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อ้วนและอ้วนลงพุง
พญ. วรรณี นิธิยานันท์

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  • LAUGH A WHILE
    That Darned Cat
    A man absolutely hated his wife's cat and decided to get rid of him one day by driving him 20 blocks from his home and leaving him at the park. As he was getting home, the cat was walking up the driveway.

    The next day he decided to drive the cat 40 blocks away. He put the beast out and headed home. Driving back up his driveway, there was the cat!

    He kept taking the cat further and further and the cat would always beat him home. At last he decided to drive a few miles away, turn right, then left, past the bridge, then right again and another right until he reached what he thought was a safe distance from his home and left the cat there.

    Hours later the man calls home to his wife: 'Jen, is the cat there?'

    'Yes', the wife answers, 'why do you ask?'

    Frustrated, the man answered, 'Put that darned cat on the phone. I'm lost and need directions!'

    DR.G. M. SINGH GENERAL MEDICAL SERVICE 3/5 WEST PATEL NAGAR NEW DELHI - 110008 INDIA 01142488406;9891635088;9990596297
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Transcript of "อ้วนและอ้วนลงพุง"

  1. 1. 懰oªœÂ¨³°oªœ¨Š¡»Š„ε¨´ŠÁž}œž{®µ­µ›µ¦–­»…š¸É­Îµ‡´…°Šž¦³Áš«Åš¥ œ°„‹µ„ÂœªÃœo¤ š¸ÉÁ¡·É¤…¹Êœ°¥nµŠ˜n°ÁœºÉ°ŠÂ¨oª 懰oªœÂ¨³°oªœ¨Š¡»Š¥´Š­nŠŸ¨„¦³š˜n°­»…£µ¡ ‡»–£µ¡¸ª·˜ ¦ª¤š´ÊŠ Á«¦¬“„·‹Â¨³­´Š‡¤°¥nµŠ„ªoµŠ…ªµŠ ­·ÉŠÁ®¨nµœ¸ÊÁž}œš¸Éž¦³‹´„¬r´—šµŠ—oµœª·µ„µ¦ ¤¸„µ¦œÎµÁ­œ° “„µ¦ ‹´—„µ¦ž{®µ£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ” Ĝš¸Éž¦³»¤­¤´µ­»…£µ¡Â®nŠµ˜·‡¦´ÊŠš¸É Ó Ž¹ÉŠ¤¸¤˜·¦´ …o°Á­œ°Â¨³Å—o—εÁœ·œ„µ¦˜n° …–³œ¸Ê¥»š›«µ­˜¦r„µ¦‹´—„µ¦ž{®µ£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœÅ—o¦´ ‡ªµ¤Á®Èœ°‹µ„‡–³¦´“¤œ˜¦¸Â¨oªÂ¨³„ε¨´Š‹´—šÎµÂŸœ—εÁœ·œŠµœ ž{‹‹´¥š¸É­nŠŸ¨Ä®oÁ„·—懰oªœÂ¨³°oªœ¨Š¡»Š¤¸®¨µ„®¨µ¥ —´Šœ´Êœ„µ¦‹´—„µ¦ž{®µ‹ÎµÁž}œ˜o°Š¤¸ œÃ¥µ¥Â¨³¥»š›«µ­˜¦rš¸É‡¦°‡¨»¤š»„—oµœÁ¡ºÉ°Ä®o¦¦¨»Ÿ¨˜µ¤Ážjµ®¤µ¥ Á‡¦º°…nµ¥‡œÅš¥Å¦o¡»ŠÅ—o —εÁœ·œ„µ¦¦–¦Š‡rÄ®o­´Š‡¤Åš¥˜¦³®œ´„™¹Šž{®µÃ¦‡°oªœÂ¨³°oªœ¨Š¡»Š Ä®o¦´¦¼o¨³Á…oµÄ‹„µ¦žj°Š„´œ ¨³Â„oŅ—oª¥®¨´„ 3 °. ‡º° °µ®µ¦ °°„„ε¨´Š„µ¥ ¨³ °µ¦¤–r ץŗo¦´„µ¦­œ´­œ»œ‹µ„­Îµœ´„Šµœ „°Šš»œ­œ´­œ»œ„µ¦­¦oµŠÁ­¦·¤­»…£µ¡ (­­­.) „µ¦—εÁœ·œŠµœ¤¸Ÿ¨­´¤§š›·Í˜n¥´Š°¥¼nĜªŠ‹Îµ„´— ®œ´Š­º° Á¨n¤œ¸ÊÁž}œ­nªœ®œ¹ÉŠ…°ŠÃ‡¦Š„µ¦ Ž¹ÉŠ¦ª¦ª¤…o°¤¼¨ª·µ„µ¦ Ÿ¨„¦³š—oµœ˜nµŠÇ ª·›¸‹´—„µ¦š¸É¤¸„µ¦ —εÁœ·œŠµœoµŠÂ¨oª ¡¦o°¤…o°Á­œ°Âœ³µŠž¦³„µ¦ ¦ª¤™¹Š„µ¦žj°Š„´œÂ¨³¦´„¬µŸ¼oš¸É¤¸Ã¦‡°oªœÂ¨³°oªœ ¨Š¡»Š Á¡ºÉ°ÄoÁž}œÂ®¨nŠ…o°¤¼¨­Îµ®¦´Ÿ¼oš¸É­œÄ‹®¦º°˜o°Š„µ¦—εÁœ·œŠµœÁ¡ºÉ°‹´—„µ¦ž{®µÃ¦‡°oªœÂ¨³ °oªœ¨Š¡»Š …°…°‡»–Ÿ¼oœ·¡œ›rš»„šnµœš¸ÉŗoÁ¦¸¥Á¦¸¥ŠÁœºÊ°®µ‹œ®œ´Š­º°¤¸‡ªµ¤­¤¼¦–r¦³—´®œ¹ÉŠ ¦ª¤š´ÊŠ ¦µª·š¥µ¨´¥°µ¥»¦Â¡š¥r®nŠž¦³Áš«Åš¥ Ĝ¡¦³¦¤¦µ¼ž™´¤£r ¨³ ­­­. š¸É­œ´­œ»œ„µ¦‹´—šÎµÂ¨³ ‹´—¡·¤¡r ®ª´ŠÁž}œ°¥nµŠ¥·ÉŠªnµ®œ´Š­º°Á¨n¤œ¸Ê‹³Á„·—ž¦³Ã¥œr˜µ¤­¤‡ª¦Â„nŸ¼oš¸ÉÁ„¸É¥ª…o°Š®¦º°„µ¦œÎµÅžÄo Ĝš»„¦³—´ ª¦¦–¸ œ·›·¥µœ´œšr ¦¦–µ›·„µ¦
  2. 2. ‹»¦¸¡¦ ‡Šž¦³Á­¦·“ ¡.., ª.ª.(„»¤µ¦Áª«µ­˜¦r), °.ª.(Áª«µ­˜¦ržj°Š„´œ …œŠ­»…£µ¡‹·˜»¤œ) Ceritifcate of Attendance, 2nd WHO-IUMSP International Seminar on the Public Health Aspects of Noncommunicable Diseases, University of Lausanne, Switzerland œµ¥Â¡š¥rÎµœµ„µ¦¡·Á«¬ ­Îµœ´„æ‡Å¤n˜·—˜n° „¦¤‡ª‡»¤Ã¦‡ „¦³š¦ªŠ­µ›µ¦–­»… ´¥µ —¸Ã¦‹œªŠ«r ¡.., ª.ª.(°µ¥»¦«µ­˜¦r), °.ª.(°µ¥»¦«µ­˜¦r˜n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤) Certificate, Fellowship in Diabetes and Endocrinology University of Newcastle Upon Tyne, United Kingdom «µ­˜¦µ‹µ¦¥r‡¨·œ·„­µ…µÃ¦‡˜n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤ £µ‡ª·µ°µ¥»¦«µ­˜¦r ¤®µª·š¥µ¨´¥¦´Š­·˜ ®œnª¥˜n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤ „¨»n¤Šµœ°µ¥»¦«µ­˜¦r 抡¥µµ¨¦µª·™¸ „¦¤„µ¦Â¡š¥r „¦³š¦ªŠ­µ›µ¦–­»… žµ‹¦¸¥r °´—»¨¨µ„µŽ·¤ œ·­·˜ž¦·µÁ°„ ª·š¥µ¨´¥ª·š¥µ«µ­˜¦r­µ›µ¦–­»… ‹»¯µ¨Š„¦–r¤®µª·š¥µ¨´¥ ¦»nŠ´¥ ªœÅ¥³„¼¨ Ph.D. (Exercise Physiology), Wollongong University, Australia M.Sc. (­¦¸¦ª·š¥µ) ¤®µª·š¥µ¨´¥¤®·—¨ B.Sc. („µ¥£µ¡Îµ´—) ¤®µª·š¥µ¨´¥¤®·—¨ Certificate, Human Thermoregulatory Research, University Wollongong, Australia Certificate, Biomedical Instrument, Purdue University, Indiana, USA Certificate, Chest Physical Therapy, New York University, USA Certificate, Spinal Orthosis, New York University, USA Certificate, Lower Limb Prosthesis, New York University, USA ¡´œ˜¦¸ Ÿ¼onª¥«µ­˜¦µ‹µ¦¥r —¦. ª·š¥µ¨´¥ª·š¥µ«µ­˜¦r¨³Áš‡ÃœÃ¨¥¸„µ¦„¸¯µ ¤®µª·š¥µ¨´¥¤®·—¨
  3. 3. Á¦ª—¸ ‹Š­»ª´•œr Ph.D. (Food, Nutrition and Dietetics) Ÿ¼onª¥«µ­˜¦µ‹µ¦¥r ­µ…µÃ£œª·š¥µ £µ‡ª·µÃ£œª·š¥µ ‡–³­µ›µ¦–­»…«µ­˜¦r ¤®µª·š¥µ¨´¥¤®·—¨ ¨´——µ Á®¤µ³­»ª¦¦– ªš.., ¡.., ª.ª.(„»¤µ¦Áª«µ­˜¦r), ª.ª.(„»¤µ¦Áª«µ­˜¦r㍜µ„µ¦) M.Sc.(Human Nutrition) ¦°Š«µ­˜¦µ‹µ¦¥r £µ‡ª·µ„»¤µ¦Áª«µ­˜¦r ‡–³Â¡š¥«µ­˜¦r ¤®µª·š¥µ¨´¥­Š…¨µœ‡¦·œš¦r ª–·µ „·‹ª¦¡´•œr ­.—.(㍜µ„µ¦­µ›µ¦–­»…) Diplomate (Community Nutrition), University of Indonesia, Indonesia Ceritifcate, Nutrition Epidemiology and Statistics, University of Queensland, Australia Certificate, International Visitor’s Programme of the North Karelia Project National Public Health Institute, Helsinki, Finland œ´„㍜µ„µ¦Îµœµ„µ¦¡·Á«¬ ­Îµœ´„㍜µ„µ¦ „¦¤°œµ¤´¥ „¦³š¦ªŠ­µ›µ¦–­»… ª·´¥ Á°„¡¨µ„¦ ¡.., °.ª.(Áª«µ­˜¦ržj°Š„´œ), °.ª.(Áª«µ­˜¦r‡¦°‡¦´ª) Ph.D. (Epidemiology) University of North Carolina at Chapel Hill, USA ¦°Š«µ­˜¦µ‹µ¦¥r ­Îµœ´„Šµœ«¼œ¥rÁª«µ­˜¦r»¤œ ‡–³Â¡š¥«µ­˜¦r 抡¥µµ¨¦µ¤µ›·—¸ ¤®µª·š¥µ¨´¥¤®·—¨ ­Îµœ´„Šµœ­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥ ª¦¦–¸ œ·›·¥µœ´œšr ¡.., °.ª.(°µ¥»¦«µ­˜¦r), °.ª.(°µ¥»¦«µ­˜¦r懘n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤) °.ª.(Áª«µ­˜¦r‡¦°‡¦´ª) Diplomate, American Board of Internal Medicine Diplomate, Subspecialty Board of Endocrinology and Metabolism «µ­˜¦µ‹µ¦¥r ­µ…µÃ¦‡˜n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤ £µ‡ª·µ°µ¥»¦«µ­˜¦r ‡–³Â¡š¥«µ­˜¦r«·¦·¦µ¡¥µµ¨ ¤®µª·š¥µ¨´¥¤®·—¨
