糖不良(110mg/dl≦空腹血糖＜126mg/dl)
7. 早發性冠狀動脈硬化心臟病之家族史
8. 男性≧45歲，女性≧55歲
1.
2.
3.
4.
飲食控制
運動指導
生活習慣修正
考慮使用減重藥物
合併症：
1. 高血壓
2. 血脂異常
3. 糖尿病
4. 冠心症
5. 睡眠呼吸中斷症
107
reference
1. Nonsurgical and Surgical Treatment of Obesity Patrick J.
Neligan, MD, Noël Williams, MD
[MDConsult ; review article]
2. Behavioral treatment of obesity Thomas A. Wadden, PhD ,
Meghan L. Butryn, MS
[MDConsult ; review article]
3.The behavioral approach to treating obesity Gary Foster,
PhD
[MDConsult ; Results of Expert Meetings]
4.AGA guideline: Obesity
5. Behavior modification in the treatment of obesity
George
A Bray, MD
[UpToDate]
6. http://barryhsu.com/Obesity.htm
7. http://www.doh.gov.tw
108
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•
•
•
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Caterson ID, Gill TP. Obesity:epidemiology and possible
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Expert Panel on the Identification, Evaluation, and Treatment of
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RIPPE, JAMES M.; CROSSLEY, SUELLYN; RINGER, RHONDA.
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109