  4. 4. «»£ª¦¦– ¼¦–¡·¦ ¡.., ª.ª.(°µ¥»¦«µ­˜¦r), ª.ª.(°µ¥»¦«µ­˜¦r懘n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤) Certificate, Fellowship in Nutrition Support and Obesity Medicine °µ‹µ¦¥r ®œnª¥˜n°¤Å¦ošn° £µ‡ª·µ°µ¥»¦«µ­˜¦r ‡–³Â¡š¥«µ­˜¦r ¤®µª·š¥µ¨´¥Á¸¥ŠÄ®¤n °£´­œ¸ »µª¦„»¨ ¡.., ª.ª.(°µ¥»¦«µ­˜¦r), ª.ª.(°µ¥»¦«µ­˜¦r懘n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤) °.ª.(Áª«µ­˜¦r‡¦°‡¦´ª) Certificate, Research Fellow in Human Nutrition, South Western Medical Center Dallas, Texas, USA ¡´œÁ°„¡·Á«¬ ¦°Š«µ­˜¦µ‹µ¦¥r ­µ…µÃ¦‡˜n°¤Å¦ošn°Â¨³Á¤Âš°¨·Ž¹É¤ £µ‡ª·µ°µ¥»¦«µ­˜¦r ®œnª¥Ã£œµ„µ¦ ¨³®œnª¥˜n°¤Å¦ošn° „°Š°µ¥»¦„¦¦¤ 抡¥µµ¨¡¦³¤Š„»‘Á„¨oµ °»¤µ¡¦ ­»š´«œrª¦ª»•· ¡.., ª.ª.(„»¤µ¦Áª«µ­˜¦r), °.ª.(„»¤µ¦Áª«µ­˜¦r㍜µ„µ¦) ¦°Š«µ­˜¦µ‹µ¦¥r £µ‡ª·µ„»¤µ¦Áª«µ­˜¦r ‡–³Â¡š¥«µ­˜¦r抡¥µµ¨¦µ¤µ›·—¸ ¤®µª·š¥µ¨´¥¤®·—¨ °´Š«·œ´œšr °·œš¦„ε®Š ‡.—.(„µ¦«¹„¬µœ°„¦³Ã¦ŠÁ¦¸¥œ), ªš.¤.(­»…«¹„¬µ), ¡¥..(„µ¦¡¥µµ¨Â¨³Ÿ—»Š‡¦¦£r) Vocational Education, UTS, Australia Ÿ¼onª¥«µ­˜¦µ‹µ¦¥r ¦°ŠŸ¼o°Îµœª¥„µ¦­™µ´œª·‹´¥¡§˜·„¦¦¤«µ­˜¦r  iµ¥‹´—„µ¦‡ªµ¤¦¼o¨³„·‹„µ¦¡·Á«¬ ­™µ´œª·‹´¥¡§˜·„¦¦¤«µ­˜¦r ¤®µª·š¥µ¨´¥«¦¸œ‡¦·œš¦ª·Ã¦•
  5. 5. ‡ÎµœÎµ „ Ÿ¼oœ·¡œ›r … šš¸É 1 Á„–”r„ε®œ—¨³„¨Å„„µ¦Á„·—°oªœÂ¨³°oªœ¨Š¡»Š 1 ª¦¦–¸ œ·›·¥µœ´œšr šš¸É 2 ¦³µ—ª·š¥µ…°Š£µª³°oªœÂ¨³°oªœ¨Š¡»ŠÄœž¦³Áš«Åš¥ 9 ª·´¥ Á°„¡¨µ„¦ šš¸É 3 ­µÁ®˜»…°Š°oªœÂ¨³°oªœ¨Š¡»Š 16 «»£ª¦¦– ¼¦–¡·¦ šš¸É 4 ž{®µ­»…£µ¡‹µ„°oªœÂ¨³°oªœ¨Š¡»Š 30 ª¦¦–¸ œ·›·¥µœ´œšr šš¸É 5 Ÿ¨„¦³š‹µ„°oªœÂ¨³°oªœ¨Š¡»Š 45 ª¦¦–¸ œ·›·¥µœ´œšr ¨³ žµ‹¦¸¥r °´—»¨¨µ„µŽ·¤ šš¸É 6 懰oªœÂ¨³°oªœ¨Š¡»ŠÄœÁ—Ȅ¨³ª´¥¦»nœ: ž{‹‹´¥š¸ÉšÎµÄ®oÁ„·—¨³ž{®µ—oµœ­»…£µ¡ 57 ¨´——µ Á®¤µ³­»ª¦¦– šš¸É 7 œÃ¥µ¥Â¨³¤µ˜¦„µ¦žj°Š„´œ°oªœÂ¨³°oªœ¨Š¡»ŠÄœÁ—Ȅ¨³ª´¥¦»nœ 71 °»¤µ¡¦ ­»š´«œrª¦ª»•· ¨³ ¨´——µ Á®¤µ³­»ª¦¦– šš¸É 8 œÃ¥µ¥Â¨³¤µ˜¦„µ¦žj°Š„´œ°oªœÂ¨³°oªœ¨Š¡»ŠÄœŸ¼oÄ®n: °»ž­¦¦‡Â¨³‡ªµ¤­ÎµÁ¦È‹ 101 ª–·µ „·‹ª¦¡´•œr šš¸É 9 ®¨´„„µ¦ ª·›¸„µ¦ ¨³Ážjµ®¤µ¥…°Š„µ¦‡ª‡»¤œÊ宜´„˜´ª 116 ‹»¦¸¡¦ ‡Šž¦³Á­¦·“ šš¸É 10 ㍜µ„µ¦Á¡ºÉ°žj°Š„´œÂ¨³¦´„¬µ°oªœÂ¨³°oªœ¨Š¡»Š 128 Á¦ª—¸ ‹Š­»ª´•œr
  6. 6. šš¸É 11 „µ¦°°„„ε¨´ŠÁ¡ºÉ°¦´„¬µÂ¨³žj°Š„´œ°oªœÂ¨³°oªœ¨Š¡»Š 138 ¦»nŠ´¥ ªœÅ¥³„¼¨ šš¸É 12 „µ¦Ä®o‡Îµž¦¹„¬µ ­¦oµŠÂ¦Š‹¼ŠÄ‹ ¦ŠŸ¨´„—´œÁ¡ºÉ°ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤Äœ„µ¦žj°Š„´œ 151 ¨³¦´„¬µ°oªœÂ¨³°oªœ¨Š¡»Š °´Š«·œ´œšr °·œš¦„ε®Š šš¸É 13 ¥µÂ¨³„µ¦Ÿnµ˜´—¦´„¬µ°oªœÂ¨³°oªœ¨Š¡»Š 188 ´¥µ —¸Ã¦‹œªŠ«r šš¸É 14 „µ¦‡ŠœÊ宜´„˜´ªš¸É¨—¨ŠÅ¤nÄ®oÁ¡·É¤…¹Êœ®¨´Š„µ¦¨—œÊ宜´„ 194 °£´­œ¸ »µª¦„»¨ šš¸É 15 š­¦»žÂ¨³…o°Á­œ°Âœ³ 201 ª¦¦–¸ œ·›·¥µœ´œšr ¨³ žµ‹¦¸¥r °´—»¨¨µ„µŽ·¤
  7. 7. 1 ª¦¦–¸ œ·›·¥µœ´œšr ¦¼ž¦nµŠš¸É­¤­nªœÁž}œ­·ÉŠ¡¹Šž¦³­Š‡r…°Šš»„‡œ ¨³°µ‹nŠ¸Ê™¹Š­»…£µ¡…°ŠŸ¼oœ´ÊœÅ—o—oª¥ „µ¦ ž¦³Á¤·œ—oª¥­µ¥˜µ­µ¤µ¦™¦³»Å—oªnµ‡œÄ—‡œ®œ¹ÉŠ¤¸¦¼ž¦nµŠž„˜· (¡°—¸) Ÿ°¤ ®¦º° °oªœ š´ÊŠœ¸Ê …¹Êœ„´ ‡ªµ¤‡·— ‡ªµ¤¡°Ä‹­nªœ»‡‡¨ Ťn¤¸¤µ˜¦“µœ Ťn°µ‹œÎµ¤µÁž¦¸¥Áš¸¥„´œÅ—o ×¥š´ÉªÅž œÊ宜´„˜´ª¤¸ ‡ªµ¤­´¤¡´œ›r„´‡ªµ¤­¼Š ¨³…¹Êœ„´ž¦·¤µ–¤ª¨„¦³—¼„ „¨oµ¤ÁœºÊ° Ņ¤´œ ¨³œÊε…°Š¦nµŠ„µ¥ „µ¦ª´— ­´—­nªœ…°Š¦nµŠ„µ¥Â¨³œÊ宜´„˜´ª‹¹ŠÁž}œ—´œ¸ž¦³Á¤·œ¦¼ž¦nµŠÂ¨³‡ªµ¤­¤­nªœš¸É´—Á‹œ…¹Êœ Á„–”r„ε®œ—°oªœÂ¨³°oªœ¨Š¡»Š °oªœ (obesity) °oªœ®¤µ¥™¹Š£µª³š¸É¤¸ž¦·¤µ–Å…¤´œ­³­¤Äœ¦nµŠ„µ¥¤µ„Á„·œž„˜· Ÿ¼oš¸É¤¸œÊ宜´„ž„˜·Á¤ºÉ°¤¸ ž¦·¤µ–Å…¤´œ­³­¤¤µ„…¹ÊœÂ¨³˜n°ÁœºÉ°Š ‹³Ÿnµœ‹µ„£µª³œÊ宜´„˜´ª¤µ„Á„·œ‹œÁ…oµ­¼n£µª³°oªœ ¦³¥³ Áª¨µÁ…oµ­¼n£µª³°oªœÁ¦Èª®¦º°oµ…¹Êœ„´°´˜¦µÁ„ȝ­³­¤Å…¤´œ Ĝ¦³¥³¥µª­nŠŸ¨„¦³š˜n°­»…£µ¡Å—o®¨µ¥ —oµœ „µ¦ª´—ž¦·¤µ–Å…¤´œ…°Š¦nµŠ„µ¥šÎµÅ—o®¨µ¥ª·›¸1 Ánœ bioelectrical impedance analysis, dilution techniques, dual energy X-ray absorptiometry, MRI ®¦º° magnetic resonance spectroscopy Á‡¦ºÉ°Š¤º°Á®¨nµœ¸Ê¤¸‡ªµ¤Â¤nœ¥Îµ ˜n¦µ‡µÂ¡Š …œµ—Ä®n ‹¹Š¤¸…o°‹Îµ„´—Äœ„µ¦Äo ĜšµŠž’·´˜· Á„–”r„ε®œ—®¦º°‡Îµ‹Îµ„´—‡ªµ¤…°Š£µª³°oªœ°µ«´¥œÊ宜´„˜´ª„´­nªœ­¼Š š¸É œ·¥¤Äo‡º° —´œ¸¤ª¨„µ¥ (body mass index, BMI) ¨³œÊ宜´„˜´ªÁš¸¥„´­nªœ­¼Š˜µ¤Á¡« Ž¹ÉŠÁ—È„ ¨³Ÿ¼oÄ®n¤¸Á„–”rª·œ·‹Œ´¥˜nµŠ„´œ —´œ¸¤ª¨„µ¥Áž}œ—´œ¸š¸Éčož¦³Á¤·œ‡ªµ¤Á®¤µ³­¤…°ŠœÊ宜´„˜´ª¤¸ ®œnª¥Áž}œ „„./¤.2 ‡Îµœª–‹µ„­¼˜¦ —´œ¸¤ª¨„µ¥ (BMI) = œÊ宜´„ („·Ã¨„¦´¤) ­nªœ­¼Š2 (Á¤˜¦) BMI Ĝ˜n¨³œµ˜·Å¤nÁ®¤º°œ„´œ2 ¡ªnµÄœ‡œÁ°Á¸¥Â¨³‡œŸ·ª…µªš¸É¤¸ BMI Ášnµ„´œ¤¸­´—­nªœ …°ŠÅ…¤´œÄœ¦nµŠ„µ¥˜nµŠ„´œ ×¥ÁŒ¨¸É¥‡œÁ°Á¸¥¤¸­´—­nªœ…°ŠÅ…¤´œ¤µ„„ªnµ ¨³¤¸­nªœš¸ÉÁž}œÃ‡¦Š­¦oµŠ „¨oµ¤ÁœºÊ°Â¨³„¦³—¼„œo°¥„ªnµ Ž¹ÉŠ­°—‡¨o°Š„´„µ¦«¹„¬µ®¨µ¥·Êœš¸É¡ªnµ ‡œÁ°Á¸¥š¸Éžiª¥—oª¥Ã¦‡ ¦³®´ªÄ‹Â¨³®¨°—Á¨º°—œ´Êœ Á„·—…¹Êœ­´¤¡´œ›r„´¦³—´ BMI š¸É˜É優nµ‡œ˜³ª´œ˜„ …o°¤¼¨Äœ‡œÅš¥ ¡ªnµŸ¼oµ¥Åš¥š¸É¤¸ BMI •23 „„./¤.2 Á­¸É¥Š˜n°„µ¦Á„·—懮¨°—Á¨º°—®´ªÄ‹3 ¦µ¥Šµœª·µ„µ¦Ã—¥ Ÿ¼oÁ¸É¥ªµš¸Éž¦¹„¬µ°Š‡r„µ¦°œµ¤´¥Ã¨„¨³°Š‡r„¦š¸ÉÁ„¸É¥ª…o°Š „ε®œ—Á„–”r BMI ­Îµ®¦´‡œÁ°Á¸¥4 ×¥„ε®œ—Ä®o£µª³œÊ宜´„Á„·œÄœ‡œÁ°Á¸¥®¤µ¥™¹ŠŸ¼oš¸É¤¸ BMI •23 „„./¤.2 ¨³°oªœ®¤µ¥™¹ŠŸ¼oš¸É¤¸ BMI •25 „„./¤.2 ‡œÅš¥š¸É¤¸°µ¥»˜´ÊŠÂ˜n 18 že…¹ÊœÅžÄoÁ„–”rœ¸Ê (˜µ¦µŠš¸É 1) º··Õè 1
  8. 8. 2 ˜µ¦µŠš¸É 1. œªšµŠ„µ¦˜´—­·œ­£µª³¦nµŠ„µ¥‡œÅš¥š¸É¤¸°µ¥» 18 že…¹ÊœÅžÃ—¥Äo—´œ¸¤ª¨„µ¥ ­£µª³¦nµŠ„µ¥ —´œ¸¤ª¨„µ¥ („„./¤.2 ) Ÿ°¤ ¦³—´ 3 ¦³—´ 2 ¦³—´ 1 < 16.0 16.0 - 16.9 17.0 - 18.4 ž„˜· 18.5 - 22.9 œÊ宜´„Á„·œ 23.0 - 24.9 °oªœ ¦³—´ 1a ¦³—´ 1b ¦³—´ 2 ¦³—´ 3 25.0 - 29.9 30.0 - 34.9 35.0 - 39.9 • 40.0 ­Îµ®¦´Á—È„¤¸„µ¦Äo—´œ¸¤ª¨„µ¥Ánœ„´œ ‡Îµœª–‡nµ—´œ¸¤ª¨„µ¥—oª¥ª·›¸Á—¸¥ª„´œ ¨oªœÎµÅž Áš¸¥„´„¦µ¢®¦º°‡nµ—´œ¸¤ª¨„µ¥°oµŠ°·Š˜µ¤°µ¥»Â¨³Á¡« Ĝ…–³œ¸Ê¥´ŠÅ¤n¤¸Á„–”r°oµŠ°·Š¤µ˜¦“µœ ­Îµ®¦´Á—È„Åš¥5 „µ¦ÄoœÊ宜´„˜´ªÁš¸¥„´­nªœ­¼ŠÂnŠ˜µ¤Á¡« ˜o°Š¤¸Á„–”rž„˜·¤µ˜¦“µœ…°Šœµ˜·œ´ÊœÇ Ánœ Ĝ­®¦´“°Á¤¦·„µ¤¸˜µ¦µŠœÊ宜´„¤µ˜¦“µœ˜µ¤­nªœ­¼ŠÄœÂ˜n¨³Á¡«š¸Éŗo‹µ„…o°¤¼¨„µ¦¤¸¸ª·˜…°Š „¨»n¤»‡‡¨š¸É˜·—˜µ¤¦³¥³¥µª ­Îµ®¦´ž¦³Áš«Åš¥Å¤n¤¸…o°¤¼¨œ¸Ê °µ‹ž¦³Á¤·œ‡¦nµªÇ ץčoœÊ宜´„˜´ª Áš¸¥„´­nªœ­¼Š —´Šœ¸Ê œÊ宜´„˜´ªš¸É‡ª¦Áž}œ…°ŠŸ¼oµ¥ („„.) = ­nªœ­¼ŠÁž}œÁŽœ˜·Á¤˜¦ ¨—oª¥ 100 œÊ宜´„˜´ªš¸É‡ª¦Áž}œ…°ŠŸ¼o®·Š („„.) = ­nªœ­¼ŠÁž}œÁŽœ˜·Á¤˜¦ ¨—oª¥ 100 ‡¼–—oª¥ 0.9 ­Îµ®¦´Á—È„ čoœÊ宜´„˜´ª¤µž¦³Á¤·œ—oª¥„¦µ¢°oµŠ°·Š„µ¦Á‹¦·Á˜·Ã˜œÊ宜´„˜µ¤‡ªµ¤­¼Š (®¦º°‡ªµ¤¥µªÄœÁ—È„°n°œ) …°ŠÁ—È„Åš¥°µ¥» 1 ª´œ ™¹Š 19 že …°Š„¦³š¦ªŠ­µ›µ¦–­»…5 ™oµœÊ宜´„˜µ¤ ‡ªµ¤­¼Š…°ŠÁ—È„¤µ„„ªnµ ‡nµœÊ宜´„¤´›¥“µœ (median) + 2 Ášnµ…°Š‡nµÁ¸É¥ŠÁœ¤µ˜¦“µœ (standard deviation, SD) ™º°ªnµœÊ宜´„Á„·œ ¨³œÊ宜´„˜µ¤‡ªµ¤­¼Š…°ŠÁ—È„š¸É¤µ„„ªnµ ‡nµœÊ宜´„¤´›¥“µœ + 3 Ášnµ…°Š‡nµÁ¸É¥ŠÁœ¤µ˜¦“µœ ™º°ªnµ°oªœ ˜µ¦µŠš¸É 2. ¦³—´‡ªµ¤¦»œÂ¦Š…°Š£µª³°oªœÄœÁ—Ȅץčo¦o°¥¨³…°ŠœÊ宜´„˜µ¤‡ªµ¤­¼Š ¦³—´ ¦o°¥¨³…°ŠœÊ宜´„˜µ¤‡ªµ¤­¼Š (%W/H) >120-140 >140-160 >160-200 >200 ‡ªµ¤¦»œÂ¦Š…°Š£µª³°oªœ (obesity) Á¨È„œo°¥ (mild) žµœ„¨µŠ (moderate) ¦»œÂ¦Š (severe) ¦»œÂ¦Š¤µ„ (morbid)
  9. 9. 3 œ°„‹µ„œ¸Ê °µ‹Äo—´œ¸ ¦o°¥¨³…°ŠœÊ宜´„˜µ¤‡ªµ¤­¼Š (% weight-for-height, %W/H) %W/H ‡Îµœª–‹µ„ œÊ宜´„˜´ª ‡¼–—oª¥ 100 ®µ¦—oª¥ ‡nµœÊ宜´„°oµŠ°·Š˜µ¤Á„–”r‡ªµ¤­¼Š ‡nµ %W/H š¸É ¤µ„„ªnµ 120 ™º°ªnµ°oªœ5 Ž¹ÉŠÂnŠ‡ªµ¤¦»œÂ¦Š˜µ¤˜µ¦µŠš¸É 2 °oªœ¨Š¡»Š (abdominal obesity) °oªœ¨Š¡»Š ®¤µ¥™¹Š£µª³š¸É¤¸Å…¤´œ­³­¤Äœn°Ššo°Š (intra-abdominal adiposity) ®¦º°°ª´¥ª³ Ĝn°Ššo°Š (visceral fat) ¤µ„Á„·œ‡ª¦ ×¥š´ÉªÅžÁ¤ºÉ°Å…¤´œ­³­¤¤µ„…¹Êœ‹³™¼„œÎµÅžÁ„ȝŪoĜÁŽ¨¨r Ņ¤´œš¸É¤¸°¥¼nš´Éª¦nµŠ„µ¥ ŗo„n Ĝ´ÊœÄ˜oŸ·ª®œ´Š š¸É°¥¼n¦°°ª´¥ª³˜nµŠÇ …°Š¦nµŠ„µ¥ ×¥ÁŒ¡µ³°¥nµŠ¥·ÉŠ °ª´¥ª³Äœn°Ššo°Š ¨³ÂŸŠÃ°Á¤Èœ˜´Ê¤ (omentum) —´Šœ´ÊœÁ¤ºÉ°¤¸Å…¤´œ­³­¤Äœn°Ššo°Š¤µ„Ç ‹³Á®Èœ®œoµ šo°Š¥ºÉœ°°„¤µ´—Á‹œ Á„–”r„ε®œ—°oªœ¨Š¡»ŠÄo‡ªµ¤¥µª¦°Á°ª (waist circumference) Áž}œ—´œ¸ nŠ¸Ê ×¥¤¸„µ¦«¹„¬µš¸É¥ºœ¥´œ‡ªµ¤­´¤¡´œ›r¦³®ªnµŠ¦°Á°ªÂ¨³ž¦·¤µ–Å…¤´œ­³­¤Äœn°Ššo°Š6 „µ¦ª´— ¦°Á°ªšÎµÅ—oŠnµ¥Â¨³ÄoŗoĜš»„„¦–¸ ¤µ˜¦“µœ¦°Á°ª…°Š‡œÂ˜n¨³ÁºÊ°µ˜·¤¸‡ªµ¤Â˜„˜nµŠ„´œ»7 (˜µ¦µŠš¸É 3) ˜µ¦µŠš¸É 3. Á„–”r¦°Á°ª˜µ¤œµ˜·­Îµ®¦´ª·œ·‹Œ´¥°oªœ¨Š¡»Š7 ÁºÊ°µ˜· ¦°Á°ª (ÁŽœ˜·Á¤˜¦) Ÿ¼o„ε®œ— µ¥ ®·Š °Á¤¦·„µ •102 •88 AHA/NHLBI, ATP III ‡œµ—µ •102 •88 Health Canada ¥»Ã¦ž •102 •88 Eur Cardiovas Society ˜³ª´œ°°„„¨µŠ, Á¤—·Á˜°Á¦Áœ¸¥œ, Sub-Saharan African •94 •80 International Diabetes Federation Ethic Central & South American, Á°ÁŽ¸¥ •90 •80 International Diabetes Federation, WHO ¸Éž»iœ •85 •90 Japan Obesity Society ‹¸œ •85 •80 Cooperative Task Force ¤µ˜¦“µœ¦°Á°ª ­Îµ®¦´‡œÅš¥‡º° Ÿ¼oµ¥œo°¥„ªnµ 90 ÁŽœ˜·Á¤˜¦ ¨³Ÿ¼o®·Šœo°¥„ªnµ 80 ÁŽœ˜·Á¤˜¦8 ¤¸…o°¤¼¨Â­—Šªnµµ¥Åš¥š¸É¤¸¦°Á°ª 85 ÁŽœ˜·Á¤˜¦…¹ÊœÅž ¤¸‡ªµ¤Á­¸É¥Š˜n°Ã¦‡®¨°—Á¨º°— ®´ªÄ‹9 Ÿ¼oš¸É°oªœ¨Š¡»Š°µ‹—¼Å¤n°oªœ®¦º°Å¤n°oªœ˜µ¤—´œ¸¸Êª´—×¥ BMI ‡º° BMI œo°¥„ªnµ 25 „„./¤.2 ¡ªnµ¦°Á°ª¤¸‡ªµ¤­´¤¡´œ›r„´„µ¦Á„·—懍´—Á‹œ„ªnµ BMI6,10 °¥nµŠÅ¦„Șµ¤ °oªœÂ¨³°oªœ¨Š¡»Š¤¸ ‡ªµ¤­Îµ‡´ÄœšµŠ­»…£µ¡Å¤nœo°¥„ªnµ„´œ ™oµ BMI š¸É­¼Šœ´ÊœÁ„·—‹µ„„µ¦¤¸Å…¤´œ­³­¤¤µ„Ťnčn‹µ„„µ¦ Á¡·É¤…¹Êœ…°Š­nªœ„¨oµ¤ÁœºÊ° ‡œÅš¥š¸É°oªœ®¦º°°oªœ¨Š¡»Š¤¸‡ªµ¤Á­¸É¥Š˜n°„µ¦Á„·—æ‡Áµ®ªµœ ™oµ°oªœ ¨³°oªœ¨Š¡»Š‹³Á¡·É¤‡ªµ¤Á­¸É¥Š­¼Š…¹Êœ11 „µ¦ª´—¦°Á°ªÄ®ošÎµÄœnªŠÁoµ …–³¥´ŠÅ¤nŗo¦´ž¦³šµœ°µ®µ¦ ˜ÎµÂ®œnŠš¸Éª´—Ťn‡ª¦¤¸Á­ºÊ°Ÿoµ žd— ®µ„¤¸Ä®oÁž}œÁ­ºÊ°ŸoµÁœºÊ°µŠ ª·›¸ª´—š¸Éœ³œÎµ‡º°
  10. 10. 4 1. °¥¼nĜšnµ¥ºœ Ášoµ 2 …oµŠ®nµŠ„´œž¦³¤µ– 10 ÁŽœ˜·Á¤˜¦ 2. ®µ˜ÎµÂ®œnŠ…°œ­»—…°Š„¦³—¼„Á·Š„¦µœÂ¨³…°¨nµŠ…°Šµ¥Ã‡¦Š 3. čo­µ¥ª´—¡´œ¦°Á°ªš¸É˜ÎµÂ®œnŠ‹»—„¹ÉŠ„¨µŠ¦³®ªnµŠ…°œ…°Š„¦³—¼„Á·Š„¦µœÂ¨³ …°¨nµŠ…°Šµ¥Ã‡¦Š ץĮo­µ¥ª´—°¥¼nĜœª…œµœ„´¡ºÊœ 4. ª´—ÄœnªŠ®µ¥Ä‹°°„ ץĮo­µ¥ª´—Âœ„´¨Îµ˜´ª¡°—¸Å¤n¦´—Âœnœ „¨Å„„µ¦Á„·—°oªœÂ¨³°oªœ¨Š¡»Š ¡¨´ŠŠµœš¸ÉÁ®¨º°Äo‹µ„°µ®µ¦š¸É„·œ¤µ„Á„·œÅž ‹³™¼„Áž¨¸É¥œÂž¨ŠÄ®oÁž}œ¡¨´ŠŠµœ­Îµ¦°ŠÄœ¦¼ž „¨´¥Ã‡Á‹œÁ„ȝŪoš¸É˜´Â¨³„¨oµ¤ÁœºÊ°¨µ¥ ¨³„¦—Å…¤´œ°·­¦³Á„ȝŪoĜÁŽ¨¨rŅ¤´œš¸É¤¸°¥¼nš´Éª¦nµŠ„µ¥Áž}œ ئ„¨¸ÁŽ°Å¦—r (triglyceride) ®¦º° ئ°³Ž·¨„¨¸ÁŽ°¦°¨ (triacylglycerols) „µ¦Á„ȝ¡¨´ŠŠµœ­Îµ¦°ŠÄœ ¦¼ž„¨´¥Ã‡Á‹œ¤¸…¸—‹Îµ„´—Äœž¦·¤µ– ˜nš¸ÉÁŽ¨¨rŅ¤´œÅ¤n¤¸…¸—‹Îµ„´—´—Á‹œ ÁŽ¨¨rŅ¤´œ‹³…¥µ¥…œµ—Ä®n …¹Êœ˜µ¤ž¦·¤µ–ئ„¨¸ÁŽ°Å¦—rš¸ÉÁ¡·É¤…¹Êœ Ĝ…–³°—°µ®µ¦ ¤¸„µ¦­¨µ¥„¨´¥Ã‡Á‹œš¸É­³­¤Äœ˜´Áž}œ „¨¼Ã‡­ (glycogenolysis) ­nŠÅžÄ®oÁŽ¨¨rčoÁž}œ¡¨´ŠŠµœ ¨³˜´­µ¤µ¦™Áž¨¸É¥œ„¦—Å…¤´œ°·­¦³Ä®oÁž}œ ­µ¦‡¸Ã˜œ (ketone) Á¡ºÉ°ÄoÁž}œ¡¨´ŠŠµœÅ—o Á¤ºÉ°¦nµŠ„µ¥¤¸‡ªµ¤˜o°Š„µ¦¡¨´ŠŠµœÁ¡·É¤Á˜·¤ Ánœ Ĝ…–³ °°„„ε¨´Š„µ¥ „¨oµ¤ÁœºÊ°‹³­¨µ¥„¨´¥Ã‡Á‹œŽ¹ÉŠ¤¸‹Îµœªœ‹Îµ„o—Áž}œ„¨¼Ã‡­¤µÄo„n°œ ˜n°¤µ‹¹Š­¨µ¥Å˜¦ „¨¸ÁŽ°Å¦—rĜÁŽ¨¨rŅ¤´œÁž}œ„¦—Å…¤´œ°·­¦³12 Ž¹ÉŠ‹³Ÿnµœ„¦³ªœ„µ¦—´—ž¨Šš¸É˜´Ä®oÁž}œ„¨¼Ã‡­ (gluconeogenesis) ­nŠÅž¥´Š„¨oµ¤ÁœºÊ°Â¨³°ª´¥ª³˜nµŠÇ Á¡ºÉ°ÄoÁž}œ¡¨´ŠŠµœ ¨³˜´­µ¤µ¦™­¦oµŠ „¨¼Ã‡­‹µ„­µ¦°ºÉœÅ—o ‡º°‹µ„ ¨‡Á˜˜ „¦—°³¤·Ãœ Á¤ºÉ°°°„„ε¨´Š„µ¥Áž}œÁª¨µœµœ „¨oµ¤ÁœºÊ°¨µ¥Äoš´ÊŠ „¨¼Ã‡­Â¨³„¦—Å…¤´œ°·­¦³Áž}œ¡¨´ŠŠµœÅ—o13 ‡ªµ¤°¥µ„°µ®µ¦ ‡ªµ¤¦¼o­¹„°·É¤ ¨³„µ¦Á„ȝ­³­¤Å…¤´œÄœÁŽ¨¨rŅ¤´œ ¤¸„¨Å„‡ª‡»¤š¸É Ž´Žo°œ14,15 ×¥«¼œ¥r‡ª‡»¤Äœ¦³ž¦³­µš­nªœ„¨µŠ±´¥Ãž›µ¨µ¤´­ (hypothalamus) ž¦³­µšÁª„´­ ¨³±°¦r䜋µ„®¨µ¥Â®¨nŠ Ánœ Á¨Èž˜·œ (leptin) ‹µ„ÁŽ¨¨rŅ¤´œ °·œŽ¼¨·œ (insulin) ‹µ„˜´°n°œ ‡°¨¸ Ž·­Ã˜Å‡œ·œ (cholecystokinin) ‹µ„šµŠÁ—·œ°µ®µ¦­nªœ˜oœ ±°¦räœÁ¡«Á°­Ã˜¦Á‹œ ÁŽ¨¨rŅ¤´œ¤¸ 2 „¨»n¤Ä®n‡º° ÁŽ¨¨rŅ¤´œÄœ´ÊœÄ˜oŸ·ª®œ´ŠÂ¨³ÁŽ¨¨rŅ¤´œš¸É°¥¼n­´¤¡´œ›r„´°ª´¥ª³ ˜nµŠÇ Ánœ ®´ªÄ‹ Ř ¨ÎµÅ­o ®¨°—Á¨º°— ×¥š´ÉªÅž„µ¦Á„ȝ­Îµ¦°Š¡¨´ŠŠµœÄœÁŽ¨¨rŅ¤´œ‹³„¦³‹µ¥Åžš´Éª ¦nµŠ„µ¥ Á¤ºÉ°°oªœ¤µ„‹¹Š¤¸¦°Á°ªÄ®n…¹Êœ˜µ¤œÊ宜´„š¸ÉÁ¡·É¤…¹Êœ (°oªœÂ¨³¨Š¡»Š) µŠ£µª³Â¨³ž{‹‹´¥ µŠ°¥nµŠ­nŠÁ­¦·¤Ä®o¤¸„µ¦­³­¤Å…¤´œÁ—nœ®¦º°¤µ„š¸ÉÁŽ¨¨rŅ¤´œš¸É°¥¼n­´¤¡´œ›r„´°ª´¥ª³Äœn°Ššo°Š Á¤ºÉ° Áš¸¥„´„µ¦­³­¤š¸ÉÁŽ¨¨rŅ¤´œÄœ´ÊœÄ˜oŸ·ª®œ´Š šÎµÄ®o¤¸¦°Á°ªÄ®n…¹Êœ®¦º°Ä®n¤µ„Ťn­´¤¡´œ›r„´ œÊ宜´„š¸ÉÁ¡·É¤…¹Êœ (°oªœ¨Š¡»Š) ÁŽ¨¨rŅ¤´œ¤¸ 2 œ·—‡º° ÁŽ¨¨rŅ¤´œ…µª (white adipose tissue) ¨³ ÁŽ¨¨rŅ¤´œ­¸œÊ嘵¨ (brown adipose tissue) š´ÊŠ­°Š¤¸‡ªµ¤Â˜„˜nµŠ…°Š‡»–­¤´˜·ÄœÂŠn„µ¦ÁŸµŸ¨µ ¡¨´ŠŠµœ (thermogenic capacity)16-18 ÁºÉ°ªnµÁŽ¨¨rŅ¤´œ­¸œÊ嘵¨Á¡·É¤„µ¦ÁŸµŸ¨µ¡¨´ŠŠµœ ¤¸­nªœšÎµ Ä®o„µ¦­³­¤Å…¤´œ¨—¨Š ž{‹‹´¥­nŠÁ­¦·¤Ä®o„µ¦­³­¤Å…¤´œÁ—nœš¸ÉÁŽ¨¨rŅ¤´œÄœ°ª´¥ª³n°Ššo°Šš¸É¡Å—o„n Á¡« °¨„°±°¨r °µ®µ¦µŠž¦³Á£š „µ¦­¼»®¦¸É ±°¦räœÁ¡«µ¥˜Éε ‡ªµ¤Ÿ·—ž„˜·šµŠ¡´œ›»„¦¦¤
  11. 11. 5 Á¡« ¡ªnµÁ¡«µ¥¤¸Å…¤´œÄœn°Ššo°Š¤µ„„ªnµÁ¡«®·Š19 ĜŸ¼oµ¥Á¤ºÉ°œÊ宜´„…¹Êœ¨´„¬–³ °oªœ‹³Áž}œÂ°oªœš¸É¡»Š (android type of obesity) ­nªœŸ¼o®·ŠÅ…¤´œ‹³­³­¤š¸É­³Ã¡„¨³˜oœ…µ ¨´„¬–³Áž}œ°oªœš¸É­nªœ¨nµŠ (gynoid type of obesity) ±°¦räœÁ¡«µ¥˜ÉεĜµ¥­¼Šª´¥ ¡ªnµµ¥­¼Šª´¥š¸É¤¸¦³—´±°¦räœÁš­Ã˜­Á˜°Ã¦œÄœÁ¨º°— ˜Éε‹³¤¸¨´„¬–³…°Š„¨»n¤°µ„µ¦Á¤Âš°¨·‡ (metabolic syndrome) Áž}œ­nªœÄ®n ¦³—´±°¦r䜚¸É˜Éε ÁºÉ°ªnµ­nªœ®œ¹ÉŠ°›·µ¥Å—o‹µ„¦³—´Ã„¨¼¨·œš¸É‹´„´±°¦räœÄœÁ¨º°— (sex hormone-binding globulin) ¨—¨Š ˜n¦³—´±°¦räœÁš­Ã˜­Á˜°Ã¦œ°·­¦³ÄœÁ¨º°— (free circulating testosterone blood level) ¨—¨ŠÁnœ„´œ °¸„­nªœ®œ¹ÉŠ°µ‹Áž}œŸ¨‹µ„„µ¦Áž¨¸É¥œÂž¨Š…°Šž{‹‹´¥°ºÉœ20,21 Ánœ ±°¦räœÁ¨Èž˜·œ ®¦º°¦¸ ÁŽÈžÁ˜°¦rš¸É¦´±°¦räœÁ¡«µ¥ (androgen receptor) ®¦º°Á°œÅŽ¤rĜ„¦³ªœ„µ¦­¦oµŠ±°¦räœÁ¡« µ¥ (steroidogenic enzymes) šÎµÄ®o¤¸¦°Á°ªÄ®n¨³„¨»n¤°µ„µ¦Á¤Âš°¨·‡ µ¥š¸É¤¸£µª³…µ—®¦º° ¡¦n°Š±°¦räœÁ¡«‹³¡¨´„¬–³Á—¸¥ª„´œ °¨„°±°¨r …o°¤¼¨šµŠ¦³µ—ª·š¥µ ¡ªnµ„µ¦—ºÉ¤Á‡¦ºÉ°Š—ºÉ¤š¸É¤¸Â°¨„°±°¨rĜž¦·¤µ–Á„·œ„ε®œ— ¨³˜n°ÁœºÉ°ŠšÎµÄ®o¤¸Å…¤´œ­³­¤Äœn°Ššo°Š¤µ„…¹Êœ22,23 ×¥ÁŒ¡µ³°¥nµŠ¥·ÉŠ„µ¦—ºÉ¤Á¸¥¦r22 œnµ‹³°›·µ¥ ‹µ„„µ¦Áž¨¸É¥œÂž¨Š…°Š±°¦räœÁ¨Èž˜·œ„´°³—·ÃžÁœÈ‡˜·œ Ž¹ÉŠ¡‹µ„„µ¦«¹„¬µÄœ®œ¼š—¨°Š24 ˜nŤn ­´¤¡´œ›r„´„µ¦Á„·—£µª³—ºÊ°°·œŽ¼¨·œ25 °µ®µ¦µŠž¦³Á£š ¡ªnµ„µ¦„·œ°µ®µ¦š¸É¤¸Å¥°µ®µ¦ (dietary fiber) ­¼Š ¤¸—´œ¸‡ªµ¤®ªµœ (glycemic index) ˜É娳ž¦·¤µ–‡µ¦rÝűÁ—¦˜ (glycemic load) œo°¥ nª¥žj°Š„´œ„µ¦Á¡·É¤…°Š œÊ宜´„¨³¦°Á°ª26.27 „µ¦—ºÉ¤Á‡¦ºÉ°Š—ºÉ¤š¸ÉŸ­¤œÊ嘵¨ (soft drink) ¨³œÊεŸ¨Å¤ož¦³‹Îµ ª´œ¨³ 2 „oª šÎµÄ®oœÊ宜´„…¹ÊœÂ¨³°oªœÅ—o ×¥ÁŒ¡µ³°¥nµŠ¥·ÉŠœÊ嘵¨¢¦»p„Ø­‹µ„…oµªÃ¡— (high fructose corn syrup) Ž¹ÉŠœ·¥¤ÄoĜ°»˜­µ®„¦¦¤Á‡¦ºÉ°Š—ºÉ¤¦¦‹»…ª—®¦º°„¦³žl°Š Á¡·É¤„µ¦Á„ȝ­³­¤Å…¤´œÄœn°Ššo°Š28-30 „µ¦­¼»®¦¸É …o°¤¼¨šµŠ¦³µ—ª·š¥µ¡ªnµµ¥Â¨³®·Šš¸ÉÁ‡¥­¼»®¦¸É®¦º°„ε¨´Š­¼»®¦¸É¤¸Å…¤´œ Ĝn°Ššo°Š­³­¤Á¡·É¤…¹Êœ22,31 Ÿ¼oš¸É­¼»®¦¸Éž¦³‹Îµ­nªœ®œ¹ÉŠ¤¸ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥Å¤n¤µ„ ˜n…o°¤¼¨š¸É¤¸ ¥´ŠÅ¤n­°—‡¨o°Š„´œš´ÊŠ®¤—31-33 ‡ªµ¤Ÿ·—ž„˜·šµŠ¡´œ›»„¦¦¤ ÁºÉ°ªnµ‡ªµ¤Ÿ·—ž„˜·šµŠ¡´œ›»„¦¦¤Áž}œž{‹‹´¥®œ¹ÉŠš¸ÉÁ„¸É¥ª…o°Š „´œÊ宜´„˜´ªÂ¨³„µ¦­³­¤Å…¤´œÄœ¦nµŠ„µ¥ ×¥¤¸ž’·­´¤¡´œ›r„´­·ÉŠÂª—¨o°¤ °µ‹Áž}œ‡ªµ¤Ÿ·—ž„˜· …°Š¥¸œš¸É­´¤¡´œ›r„´°oªœÃ—¥˜¦Š34 ¥¸œ°ºÉœ ®¦º°¥¸œš¸É‡ª‡»¤­¤—»¨¡¨´ŠŠµœ…°Š¦nµŠ„µ¥ (¦µ¥¨³Á°¸¥— Á¡·É¤Á˜·¤Äœ­µÁ®˜»…°Š°oªœÂ¨³°oªœ¨Š¡»Š) ×¥­¦»ž œÊ宜´„ ­nªœ­¼Š ¨³¦°Á°ª Áž}œ…o°¤¼¨š¸Éª´—Å—oŠnµ¥Â¨³ÄoÁž}œÁ„–”r„ε®œ—£µª³ °oªœÂ¨³°oªœ¨Š¡»Šš´ÉªÃ¨„ ­Îµ®¦´‡œÅš¥Ÿ¼oÄ®n°·Š…o°¤¼¨…°ŠµªÁ°Á¸¥ ˜o°Š„µ¦Šµœª·‹´¥Á¡·É¤Á˜·¤Á¡ºÉ° ¥ºœ¥´œªnµ¦°Á°ªš¸ÉÁ®¤µ³­¤…°Šµ¥Åš¥‡ª¦˜É優nµ 85 ÁŽœ˜·Á¤˜¦ ­Îµ®¦´Á—È„Åš¥Äo„¦µ¢°oµŠ°·Š„µ¦ Á‹¦·Á˜·Ã˜œÊ宜´„˜µ¤‡ªµ¤­¼Š®¦º°‡ªµ¤¥µª˜´ª…°ŠÁ—È„Åš¥°µ¥» 1 ª´œ ™¹Š 19 že …°Š„¦³š¦ªŠ ­µ›µ¦–­»… ž{‹‹´¥£µ¥ÄœÂ¨³­·ÉŠÂª—¨o°¤®¨µ¥°¥nµŠ­nŠÁ­¦·¤Ä®oœÊ宜´„¨³¦°Á°ªÁ¡·É¤…¹Êœ‹œÁ„·—£µª³ °oªœÂ¨³°oªœ¨Š¡»Š
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  15. 15. 9 ª·´¥ Á°„¡¨µ„¦ °Š‡r„µ¦°œµ¤´¥Ã¨„ ŗo­—Š…o°¤¼¨‡ªµ¤»„…°Š£µª³œÊ宜´„Á„·œÂ¨³°oªœÄœ 90 ž¦³Áš« (Global Data on Body Mass Index) ¡ªnµ‡ªµ¤»„…°Š£µª³œÊ宜´„Á„·œ (body mass index, BMI •25 „„./¤.2 ) Ĝž¦³Áš«˜nµŠÇ ¤¸˜´ÊŠÂ˜n˜É優nµ¦o°¥¨³ 5 Ĝž¦³Áš«Áª¸¥—œµ¤Â¨³°·œÁ—¸¥ ‹œ„¦³š´ÉŠ­¼Š „ªnµ¦o°¥¨³ 50 Ĝž¦³Áš«­®¦´“°Á¤¦·„µ Seychelles œ·ªŽ¸Â¨œ—r ¨³°°­Á˜¦Á¨¸¥ ­Îµ®¦´‡ªµ¤»„…°Š £µª³œÊ宜´„Á„·œÂ¨³°oªœÄœž¦³µœ…°ŠµŠž¦³Áš«Äœšª¸žÁ°Á¸¥—´ŠÂ­—ŠÄœ˜µ¦µŠš¸É 1 Ž¹ÉŠ­™·˜·œ¸Ê¤¸ …o°‹Îµ„´—Äœ„µ¦Áž¦¸¥Áš¸¥¦³®ªnµŠž¦³Áš« ÁœºÉ°Š‹µ„˜n¨³ž¦³Áš«¤·Å—oÁ„ȝ…o°¤¼¨ÄœnªŠÁª¨µÁ—¸¥ª„´œ ª·›¸„µ¦Á„ȝ…o°¤¼¨ ¨³„¨»n¤°µ¥»š¸É¤¸„µ¦­Îµ¦ª‹¤¸‡ªµ¤Â˜„˜nµŠ„´œ ˜n…o°¤¼¨œ¸Ê­µ¤µ¦™Â­—Š­™µœ„µ¦–r …°Šž{®µÃ¦‡°oªœÄœÂ˜n¨³ž¦³Áš« ĜnªŠÁª¨µ—´Š„¨nµª1,2 ˜µ¦µŠš¸É 1. ‡ªµ¤»„£µª³œÊ宜´„Á„·œÂ¨³‡ªµ¤»„懰oªœÄœž¦³µ„¦Á°Á¸¥ BMI •25 „„./¤.2 BMI •30 „„./¤.2 ž¦³Áš« že ‡«. š¸É­Îµ¦ª‹ °µ¥» µ¥ ®·Š ¦ª¤ µ¥ ®·Š ¦ª¤ „´¤¡¼µ 2005 15-49 9.6 ‹¸œ 2002 18+ 19.1 18.8 2.4 3.4 ±n°Š„Š 1995/6 25-74 38 34 5 7 °·œÁ—¸¥ 2005/6 15-49 9.3 12.6 1.3 2.8 °·œÃ—œ¸ÁŽ¸¥ 2000 20+ 11.5 21.9 1.3 4.5 ¸Éž»iœ 2004 15-100 27.3 19.9 23.2 2.8* 3.3* 3.1* Á„µ®¨¸Ä˜o 2005 20+ 35.2 28.3 31.8 1.7* 3.0** 2.4** ¤µÁ¨ÁŽ¸¥ 1996 18+ 24.1 29.0 4.0 7.6 Áœžµ¨ 2006 15-49 8.7 1.1 ¢d¨·žždœ­r 1998 20+ 17.0 23.3 16.9 2.1 4.4 3.3 ­·Š‡Ãž¦r 2004 18-69 35 29.9 32.5 6.4 7.3 6.9 Řo®ª´œ 1993-6 20+ 24.7 25.1 25.8 2.4 5.9 21.1 Ś¥ 2004 18+ 22.4 34.3 4.7 9.1 Áª¸¥—œµ¤ 2001/2 19+ 4.4 6.6 http://iotf.org/database/documents/GlobalPrevalenceofAdultObesity20thJanuary2010.pdf *…o°¤¼¨že 2001, **…o°¤¼¨ že 1998 ­Îµ®¦´­™·˜·Äœž¦³Áš«Åš¥ ¤oªnµ‡ªµ¤»„懰oªœ¥´ŠÅ¤nÁš¸¥Ášnµ‡œÄœÂ™˜³ª´œ°°„„¨µŠ ¥»Ã¦ž ¨³°Á¤¦·„µ ˜nœªÃœo¤‡ªµ¤»„…°ŠÃ¦‡°oªœ¤¸Á¡·É¤…¹Êœ˜µ¤¨Îµ—´ ¨³‡ªµ¤»„Ťnœo°¥Åž„ªnµ º··Õè 2
  16. 16. 10 µŠž¦³Áš«ÄœÁ°Á¸¥ Ánœ ž¦³Áš«‹¸œ Á„µ®¨¸ ¸Éž»iœ ¨³­·Š‡Ãž¦r ‡ªµ¤»„…°Š£µª³°oªœš¸É‹³„¨nµª ˜n°Åžœ¸Ê‹³Äo BMI ˜µ¤Á„–”r­Îµ®¦´‡œÁ°Á¸¥3 ‡º°˜´—š¸É¦³—´ BMI •25 „„./¤.2 œªÃœo¤…°Š‡ªµ¤»„…°Š£µª³°oªœ BMI •25 „„./¤.2 Ĝž¦³µ„¦Åš¥ œªÃœo¤‡ªµ¤»„…°Š£µª³°oªœ ˜µ¤Ÿ¨„µ¦­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥Ã—¥„µ¦˜¦ª‹¦nµŠ„µ¥ ‡¦´ÊŠ 1- 4 čoÁ„–”r BMI •25 „„./¤.2 ¨³ BMI •30 „„./¤.2 ˜µ¤¨Îµ—´ ‡ªµ¤»„…°Š£µª³°oªœš¸É BMI •25 „„./¤.2 Ĝž¦³µ„¦°µ¥» 18 že…¹ÊœÅž Á¡·É¤‹µ„¦o°¥¨³ 18.2 Ĝže ¡.«. 2534 Áž}œ¦o°¥¨³ 24.1 Ĝže 2540 ¨³Á¡·É¤Áž}œ¦o°¥¨³ 28.1 ¨³¦o°¥¨³ 36.5 Ĝže ¡.«. 2547 ¨³ 2552 ˜µ¤¨Îµ—´ ­Îµ®¦´‡ªµ¤ »„…°Š£µª³°oªœš¸É BMI •30 „„./¤.2 Á¡·É¤‹µ„¦o°¥¨³ 3.5 Ĝže ¡.«. 2534 Áž}œ¦o°¥¨³ 5.8, ¦o°¥¨³ 6.9 ¨³¦o°¥¨³ 9.0 ˜µ¤¨Îµ—´ ĜnªŠže—´Š„¨nµª (˜µ¦µŠš¸É 2) ×¥‡ªµ¤»„…°ŠÃ¦‡°oªœÄœÁ¡«®·Š¤µ„„ªnµ Á¡«µ¥ œ°„‹µ„œ¸Ê‡ªµ¤»„Á¡·É¤…¹Êœ˜µ¤°µ¥»š¸ÉÁ¡·É¤…¹Êœ‹œ¤¸‡ªµ¤»„­¼Š­»—Äœ„¨»n¤ °µ¥» 45-54 že4,5 ˜µ¦µŠš¸É 2. ­—Š‡ªµ¤»„ (¦o°¥¨³) …°Š£µª³°oªœÄœž¦³µ„¦Åš¥°µ¥» 18 že…¹ÊœÅžÄœ nªŠÁª¨µ˜nµŠÇ ¡.«. 2534 ¡.«. 2540 ¡.«. 2547 ¡.«. 2552 BMI •25 „„./¤.2 18.2 24.1 28.1 36.5 BMI •30 „„./¤.2 3.5 5.8 6.9 9.0 ‡ªµ¤»„…°ŠÃ¦‡°oªœ Ĝže ¡«. 2552 „µ¦­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥‡¦´ÊŠš¸É 4 ¡.«. 2552 ‡ªµ¤»„…°Š£µª³°oªœÄœž¦³µ„¦Åš¥ °µ¥» 15 že…¹ÊœÅž ¡ªnµÁ¡«µ¥¦o°¥¨³ 28.3 ¨³Á¡«®·Š¦o°¥¨³ 40.7 ¤¸£µª³°oªœ (BMI •25 „„./¤.2 ) ×¥‡ªµ¤»„­¼Š­»—Äœ„¨»n¤°µ¥» 45-59 že ‡ªµ¤»„¨—¨ŠÄœ„¨»n¤Ÿ¼o­¼Š°µ¥» ¨³˜Éε­»—Äœ„¨»n¤°µ¥» 80 že…¹Êœ Ş (¦¼žš¸É 1) ¦¼žš¸É 1. ‡ªµ¤»„…°Š£µª³°oªœ (BMI •25 „„./¤.2 ) Ĝž¦³µ„¦Åš¥°µ¥» 15 že…¹ÊœÅž ‹ÎµÂœ„˜µ¤Á¡«Â¨³°µ¥»
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  21. 21. 15 ­»…£µ¡¦³—´ž{‹Á‹„ (individual approach) ŗo„n„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤…°Šž¦³µœÄœÁ¦ºÉ°Š„µ¦ „·œ°µ®µ¦š¸ÉÁ®¤µ³­¤ ¨³­nŠÁ­¦·¤Ä®o¤¸„·‹„¦¦¤šµŠ„µ¥š¸ÉÁ¡¸¥Š¡°‹¹ŠÁž}œ­·ÉŠš¸É˜o°Š—εÁœ·œ„µ¦Ä®o¤¸‡ªµ¤ Á…o¤Šª—¤µ„…¹Êœ˜n°Åž Á°„­µ¦°oµŠ°·Š 1. http://iotf.org/database/documents/GlobalPrevalenceofAdultObesity20thJanuary2010.pdf 2. Global data base on Body Mass Index. http://apps.who.int/bmi/index.jsp?introPage=intro_5.html 3. WHO/IASO/IOTF. The Asia-Pacific perspective: redefining obesity and its treatment. Health Communications Australia: Melbourne. 4. Aekplakorn W, Mo-Suwan L. Prevalence of obesity in Thailand. Obes Rev. 2009; 10: 589- 92. 5. Aekplakorn W, Hogan MC, Chongsuvivatwong V, Tatsanavivat P, Chariyalertsak S, Boonthum A, Tiptaradol S, Lim SS. Trends in obesity and associations with education and urban or rural residence in Thailand. Obesity (Silver Spring) 2007; 15: 3113-21. 6. ª·´¥ Á°„¡¨µ„¦ (¦¦–µ›·„µ¦). ¦µ¥Šµœ„µ¦­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥Ã—¥„µ¦˜¦ª‹¦nµŠ„µ¥ ‡¦´ÊŠš¸É 4 ¡.«. 2551-2552. œœš»¦¸: ­Îµœ´„Šµœ­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥ / ­™µ´œª·‹´¥¦³ ­µ›µ¦–­»…; 2553.
  22. 22. 16 «»£ª¦¦– ¼¦–¡·¦ 懰oªœÂ¨³°oªœ¨Š¡»Š¤¸Á®˜»‹µ„ 3 ž{‹‹´¥®¨´„‡º° „µ¦‡ª‡»¤‡ªµ¤­¤—»¨…°Š¡¨´ŠŠµœ ¡§˜·„¦¦¤„µ¦—ε¦Š¸ª·˜ ¨³¡´œ›»„¦¦¤ Ĝ¦³¥³ 2-3 š«ª¦¦¬š¸ÉŸnµœ¤µ ŗo¤¸„µ¦«¹„¬µ®µ­µÁ®˜» …°Š‡ªµ¤Ÿ·—ž„˜·šµŠ¥¸œš¸ÉšÎµÄ®o°oªœ ¨³¡Ãž¦˜¸œ®¦º°±°¦r䜚¸É‡ª‡»¤‡ªµ¤­¤—»¨…°Š¡¨´ŠŠµœ ×¥‡ª‡»¤‡ªµ¤®·ª®¦º°‡ªµ¤°·É¤®¨µ¥œ·— ­¤—»¨…°Š¡¨´ŠŠµœ1 neuropeptides ¨³ neurotransmitter ‹µ„­¤°Š¦nª¤„´­´µ–‹µ„£µ¥œ°„¤¸Ÿ¨¦nª¤„´œ˜n° „µ¦‡ª‡»¤­¤—»¨…°Š¡¨´ŠŠµœ ×¥¡ªnµ®¨µ¥­´µ–‡ª‡»¤š´ÊŠ„µ¦¦·Ã£‡°µ®µ¦ (energy intake) ¨³„µ¦œÎµÁ°µ¡¨´ŠŠµœÅžÄo (energy expenditure) ×¥ peptide š¸É‡ª‡»¤‡ªµ¤°¥µ„°µ®µ¦¤¸ ˜µ¦µŠš¸É 1. ­—Š¥¸œš¸É¤¸šµšÄœ„µ¦‡ª‡»¤œÊ宜´„1 Gene influencing weight control Gene Model Tissue Body weight Food intake Energy expenditure Leptin Leptin receptor MC4 receptor MC3 receptor Melanin concentrating hormone (MCH) GPR7 Perilipin ASP (C3) Neuropeptides B and W Acetyl CoA Carboxylase NO synthase PKA RII beta Beta adrenergic receptor Uncoupling protein Cidea Stearoyl CoA desaturase ob/ob db/db MC4-/- MC3-/- MCH-/- GPR7-/- P1-/- C3-/- GPR7-/- Acc 2-/- NOS-/- RII-/- Beta AR 1,2,3-/- UPC1-/- Cidea-/- Scd-/- Adipose Brain Brain Brain Brain Brain Adipose Adipose Brain Widely Adipose All BAT BAT Liver n n n l p n p p n p n p n l l p n n n l n n n n n l l l l l n p p p n n p n n p n p n p l n n º··Õè 3
  23. 23. 17 šµš˜n°„µ¦œÎµÁ°µ¡¨´ŠŠµœÅžÄo ĜšµŠ˜¦Š„´œ…oµ¤ ‡º° peptide š¸É„¦³˜»oœÄ®o„·œÁ¡·É¤…¹Êœ‹³¨—„µ¦ œÎµÁ°µ¡¨´ŠŠµœÅžÄo šÎµÄ®o¤¸„µ¦­³­¤¡¨´ŠŠµœÁ¡·É¤…¹Êœ …–³š¸É peptide š¸É¥´¥´ÊŠ„µ¦„·œ°µ®µ¦‹³Á¡·É¤ „µ¦œÎµÁ°µ¡¨´ŠŠµœÅžÄo —´Š˜µ¦µŠš¸É 1 Neuropeptide Ĝ hypothalamus š¸É¤¸šµšÄœ„µ¦‡ª‡»¤œÊ宜´„¤¸®¨µ¥œ·— Ánœ neuropeptide Y (NPY), agouti-related peptide (AGRP), melanin-concentrating hormone (MCH), galanin, E-endorphin, dynorphin, enkephalin ¨³ orexins …–³š¸É peptide š¸É¥´¥´ÊŠ„µ¦„·œ°µ®µ¦ ŗo„n D-melanocyte-stimulating hormone (D-MSH), cocaine-amphetamine responsive transcript (CART), corticotrophin-releasing hormone, urocortin, neurotensin ¨³ neuromedin ­´µ–‹µ„šµŠÁ—·œ°µ®µ¦‡º° gut peptide ®¨µ¥œ·—¤¸Ÿ¨˜n°„µ¦‡ª‡»¤œÊ宜´„ ŗo„n cholecystokinin (CCK) š¸É­¦oµŠ‹µ„šµŠÁ—·œ°µ®µ¦­nªœ˜oœ duodenum ¨³ jejunum ¤¸šµšÄœ„µ¦ ¥´¥´ÊŠ‡ªµ¤°¥µ„°µ®µ¦ ­Îµ®¦´ peptide YY (PYY) ­¦oµŠ‹µ„šµŠÁ—·œ°µ®µ¦­nªœž¨µ¥ Á¡ºÉ°¥´¥´ÊŠ„µ¦ Á‡¨ºÉ°œ…°Š°µ®µ¦°°„‹µ„„¦³Á¡µ³ (gastric emptying) ¨³¥´Š­µ¤µ¦™Ÿnµœ blood brain barrier ޤ¸ Ÿ¨˜n° arcuate nucleus šÎµÄ®o¥´¥´ÊŠ„µ¦„·œ ­nªœ glucagon-like peptide 1 (GLP1) ¨³ oxynto- modulin ™¼„­¦oµŠ‹µ„¨ÎµÅ­o¨³­¤°Š ×¥Áž}œŸ¨Ÿ¨·˜…°Š preproglucagon gene Á¡ºÉ°Åž¥´¥´ÊŠ„µ¦„·œ Gut peptide Á¡¸¥Š˜´ªÁ—¸¥ªš¸ÉšÎµÄ®o°¥µ„°µ®µ¦¤µ„…¹Êœ‡º° ghrelin š¸É­¦oµŠ‹µ„„¦³Á¡µ³°µ®µ¦ ¨³Åž¤¸Ÿ¨˜n°ÁŽ¨¨rž¦³­µšÄœ arcuate nucleus ­´µ–‹µ„¦°œ°„ (peripheral signal) ‡º°‹µ„Á­oœž¦³­µšÁª„´­ (vagus nerve) ­nŠ ­´µ–Åž¥´Š dorsal motor nuclear ¨³ nucleus of solitary tract šÎµÄ®o˜°­œ°Š˜n° ghrelin ¨³ MSH œ°„‹µ„œ¸Ê vagus nerve ¥´Š¦´…o°¤¼¨…°Š fatty acid oxidation Ĝ˜´ Ž¹ÉŠ¤¸Ÿ¨˜n°‡ªµ¤°¥µ„ °µ®µ¦ ×¥™oµ…ªœ„µ¦ oxidation œ¸Ê™¼„¥´¥´ÊŠ‹³šÎµÄ®o°¥µ„°µ®µ¦Á¡·É¤…¹Êœ ¦¼žš¸É 1. ­—Š„µ¦šÎµŠµœ…°Š±°¦räœÁ¨Èž˜·œÄœ¦³ž¦³­µš1 Leptin Released to circulation Cross blood brain barrier to act on neurons in arcuate nucleus through leptin receptor Act on MC4-R and MC3-R Stimulate POMC neurons, nD-MSH Decrease feeding and increase energy expenditure
  24. 24. 18 ±°¦r䜰·œŽ¼¨·œ¤¸šµšÄœ„µ¦¥´¥´ÊŠ‡ªµ¤°¥µ„°µ®µ¦ ¨³¡ªnµÁŽ¨¨rž¦³­µšÄœ arcuate ¤¸ insulin receptor ¨³˜°­œ°Š˜n° insulin —´Šœ´ÊœœÊ宜´„˜´ª‹³™¼„‡ª‡»¤Ã—¥ž’·­´¤¡´œ›r…°Š ­´µ–˜nµŠÇ ‹µ„¨ÎµÅ­o¨³­¤°Š°¥nµŠŽ´Žo°œ Á¨Èž˜·œ (Leptin) Áž}œ±°¦r䜚¸É­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œ ™¼„­nŠŸnµœ blood brain barrier Ş¥´ŠÁŽ¨¨r ž¦³­µšÄœ arcuate ×¥ÁŒ¡µ³ÁŽ¨¨rš¸É­¦oµŠ preproopiomelanocortin (POMC) Á¨Èž˜·œšÎµÄ®oÁŽ¨¨r­¦oµŠ POMC ¨³ POMC gene product ‡º° D-MSH ¤µ„…¹Êœ ޚ劵œŸnµœšµŠ melanocortin-4 receptor ¨³ melanocortin-3 receptor Á¡ºÉ°Á¡·É¤ energy expenditure ¨³¨—„µ¦„·œ°µ®µ¦ (¦¼žš¸É 1) ¡§˜·„¦¦¤„µ¦—ε¦Š¸ª·˜ (Life style) ­µÁ®˜»…°ŠÃ¦‡°oªœÁ„·—‹µ„„µ¦„·œ¤µ„Á„·œÅž (overeating) ®¦º°„µ¦¤¸„·‹„¦¦¤šµŠ„µ¥œo°¥¨Š (under-activity) ¥´ŠÁž}œš¸É™„Á™¸¥Š„´œ ˜n¤¸…o°¤¼¨ªnµ¡¨´ŠŠµœš¸É¦·Ã£‡Ã—¥¦ª¤š´ÊŠ‹µ„°µ®µ¦Â¨³Á‡¦ºÉ°Š—ºÉ¤ ¨—¨ŠÄœnªŠ 20 žeš¸ÉŸnµœ¤µ2,3 ˜n„·‹„¦¦¤šµŠ„µ¥°´œÁž}œœ·­´¥„Ȩ—¨Š°¥nµŠ¤µ„ ¤µ„„ªnµ„µ¦¨—„µ¦ ¦·Ã£‡°µ®µ¦4,5 šÎµÄ®o°»´˜·„µ¦–r…°ŠÃ¦‡°oªœÁ¡·É¤…¹Êœ 懰oªœÁž}œŸ¨‹µ„ž{‹‹´¥šµŠ¡§˜·„¦¦¤ ¦nª¤„´¡´œ›»„¦¦¤ ­·ÉŠÂª—¨o°¤ ­¦¸¦ª·š¥µ ­´Š‡¤Â¨³ ª´•œ›¦¦¤ Ž¹ÉŠšÎµÄ®oÁ„·—‡ªµ¤Å¤n­¤—»¨…°Š¡¨´ŠŠµœš¸¨³œo°¥ÄœÁª¨µš¸ÉŸnµœ¤µ šÎµÄ®o¤¸„µ¦­³­¤¡¨´ŠŠµœ ­nªœÁ„·œÄœ¦¼ž…°ŠÅ…¤´œ ¤oªnµ¡´œ›»„¦¦¤‹³¤¸šµš­Îµ‡´Äœ„µ¦‡ª‡»¤œÊ宜´„˜´ª °Š‡r„µ¦°œµ¤´¥ è„Å—o­¦»žªnµ6 ž{‹‹´¥šµŠ¡´œ›»„¦¦¤Â¨³­·ÉŠÂª—¨o°¤ ×¥ÁŒ¡µ³„µ¦—εÁœ·œ¸ª·˜Â…µ—„µ¦°°„„ε¨´Š „µ¥ ¦nª¤„´„µ¦¦´ž¦³šµœ°µ®µ¦¤µ„Á„·œÅžÁž}œ­µÁ®˜»®¨´„…°Š„µ¦Á¡·É¤°»´˜·„µ¦–r…°ŠÃ¦‡°oªœ°¥nµŠ ¤µ„¤µ¥Äœ 2 š«ª¦¦¬š¸ÉŸnµœ¤µ …–³š¸É„µ¦„·œ°µ®µ¦°µ‹Å¤nŗoÁ¡·É¤…¹ÊœÄœÂŠn…°Š¡¨´ŠŠµœ ˜n­nªœž¦³„°…°Š°µ®µ¦š¸É„·œ Áž¨¸É¥œÂž¨ŠÅž¤µ„ ×¥¡ªnµ°µ®µ¦š¸É¦·Ã£‡¤¸¡¨´ŠŠµœ˜n°ž¦·¤µ–š¸É¦·Ã£‡ (energy dense) Á¡·É¤…¹Êœ ¤µ„ ¤¸‡ªµ¤®ªµœ¤µ„…¹ÊœÂ¨³Ÿnµœ…ªœ„µ¦Ÿ¨·˜¤µ„…¹Êœ ¤¸œÊ嘵¨¤µ„…¹ÊœÂ˜nÄ¥°µ®µ¦¨—¨Š ¤¸ž¦·¤µ– Ņ¤´œÃ—¥¦ª¤¨—¨Š ˜n¤¸Å…¤´œ°·É¤˜´ªÂ¨³Å…¤´œš¦µœ­rÁ¡·É¤…¹Êœ „·œ°µ®µ¦˜µ¤›¦¦¤µ˜·Ánœ Ÿ´„ Ÿ¨Å¤o ¨—¨Š7 ¡§˜·„¦¦¤„µ¦„·œ°µ®µ¦¤¸šµš¤µ„˜n°„µ¦Á„·—懰oªœ ×¥¤¸„µ¦„·œ°µ®µ¦¤µ„Á„·œ ÁœºÉ°Š‹µ„°µ®µ¦¦µ‡µ™¼„ °µ®µ¦¤¸¡¨´ŠŠµœ­¼Š ¤¸¦oµœ°µ®µ¦¤µ„¤µ¥Ä®oÁ¨º°„„·œ ¤¸°µ®µ¦Ä®oÁ¨º°„ ¤µ„¤µ¥ÄœÂ˜n¨³¤ºÊ° ¨³ž¦·¤µ–°µ®µ¦˜n°‹µœ¤µ„…¹Êœ (large portion size) °µ®µ¦‹µœ—nªœ (fast food) ¨³°µ®µ¦­³—ª„ŽºÊ° Ž¹ÉŠ¤¸¡¨´ŠŠµœ­¼ŠÂ˜n¤¸‡»–‡nµšµŠÃ£œµ„µ¦˜Éε ¤¸Ä®oÁ¨º°„ŽºÊ°¤µ„¤µ¥ ¦ª¤™¹Š¡§˜·„¦¦¤š¸ÉÁž¨¸É¥œÂž¨ŠÅžÄœª´œ®¥»— šÎµÄ®o¤¸œÊ宜´„…¹ÊœÅ—o¤µ„ ×¥ÁŒ¡µ³Äœ‡œ°oªœ ¤¸„µ¦„·œ °µ®µ¦¤µ„…¹ÊœšÎµÄ®oŗo¦´¡¨´ŠŠµœ­¼Š…¹Êœ ˜n¦o°¥¨³…°ŠÅ…¤´œš¸É¦·Ã£‡Áš¸¥„´¡¨´ŠŠµœš¸É¦·Ã£‡„¨´ ¨—¨Š8 —´Šœ´ÊœÅ…¤´œÄœ¦nµŠ„µ¥Å¤nŗo™¼„‡ª‡»¤Ã—¥°µ®µ¦Å…¤´œ9 šÎµÄ®o°›·µ¥Å—oªnµ°µ®µ¦Å…¤´œ˜Éε ®¦º°Å¦oŅ¤´œÂ˜n¤¸¡¨´ŠŠµœÁšnµ„´°µ®µ¦Å…¤´œÁ˜È¤­nªœÅ¤nnª¥Äœ„µ¦¨—œÊ宜´„10 „µ¦°°„„ε¨´Š„µ¥Å¤nªnµ‹³Áµ®¦º°®œ´„Á¡¸¥ŠÄ— ¤¸Ÿ¨˜n°„µ¦œÎµ¡¨´ŠŠµœÅžÄo¨³­¤—»¨…°Š ¡¨´ŠŠµœ ž{‹‹»´œ¤¸Áš‡ÃœÃ¨¥¸¤µ„¤µ¥¤µnª¥Äœ„µ¦—ε¦Š¸ª·˜ Ánœ ¤¸¥µœ¡µ®œ³ ¨·¢˜r ´œÅ—Á¨ºÉ°œ remote control „µ¦—¼š¸ª¸Â¨³Äo‡°¤¡·ªÁ˜°¦r¤µ„…¹ÊœšÎµÄ®o¤¸„·‹„¦¦¤šµŠ„µ¥¨—¨Š ‹¹Š¤¸Ã¦‡°oªœ¤µ„…¹Êœ ¤o‹³¤¸‡œ°°„„ε¨´Š„µ¥¤µ„…¹ÊœÂ˜n¥´ŠÅ¤n­¤—»¨„´„µ¦¤¸¸ª·˜š¸É¤¸„·‹„¦¦¤šµŠ„µ¥ÄœnªŠÁª¨µ°ºÉœš¸É œo°¥¨Š (sedentary lifestyle) ¨³„µ¦¦·Ã£‡š¸É¤µ„…¹Êœ
  25. 25. 19 …o°¤¼¨‹µ„ National Health Interview Survey11 ¡ªnµ‡œš¸ÉÁ‡¥°°„„ε¨´Š„µ¥°¥nµŠ®œ´„ ‹³ ¨—„µ¦°°„„ε¨´Š„µ¥¨Š‹µ„°µ¥» 12 že Ş‹œ°µ¥» 21 že ×¥¨—¨Š¤µ„nªŠ°µ¥» 15-18 že ¨³ 18-29 že …o°¤¼¨‹µ„„µ¦­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥Ã—¥„µ¦˜¦ª‹¦nµŠ„µ¥‡¦´ÊŠš¸É 4 ¡.«.2551-2552 ¡ªnµ„¨»n¤š¸É ¤¸‡ªµ¤Á­¸É¥Šš¸É‹³Áž}œÃ¦‡°oªœ‡º° °µ¥»š¸É¤µ„…¹ÊœÃ—¥ÁŒ¡µ³nªŠ°µ¥» 45-59 že Á¡«®·Š „¨»n¤š¸É°¥¼nĜÁ…˜ Áš«µ¨ ×¥ÁŒ¡µ³Äœ£µ‡„¨µŠÂ¨³„¦»ŠÁš¡¤®µœ‡¦12 Drewnorski ¨³‡–³13 ¡ªnµ Ÿ¼o®·Š¤¸Ã¦‡°oªœ¤µ„„ªnµŸ¼oµ¥Ã—¥­´¤¡´œ›r„´„µ¦¤¸¦µ¥Å—oœo°¥ ¨³¤¸„µ¦«¹„¬µ˜Éε Ž¹ÉŠ˜¦Š„´…o°¤¼¨…°Š National Health Interview Survey11 ¨³¡ªnµ°µ®µ¦š¸É¤¸ ¡¨´ŠŠµœ­¼Š¤¸Ÿ¨„¦³š˜n°¡¨´ŠŠµœ¦ª¤š¸É„·œÁ…oµÅž ×¥°µ®µ¦š¸É¤¸¡¨´ŠŠµœ­¼ŠšÎµÄ®o¡¹Š¡°Ä‹Â¨³Å¤n°·É¤ šÎµÄ®o„·œÁ¡·É¤…¹Êœ …–³š¸É°µ®µ¦š¸É¤¸œÊεÁž}œ­nªœž¦³„°¤µ„ šÎµÄ®o¦¼o­¹„°·É¤Á¦Èª…¹Êœ šÎµÄ®oŗo¡¨´ŠŠµœ¦ª¤ ¨—¨Š ×¥š¸É°µ®µ¦š¸É¤¸¡¨´ŠŠµœ­¼Š °µ‹¤¸Å…¤´œ œÊ嘵¨ ®¦º°ÂžjŠÁž}œ°Š‡rž¦³„°®¨´„ Ánœ °µ®µ¦‹µœ —nªœ °µ®µ¦ªnµŠ …°Š®ªµœ Ž¹ÉŠ‹³¤¸¦µ‡µ™¼„„ªnµ°µ®µ¦š¸É¤¸¡¨´ŠŠµœ˜Éε Ánœ Ÿ´„ Ÿ¨Å¤o Brary GA ¨³‡–³14 ¡ªnµ¤¸„µ¦„·œœÊεÁºÉ°¤…oµªÃ¡—š¸É¤¸œÊ嘵¨¢¦»p„Ø­­¼Š (high-fructose corn syrup: HFCS) Ĝž¦·¤µ–š¸É¤µ„…¹Êœ¤µ„„ªnµ 1000% Ĝ¦³®ªnµŠže 1970 ™¹Šže 1990 Ž¹ÉŠ¡ªnµ¢¦»p„ Ø­Áž}œ­µ¦š¸ÉÄ®o¡¨´ŠŠµœ¤µ„„ªnµ 40% …°Š­µ¦Ä®o‡ªµ¤®ªµœÄœÁ‡¦ºÉ°Š—ºÉ¤Äœž{‹‹»´œ šÎµÄ®oÁ„·—æ‡ °oªœ¦³µ— Ž¹ÉŠ¢¦»p„Ø­‹³¤¸„µ¦¥n°¥ „µ¦—¼—Ž¹¤ ¨³„µ¦ÁŸµŸ¨µ¡¨´ŠŠµœÂ˜„˜nµŠ‹µ„„¨¼Ã‡­ ×¥ ¢¦»p„حŤn„¦³˜»oœ„µ¦®¨´ÉŠ°·œŽ¼¨·œ®¦º°„µ¦­¦oµŠ leptin Ž¹ÉŠÁž}œ˜´ª®¨´„Äœ„µ¦‡ª‡»¤„µ¦¦·Ã£‡°µ®µ¦ ¨³œÊ宜´„˜´ª „µ¦„·œ°µ®µ¦š¸É¤¸¢¦»p„Ø­­¼Š °µ‹šÎµÄ®oŗo¦´¡¨´ŠŠµœ¦ª¤Á¡·É¤…¹Êœ šÎµÄ®o¤¸œÊ宜´„˜´ª Á¡·É¤…¹ÊœÅ—o ‡œš¸É„·œÁ‡¦ºÉ°Š—ºÉ¤š¸É¤¸‡ªµ¤®ªµœ¤µ„ °µ‹šÎµÄ®oŗo¡¨´ŠŠµœ¦ª¤Á„·œÅž¤µ„—oª¥Ánœ„´œ ¡¨´ŠŠµœ­nªœÁ„·œ‹³™¼„­³­¤Áž}œÅ…¤´œ (triaceylglycerols) ­³­¤ÅªoĜÁœºÊ°Á¥ºÉ°Å…¤´œ (adipose tissue) ×¥ÁœºÊ°Á¥ºÉ°Å…¤´œ¤¸®œoµš¸É®¨´„Á¡ºÉ°Á„ȝ­³­¤¡¨´ŠŠµœ Á¤ºÉ°¡¨´ŠŠµœš¸É„·œÁ…oµÅž¤µ„Á„·œ ¨³—¹Š ¡¨´ŠŠµœš¸É­³­¤ÅªoŞčoÁ¤ºÉ°‡ªµ¤˜o°Š„µ¦¡¨´ŠŠµœ¤µ„„ªnµš¸É¦·Ã£‡Á…oµÅž15 ¡¨´ŠŠµœ­nªœÁ„·œÁ¡¸¥ŠÂ‡n 10 „·Ã¨Â‡¨°¦¸É/ª´œ ­µ¤µ¦™šÎµÄ®oœÊ宜´„˜´ªÁ¡·É¤…¹Êœ 0.45 „·Ã¨„¦´¤/že ™oµÁ„·—˜n°ÁœºÉ°ŠÁž}œÁª¨µ 10 že „Ȥ¸ ‡ªµ¤­Îµ‡´šµŠ‡¨·œ·„Å—o œÊ宜´„š¸ÉÁ¡·É¤…¹ÊœÄœŸ¼oÄ®nšÎµÄ®oÁ„·— adipocyte hypertrophy Ž¹ÉŠ‹ÎµÁž}œ ­Îµ®¦´„µ¦¤¸¸ª·˜™oµ…µ—‡¨œ°µ®µ¦15 ˜nŤn¤¸ž¦³Ã¥œrÁ¤ºÉ°¤¸°µ®µ¦Ä®oÁ¨º°„¤µ„¤µ¥ …–³Á—¸¥ª„´œ ÁŽ¨¨rŅ¤´œ (adipocyte) ¥´ŠšÎµ®œoµš¸ÉĜ¨´„¬–³…°Š˜n°¤Å¦ošn° ×¥„µ¦­¦oµŠ±°¦räœÂ¨³ž{‹‹´¥š¸ÉšÎµÄ®o Á‹¦·Á˜·Ã˜Ž¹ÉŠ‡ª‡»¤„µ¦ÁŸµŸ¨µÅ…¤´œÃ—¥ŸnµœšµŠ„¨Å„¥o°œ„¨´ (feedback mechanism) ×¥ ±°¦r䜘´ª®œ¹ÉŠš¸É‡ª‡»¤‡º° leptin16 Ž¹ÉŠ™¼„‡oœ¡Äœže 1994 ×¥ leptin ‹³™¼„­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œ Áž}œ­´—­nªœš¸É­´¤¡´œ›r„´ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥ ¥·ÉŠ¤¸ÁŽ¨¨rŅ¤´œ¤µ„‹³­¦oµŠ leptin ŗo¤µ„17 懰oªœ ‹¹Š­´¤¡´œ›r„´„µ¦¤¸¦³—´…°Š leptin Ĝ„¦³Â­Á¨º°—Á¡·É¤…¹Êœ18 „µ¦„·œ°µ®µ¦¤¸Ÿ¨˜n°¦³—´ leptin ×¥ ¡ªnµ„µ¦‹Îµ„´—°µ®µ¦Äœ¦³¥³Áª¨µ­´ÊœÇ ‹³¨—¦³—´ leptin ŗo19 Ĝ®œ¼ leptin ‹³šÎµÄ®o¨—¡¨´ŠŠµœš¸É„·œ ¨³Á¡·É¤„µ¦Äo¡¨´ŠŠµœ20 —´Šœ´Êœ‹¹ŠÁºÉ°ªnµ‡œ°oªœ‹³¤¸ leptin resistance17 ˜n¡ªnµ leptin Ťnŗo¤¸ šµš˜n°„µ¦Á„·—懰oªœÄœ‡œ ¥„Áªoœ‡œš¸É¤¸ genetic mutatin ˜n°„µ¦­¦oµŠ leptin Ž¹ÉŠ¡Å—oœo°¥¤µ„
  26. 26. 20 ¡´œ›»„¦¦¤ („¦¦¤¡´œ›»r) ¤¸®¨´„“µœªnµ„¦¦¤¡´œ›»ršÎµÄ®oÁ„·—懰oªœ ÁœºÉ°Š‹µ„‡œÄœ‡¦°‡¦´ª…°Š‡œ°oªœ‹³¤¸Å…¤´œ ­³­¤Á¡·É¤…¹Êœ (increase adiposity) ×¥¤¸‡ªµ¤Á­¸É¥ŠÁ¡·É¤ 3-7 ÁšnµÄœµ˜·¡¸Éœo°Š ¨³¤¸„µ¦ž¦³¤µ–ªnµ „¦¦¤¡´œ›»r¤¸­nªœ¦´Ÿ·—°˜n°Ã¦‡°oªœ 40-70%21 …o°¤¼¨‹µ„„µ¦«¹„¬µ‡¼n —¡ªnµ„¦¦¤¡´œ›»r¤¸Ÿ¨˜n° ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥¤µ„„ªnµÃ¦‡°ºÉœÇ ×¥¡ªnµ¤¸Ÿ¨˜n° BMI 0.5-0.7, ˜n° body fat distribution 0.71-0.86, ˜n° total body fat 0.75-0.8, ˜n° skin fold thickness ¨³ waist circumference 0.72- 0.82, ¨³˜n° waist-hip ratio 0.36-0.61, ˜n° cognitive restraint of eating 0.59, ˜n° emotional eating 0.6, ¨³˜n° uncontrol eating 0.4522 ‡ªµ¤­´¤¡´œ›r…°Š„¦¦¤¡´œ›»r˜n°„µ¦Á„·—„µ¦­³­¤Å…¤´œ ­œ´­œ»œÁ¦ºÉ°Ššµš…°Š¥¸œÂ˜nŤn°„ªnµ‹Îµœªœ…°Š¥¸œÂ¨³¥¸œÅž¤¸Ÿ¨°¥nµŠÅ¦˜n°­·ÉŠÂª—¨o°¤ „µ¦«¹„¬µšµš…°Š¡´œ›»„¦¦¤˜n°Ã¦‡°oªœ¡ªnµ  —šo‹³¤¸œÊ宜´„Ä„¨oÁ‡¸¥Š„´œ¤µ„„ªnµ  —Áš¸¥¤š¸É°µ¥» 20 že ¨³¡ªnµ¨¼„»›¦¦¤¤¸œÊ宜´„š¸É­´¤¡´œ›r„´œÊ宜´„…°Š¡n°Â¤nš¸Éšo‹¦·Š ץŤn ¤¸‡ªµ¤­´¤¡´œ›r„´œÊ宜´„…°Š¡n°Â¤n»›¦¦¤š¸ÉÁ¨¸Ê¥Š—¼„´œ¤µÁ¨¥ Maes ¨³‡–³23 ž¦³¤µ–„µ¦ªnµ ž{‹‹´¥šµŠ„¦¦¤¡´œ›»r­nŠŸ¨ 50-90% ˜n°‡ªµ¤Â˜„˜nµŠ…°Š—´œ¸¤ª¨„µ¥ ž’·­´¤¡´œ›r¦³®ªnµŠ„¦¦¤¡´œ›»r¨³­·ÉŠÂª—¨o°¤¤¸šµš˜n°„µ¦Á„·—懰oªœ Bouchard ¨³ ‡–³24 ­—ŠÄ®oÁ®Èœªnµ‹Îµœªœ…°ŠœÊ宜´„¨³Å…¤´œš¸ÉÁ¡·É¤…¹Êœ ¦ª¤™¹Š„µ¦„¦³‹µ¥˜´ª…°ŠÅ…¤´œš¸ÉÁ¡·É¤…¹Êœ ‹µ„„µ¦„·œš¸É¤µ„Á„·œ‹³¤¸‡ªµ¤Á®¤º°œ„´œÄœ‡¼n —šo¤µ„„ªnµÂ —Áš¸¥¤ „¨Å„®œ¹ÉŠš¸ÉnŠ°„ªnµ ¥¸œ (genotype) ¤¸Ÿ¨„¦³š˜n°œÊ宜´„˜´ª‡º°¤¸Ÿ¨Äœ„µ¦‡ª‡»¤„µ¦Äo¡¨´ŠŠµœ (energy expenditure) ¤¸ „µ¦ž¦³¤µ–ªnµ‡ªµ¤Â˜„˜nµŠ…°Š energy expenditure ×¥ž¦³¤µ– 40% ץŤnœ´„µ¦°°„„ε¨´Š „µ¥°¥nµŠ®œ´„Áž}œŸ¨‹µ„¥¸œ23 °¥nµŠÅ¦„Șµ¤°»´˜·„µ¦–r…°ŠÃ¦‡°oªœš¸ÉÁ¡·É¤…¹Êœ°¥nµŠ¦ª—Á¦ÈªÄœÃ¨„ ˜³ª´œ˜„nŠ°„ªnµž{‹‹´¥šµŠ„¦¦¤¡´œ›»rŤn­µ¤µ¦™Áž}œž{‹‹´¥®¨´„Äœ„µ¦šÎµÄ®oÁ„·—…¹Êœ ÁœºÉ°Š‹µ„„µ¦ Áž¨¸É¥œÂž¨ŠšµŠ¡´œ›»„¦¦¤Äœž¦³µ„¦‹Îµœªœ¤µ„ŤnŗoÁ„·—…¹ÊœÄœ¦³¥³Áª¨µ­´ÊœÇ …–³š¸Éž{‹‹´¥šµŠ ¡§˜·„¦¦¤Â¨³­·ÉŠÂª—¨o°¤¤¸Ÿ¨¤µ„…¹Êœ ¨³¡ªnµž{‹‹´¥šµŠ­·ÉŠÂª—¨o°¤¤¸Ÿ¨˜n°—´œ¸¤ª¨„µ¥¤µ„…¹Êœ ×¥¡ªnµ¡¸Éœo°Š˜nµŠ­µ¥Á¨º°—š¸É°µ¥»Ä„¨oÁ‡¸¥Š„´œ ¨³™¼„Á¨¸Ê¥Š¤µ—oª¥„´œ˜´ÊŠÂ˜nÁ¨È„Ç ‹³¤¸—´œ¸¤ª¨„µ¥ Ą¨oÁ‡¸¥Š„´œ šÎµÄ®o‡·—ªnµÃ¦‡°oªœš¸É¦³µ—°¥¼nĜž{‹‹»´œÁž}œŸ¨‹µ„ž’·­´¤¡´œ›r¦³®ªnµŠž{‹‹´¥šµŠ ­·ÉŠÂª—¨o°¤Â¨³¡§˜·„¦¦¤„´‡ªµ¤Á­¸É¥Š‹µ„šµŠ¡´œ›»„¦¦¤25 ž{‹‹»´œ¤¸¥¸œš¸É­´¤¡´œ›r„´Ã¦‡°oªœ (genetic syndrome associated with obesity) ×¥šÎµÄ®o¤¸ ¨´„¬–³ÁŒ¡µ³…°ŠÃ¦‡¤µ„„ªnµ 25 ¥¸œ Ánœ Prader Willi, Aistrom, Bardet-Biedl ¨³°ºÉœÇ ¨³¤¸ nonsyndromic forms of obesity ‹µ„‡ªµ¤Ÿ·—ž„˜·…°Š¥¸œ Lep, LepR, MC4R, POMC ¨³°ºÉœÇ ˜n ¡ªnµ‡ªµ¤Ÿ·—ž„˜·…°Š¥¸œ˜´ªÄ—˜´ª®œ¹ÉŠ Áž}œ­µÁ®˜»­nªœœo°¥…°Š„µ¦Á„·—懰oªœÁšnµœ´Êœ 懚µŠ¡´œ›»„¦¦¤š¸É­´¤¡´œ›r„´Ã¦‡°oªœ26, 27 ­µ¤µ¦™ÂnŠÅ—oÁž}œ 2 „¨»n¤ ‡º° 1. 懰oªœ„¦¦¤¡´œ›»rš¸É¡¦nª¤„´„µ¦¡´•œµ„µ¦oµ„ªnµª´¥ (Obesity associated with development delay) 2. 懰oªœ„¦¦¤¡´œ›»rš¸ÉŤn¤¸‡ªµ¤Ÿ·—ž„˜·…°Š„µ¦¡´•œµ„µ¦˜µ¤ª´¥ (Obesity not associated with development delay)
  27. 27. 21 ˜µ¦µŠš¸É 2. ­—ŠÁ„–”r„µ¦ª·œ·‹Œ´¥Ã¦‡ Prader-Willi syndrome Diagnostic criteria for Prader-Willi syndrome Major criteria x Neonatal and infantile hypotonia, with poor suck and subsequent improvement with age x Feeding problems with poor weight gain in infancy, needing gavage or other special feeding techniques x Weight gain (rapid onset 1 to 6 years old) that leads to central obesity x Characteristic facial features, including narrow bifrontal diameter, almond-shaped palpebral fissures, and turned-down mouth x Hypogonadism/hypogenistalism: genital hypoplasia (small labia minora and clitoris in females, and hypoplastic scrotum in males); incomplete and delayed puberty; and infertility x Developmental delay/mild to moderate mental retardation/multiple learning disabilities x Hyperphagia/obsession with food x Chromosome 15q11-q13 abnormality Minor criteria x Reduced fetal movement and infantile lethargy, which improves with age x Characteristic behavioral problems, including temper tantrums, obsessive-compulsive behavior, stubbornness, rigidity, stealing, and lying x Sleep disturbance or apnea x Short stature for family by 15 years of age x Hypopigmentation x Small hands and feet for height and age x Narrow hands with straight ulnar border x Eye abnormalities, including esotropis and myopia x Thick viscous saliva x Speech articulation defect x Skin picking Additional features x High pain threshold x Decreased vomiting x Altered temperature sensitivity x Scoliosis and kyphosis x Early adrenarche x Osteoporosis x Unusual skill with jigsaws x Normal neuromuscular studies (e.g., muscle biopsy and electromyography)
  28. 28. 22 懰oªœ„¦¦¤¡´œ›»rš¸É¡¦nª¤„´„µ¦¡´•œµoµ„ªnµª´¥ ŗo„n 1. Prader-Willi Syndrome (PWS) Á„·—‹µ„ deletion ®¦º° disruption …°Š paternally imprinted gene ®¦º° gene œ proximal long arm …°Š chromosome 15 ¡ªnµ‡œš¸ÉÁž}œ PWS ‹³¤¸¦³—´ fasting plasma ghrelin ­¼ŠÁž}œ 4.5 Ášnµ…°Š‡œ°oªœš¸ÉŤnÁž}œ PWS šÎµÄ®oÁ„·—£µª³„·œ‹» (hyperphagia) °µ„µ¦Â­—Š¡˜´ÊŠÂ˜nÁž}œšµ¦„Äœ‡¦¦£r šµ¦„Á‡¨ºÉ°œÅ®ªœo°¥ (fetal activity ¨—¨Š), ¤¸ hypotonia, mental retardation, short stature, hypogonadotropic hypogonadism ¨³ obesity šµ¦„š¸ÉÁž}œ PWS ‹³¤¸ prenatal growth retardation Á¨È„œo°¥ šÎµÄ®o¤¸œÊ宜´„¦„‡¨°—˜Éε‡º° ž¦³¤µ– 2.8 „·Ã¨„¦´¤ ¤¸ hyporeflexia ¨³ poor feeding ÁœºÉ°Š‹µ„¤¸ž{®µÄœ„µ¦„¨ºœÂ¨³„µ¦—¼—œ¤ (sucking reflex) ˜o°ŠÅ—o¦´‡ªµ¤nª¥Á®¨º°Äœ„µ¦—¼—œ¤‹œ°µ¥» 3-4 Á—º°œ ¨³ž{®µ‹³®¤—ŞĜ 6 Á—º°œ ¡°°µ¥» 12-18 Á—º°œ ‹³¤¸£µª³„·œ‹» ¨³¤¸¡§˜·„¦¦¤„·œ­·ÉŠ…°Šš¸ÉŤnčn°µ®µ¦ (pica eating) Ĝ ª´¥Á—È„‹³¤¸„µ¦Á‹¦·Á˜·Ã˜oµ ¤¸¤ª¨„¨oµ¤ÁœºÊ°œo°¥ ¨³¤¸ž¦·¤µ–Å…¤´œ¤µ„Á®¤º°œ‡œš¸É…µ—±°¦räœ Á‹¦·Á˜·Ã˜ (growth hormone) Á—È„µ¥‹³¤¸ hypoplasia …°Š external genitaria ¦ª¤š´ÊŠ micropenis …–³š¸ÉÁ—È„®·Š‹³¤¸ hypoplasia …°Š labia minora ¤¸£µª³ early aderenache ˜n¤¸ gonadal maturation oµ ®¦º°Å¤n­¤¼¦–r ‹µ„ hypogonadotropic hypogonadism „µ¦ª·œ·‹Œ´¥Ã—¥°µ«´¥°µ„µ¦Â­—ŠšµŠ‡¨·œ·„×¥˜o°ŠÅ—o‡³Âœœ°¥nµŠœo°¥ 8.5 ‡³Âœœ ×¥ 1 major criteria ŗo 1 ‡³Âœœ …–³š¸É 1 minor criteria ŗo 0.5 ‡³Âœœ (˜µ¦µŠš¸É 2) „µ¦¦´„¬µÄ®o‡ÎµÂœ³œÎµÁ¦ºÉ°Š°µ®µ¦¡¨´ŠŠµœ˜Éε¦nª¤„´„µ¦°°„„ε¨´Š„µ¥°¥nµ­¤ÉεÁ­¤° Ä®o„µ¦ —¼Â¨°¥nµŠÄ„¨o·— ‹Îµ„´—°µ®µ¦Â¨³ÁŠ·œÄo‹nµ¥ ¨³Ä®oŸ¼ožiª¥Â¨³‡¦°‡¦´ªÅ—o¦´‡ÎµÂœ³œÎµ—oµœ‹·˜Ä‹Â¨³ ¡§˜·„¦¦¤°¥nµŠÁ®¤µ³­¤ „µ¦Ä®o¥µ¨—œÊ宜´„š¸É¨—‡ªµ¤°¥µ„°µ®µ¦°µ‹Å¤nŗoŸ¨ „µ¦Ä®o growth hormone ĜÁ—È„š¸ÉÁž}œ PWS šÎµÄ®o°´˜¦µ„µ¦Á‹¦·Á˜·Ã˜—¸…¹Êœ final high ­¼Š…¹Êœ nª¥¨—ž¦·¤µ–Å…¤´œ ¨³Á¡·É¤¤ª¨„¨oµ¤ÁœºÊ° Á¡·É¤„µ¦ÁŸµŸ¨µÅ…¤´œ ¨³„µ¦œÎµÁ°µ¡¨´ŠŠµœÅžÄo ¥µ clomiphene citrate šÎµÄ®o¦³—´ LH, testosterone ¨³ urirary gonadotropin ž„˜· šÎµÄ®oÁ„·—„µ¦­¦oµŠ­Ážd¦r¤ž„˜·Â¨³Áž}œ ®œ»n¤­µªÅ—o 2. Fragile X syndrome Áž}œÃ¦‡ž{µ°n°œ„¦¦¤¡´œ›»rš¸É¡Å—on°¥š¸É­»— ×¥Ÿ¼ožiª¥‹³¤¸ž{µ°n°œžµœ„¨µŠ™¹Š¦»œÂ¦Š (moderate to severe mental retardation), macro-orchidism, large ears, macrocephaly, prominent jaw ×¥¤¸‡µŠ¥ºÉœ ¨³ high-pitched jocular speech ĜÁ—È„‹³¤¸„µ¦Äo£µ¬µÅ¤n—¸Â¨³¤¸ ž{®µ—oµœ¡§˜·„¦¦¤ Ÿ¼ožiª¥‹³¤¸£µª³°oªœ¤µ„ ¤¸®œoµ„¨¤ ¤º°ÁšoµÁ¨È„¨³„ªoµŠ ¨³¤¸ regional skin hyperpigmentation „µ¦ª·œ·‹Œ´¥‡º°„µ¦˜¦ª‹¡ fragile X locus Ĝ FMR1gene „µ¦¦´„¬µÁ¦ºÉ°Š‡ªµ¤ Ÿ·—ž„˜·šµŠ¡§˜·„¦¦¤°µ‹Äo¥µ clonidine, valproate ¨³ carbamazepine nª¥ 3. Bardet-Biedl syndrome (BBS) Áž}œÃ¦‡š¸É™nµ¥š°— autosomal-recessive ×¥¤¸ central obesity, mental retardation, dysphormic extremities (syndactyly, brachydactyly ®¦º° polydactyly), retinal dystrophy ®¦º°
  29. 29. 22 懰oªœ„¦¦¤¡´œ›»rš¸É¡¦nª¤„´„µ¦¡´•œµoµ„ªnµª´¥ ŗo„n 1. Prader-Willi Syndrome (PWS) Á„·—‹µ„ deletion ®¦º° disruption …°Š paternally imprinted gene ®¦º° gene œ proximal long arm …°Š chromosome 15 ¡ªnµ‡œš¸ÉÁž}œ PWS ‹³¤¸¦³—´ fasting plasma ghrelin ­¼ŠÁž}œ 4.5 Ášnµ…°Š‡œ°oªœš¸ÉŤnÁž}œ PWS šÎµÄ®oÁ„·—£µª³„·œ‹» (hyperphagia) °µ„µ¦Â­—Š¡˜´ÊŠÂ˜nÁž}œšµ¦„Äœ‡¦¦£r šµ¦„Á‡¨ºÉ°œÅ®ªœo°¥ (fetal activity ¨—¨Š), ¤¸ hypotonia, mental retardation, short stature, hypogonadotropic hypogonadism ¨³ obesity šµ¦„š¸ÉÁž}œ PWS ‹³¤¸ prenatal growth retardation Á¨È„œo°¥ šÎµÄ®o¤¸œÊ宜´„¦„‡¨°—˜Éε‡º° ž¦³¤µ– 2.8 „·Ã¨„¦´¤ ¤¸ hyporeflexia ¨³ poor feeding ÁœºÉ°Š‹µ„¤¸ž{®µÄœ„µ¦„¨ºœÂ¨³„µ¦—¼—œ¤ (sucking reflex) ˜o°ŠÅ—o¦´‡ªµ¤nª¥Á®¨º°Äœ„µ¦—¼—œ¤‹œ°µ¥» 3-4 Á—º°œ ¨³ž{®µ‹³®¤—ŞĜ 6 Á—º°œ ¡°°µ¥» 12-18 Á—º°œ ‹³¤¸£µª³„·œ‹» ¨³¤¸¡§˜·„¦¦¤„·œ­·ÉŠ…°Šš¸ÉŤnčn°µ®µ¦ (pica eating) Ĝ ª´¥Á—È„‹³¤¸„µ¦Á‹¦·Á˜·Ã˜oµ ¤¸¤ª¨„¨oµ¤ÁœºÊ°œo°¥ ¨³¤¸ž¦·¤µ–Å…¤´œ¤µ„Á®¤º°œ‡œš¸É…µ—±°¦räœ Á‹¦·Á˜·Ã˜ (growth hormone) Á—È„µ¥‹³¤¸ hypoplasia …°Š external genitaria ¦ª¤š´ÊŠ micropenis …–³š¸ÉÁ—È„®·Š‹³¤¸ hypoplasia …°Š labia minora ¤¸£µª³ early aderenache ˜n¤¸ gonadal maturation oµ ®¦º°Å¤n­¤¼¦–r ‹µ„ hypogonadotropic hypogonadism „µ¦ª·œ·‹Œ´¥Ã—¥°µ«´¥°µ„µ¦Â­—ŠšµŠ‡¨·œ·„×¥˜o°ŠÅ—o‡³Âœœ°¥nµŠœo°¥ 8.5 ‡³Âœœ ×¥ 1 major criteria ŗo 1 ‡³Âœœ …–³š¸É 1 minor criteria ŗo 0.5 ‡³Âœœ (˜µ¦µŠš¸É 2) „µ¦¦´„¬µÄ®o‡ÎµÂœ³œÎµÁ¦ºÉ°Š°µ®µ¦¡¨´ŠŠµœ˜Éε¦nª¤„´„µ¦°°„„ε¨´Š„µ¥°¥nµ­¤ÉεÁ­¤° Ä®o„µ¦ —¼Â¨°¥nµŠÄ„¨o·— ‹Îµ„´—°µ®µ¦Â¨³ÁŠ·œÄo‹nµ¥ ¨³Ä®oŸ¼ožiª¥Â¨³‡¦°‡¦´ªÅ—o¦´‡ÎµÂœ³œÎµ—oµœ‹·˜Ä‹Â¨³ ¡§˜·„¦¦¤°¥nµŠÁ®¤µ³­¤ „µ¦Ä®o¥µ¨—œÊ宜´„š¸É¨—‡ªµ¤°¥µ„°µ®µ¦°µ‹Å¤nŗoŸ¨ „µ¦Ä®o growth hormone ĜÁ—È„š¸ÉÁž}œ PWS šÎµÄ®o°´˜¦µ„µ¦Á‹¦·Á˜·Ã˜—¸…¹Êœ final high ­¼Š…¹Êœ nª¥¨—ž¦·¤µ–Å…¤´œ ¨³Á¡·É¤¤ª¨„¨oµ¤ÁœºÊ° Á¡·É¤„µ¦ÁŸµŸ¨µÅ…¤´œ ¨³„µ¦œÎµÁ°µ¡¨´ŠŠµœÅžÄo ¥µ clomiphene citrate šÎµÄ®o¦³—´ LH, testosterone ¨³ urirary gonadotropin ž„˜· šÎµÄ®oÁ„·—„µ¦­¦oµŠ­Ážd¦r¤ž„˜·Â¨³Áž}œ ®œ»n¤­µªÅ—o 2. Fragile X syndrome Áž}œÃ¦‡ž{µ°n°œ„¦¦¤¡´œ›»rš¸É¡Å—on°¥š¸É­»— ×¥Ÿ¼ožiª¥‹³¤¸ž{µ°n°œžµœ„¨µŠ™¹Š¦»œÂ¦Š (moderate to severe mental retardation), macro-orchidism, large ears, macrocephaly, prominent jaw ×¥¤¸‡µŠ¥ºÉœ ¨³ high-pitched jocular speech ĜÁ—È„‹³¤¸„µ¦Äo£µ¬µÅ¤n—¸Â¨³¤¸ ž{®µ—oµœ¡§˜·„¦¦¤ Ÿ¼ožiª¥‹³¤¸£µª³°oªœ¤µ„ ¤¸®œoµ„¨¤ ¤º°ÁšoµÁ¨È„¨³„ªoµŠ ¨³¤¸ regional skin hyperpigmentation „µ¦ª·œ·‹Œ´¥‡º°„µ¦˜¦ª‹¡ fragile X locus Ĝ FMR1gene „µ¦¦´„¬µÁ¦ºÉ°Š‡ªµ¤ Ÿ·—ž„˜·šµŠ¡§˜·„¦¦¤°µ‹Äo¥µ clonidine, valproate ¨³ carbamazepine nª¥ 3. Bardet-Biedl syndrome (BBS) Áž}œÃ¦‡š¸É™nµ¥š°— autosomal-recessive ×¥¤¸ central obesity, mental retardation, dysphormic extremities (syndactyly, brachydactyly ®¦º° polydactyly), retinal dystrophy ®¦º°
  30. 30. 23 pigmentary retinopathy, hypogonadism ®¦º° hypogenitalism ¨³¤¸Å˜¦¼ž¦nµŠ®¦º°„µ¦šÎµŠµœ Ÿ·—ž„˜·Åž Áž}œ‡ªµ¤Ÿ·—ž„˜·Â heterogenous …°Š¥¸œÄœ 8 ˜ÎµÂ®œnŠ‡º° 11q13(BBS1), 16q21(BBS2), 3p13-p12(BBS3), 15q22.3-q23(BBS4), 2q31(BBS5), 20p12(BBS6), 4q27(BBS7) ¨³ 14q32.11(BBS8) ×¥‡ªµ¤Ÿ·—ž„˜·…°ŠÃ‡¦Ã¤ÃŽ¤ 3 šÎµÄ®oÁ„·— polydactyly …°Šš´ÊŠ 4 ¦³¥µŠ‡r …–³š¸É‡ªµ¤Ÿ·—ž„˜·…°ŠÃ‡¦Ã¤ÃŽ¤ 15 šÎµÄ®oÁ„·— polydactyly …°Š¤º° 2 …oµŠ ¨³¤¸£µª³°oªœ¦»œÂ¦Š ˜´ÊŠÂ˜n¦„ …–³š¸É‡ªµ¤Ÿ·—ž„˜·…°ŠÃ‡¦Ã¤ÃŽ¤ 16 ŤnšÎµÄ®o°oªœ ž{‹‹»´œ„µ¦ª·œ·‹Œ´¥Ã¦‡œ¸Ê°µ«´¥°µ„µ¦ ¨³°µ„µ¦Â­—Š „µ¦¦´„¬µÄ®o¦´„¬µ˜µ¤°µ„µ¦š¸ÉŸ·—ž„˜· Ánœ¤¸œ·ÊªÁ„·œ œ³œÎµÄ®o˜´—°°„˜´ÊŠÂ˜n…ªže ¦„ ÁšoµŸ·—¦¼ž¦nµŠÄ®oÄ­n¦°ŠÁšoµš¸ÉÁ®¤µ³­¤ ˜¦ª‹˜µÁ¡ºÉ°®µ‡ªµ¤Ÿ·—ž„˜·Â¨³Â„oŅ 4. Böjeson-Forssman-Lehmann syndome Áž}œÃ¦‡š¸É¤¸£µª³ž{µ°n°œžµœ„¨µŠ™¹Š¦»œÂ¦Š, epilepsy, hypogonadism, obesity with marked gynecomastia, swelling of subcutaneous tissue of face, narrow palpebral fissures ¨³ ®¼Ä®n˜n¦¼ž¦nµŠŸ·—ž„˜· Á„·—‹µ„‡ªµ¤Ÿ·—ž„˜·…°Š¥¸œš¸É˜ÎµÂ®œnŠ xq26-q27 ¨³¤¸ gene zinc-finger (plant hormeodomain-like finger:PHF6) Ĝ‡¦°‡¦´ª…°Š‡œš¸ÉÁž}œÃ¦‡œ¸Ê 5. Wilson-Turner Syndrome ™nµ¥š°— X-linked-recessive ×¥¤¸£µª³ obesity, gynecomastia, speech difficulties, emotional lability, tapering fingers ¨³ small feet ¦nª¤„´ mental retardation ×¥‡ªµ¤Ÿ·—ž„˜· …°Š¥¸œ°¥¼nš¸É Xp21.1-q22 6. Cohan syndrome ¤¸„µ¦™nµ¥š°— autosomal-recessive ×¥¤¸ nonprogressive mild-to-severe psychomotor retardation, motor clumsiness, microcephaly, characteristic facial features, childhood hypotonia ¨³ joint laxity, progressive retinochoroidal dystrophy, myopia, intermittent isolated neutropenia ¨³ cheerful disposition ×¥ specific facial feature ž¦³„°—oª¥ high-arched ®¦º° wave-shaped eyelids, long, thick eyelashes, thick eyebrows, promiment root of nose, short philtrum, small or absent lobule of ears, thick hair ¨³ low hairline, narrow hands and feet, ¨³ mild syndactyly ×¥˜o°Š˜¦ª‹ ¡ retinocharoidal dystrophy Á­¤°Äœ„µ¦ª·œ·‹Œ´¥Ã¦‡ ­µ¥˜µ‹³Â¥n¨Š˜´ÊŠÂ˜nÁ—È„ ˜n‹³¦»œÂ¦ŠÄœnªŠ °µ¥» 40 že °µ‹¤¸˜µ°—Å—o ‡ªµ¤Ÿ·—ž„˜·°¥¼nš¸É¥¸œœÃ‡¦Ã¤ÃŽ¤ 8q21.3-q22.1 7. Albright hereditary osteodystrophy ¤¸£µª³ short stature, obesity, round facies, brachydactyly ¨³ ectopic soft-tissue ossification (osteoma cutis) ¨³ mild developmental delay ‡ªµ¤Ÿ·—ž„˜·™nµ¥š°— autosomal-dominant Á„·—‹µ„ germ line mutation Ĝ GNAS1 šÎµÄ®o¨—¦³—´Â¨³„µ¦šÎµŠµœ…°Š GsD protein ‡ªµ¤Ÿ·—ž„˜·…°Š GNAS1 š¸É™nµ¥š°—¤µ‹µ„¤n šÎµÄ®oÁ„·—懜¸Ê¦nª¤„´£µª³—ºÊ°˜n° ±°¦r䜮¨µ¥Ç ˜´ª Ánœ parathyroid hormone šÎµÄ®oÁ„·—£µª³ pseudohypoparathyroidism type 1A
  31. 31. 25 Áž}œŸ¼oÄ®nš¸É˜´ªÁ˜¸Ê¥ ¤¸‹Îµœªœ T cell ¨³„µ¦šÎµŠµœ…°Š T cell Ÿ·—ž„˜·šÎµÄ®oÁ„·—懘·—ÁºÊ°Å—on°¥ ¡ £µª³ sleep apnea ŗon°¥ ª·œ·‹Œ´¥ congenital leptin deficiency ŗo ×¥„µ¦˜¦ª‹Å¤n¡ leptin Ĝ Á¨º°— ¦nª¤„´¡ ob gene ¨³ª·œ·‹Œ´¥ leptin receptor deficiency ŗo×¥¡¤¸°µ„µ¦Â­—ŠÁ®¤º°œ congenital leptin deficiency ˜n¤¸¦³—´ leptin Ĝ„¦³Â­Á¨º°—­¼Š¤µ„Ç Ÿ¼ožiª¥„¨»n¤œ¸Ê‹³˜°­œ°ŠÅ—o—¸˜n°„µ¦Ä®o recombinant human leptin Œ¸— subcutaneously š»„ ª´œšÎµÄ®oœÊ宜´„˜´ªÂ¨³ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥¨—¨Š ץčo…œµ—¥µÁ¦·É¤˜oœ 0.01 ¤„./„„.…°ŠœÊ宜´„ „¨oµ¤ÁœºÊ°Ã—¥šÎµÄ®o‡ªµ¤°¥µ„°µ®µ¦¨—¨Š „·œœo°¥¨Š ¨³¨—¡¨´ŠŠµœš¸É„·œ¨ŠÅ—o¤µ„™¹Š 84% šÎµÄ®o Á„·— pubertal development Áž}œž„˜· ¤¸ secondary sexual characteristics ¨³¤¸ gonadrotropin Á¡·É¤ ¤¸„µ¦Á¡·É¤¦³—´…°Š FT4 FT3 ¨³ TSH …¹ÊœÁ¨È„œo°¥ 5. Partial leptin deficiency in heterozygote carriers „µ¦¤¸¦³—´ leptin Á¡·É¤…¹ÊœÁ¡¸¥ŠÁ¨È„œo°¥¤¸Ÿ¨˜n°‡ªµ¤°¥µ„°µ®µ¦Â¨³œÊ宜´„˜´ª°¥nµŠ¤µ„ Ĝ heterozygote carrier …°Š leptin deficiency ‹³¤¸¦³—´ leptin ˜É優nµš¸É‡µ—ŪoÁ¤ºÉ°Áš¸¥„´ž¦·¤µ– …°ŠÅ…¤´œÄœ¦nµŠ„µ¥ ¨³‡œ„¨»n¤œ¸Ê‹³¤¸°»´˜·„µ¦–r…°ŠÃ¦‡°oªœ­¼Š„ªnµž¦³µ„¦š´ÉªÅžš¸É°µ¥» Á¡« ¨³ ÁºÊ°µ˜·Á—¸¥ª„´œ ¨³¤¸­´—­nªœ…°ŠÅ…¤´œÄœ¦nµŠ„µ¥¤µ„„ªnµ„¨»n¤‡ª‡»¤š¸É¤¸‡ªµ¤­¼ŠÂ¨³œÊ宜´„¨³ ÁºÊ°µ˜·Á—¸¥ª„´œ Ĝ„¨»n¤œ¸Ê„µ¦Ä®o leptin ¦´„¬µ‹³nª¥¨—ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥¨ŠÅ—o 6. Complete POMC deficiency Á„·—‹µ„ congenital proopiomelanocortin (POMC) gene deficiency Ž¹ÉŠÁ„·—‹µ„ mutation …°Š POMC gene  compound heterozygote ®¦º° homozygous š¸Éަ„ªœ„µ¦Á„·— POMC translational initiation Ÿ¼ožiª¥š»„‡œ‹³¤µ—oª¥ hypoglycemia ‹µ„ ACTH deficiency ˜´ÊŠÂ˜n°µ¥»œo°¥Ç šÎµÄ®oÁ„·—£µª³ hypoglycemia, prolong jaundice, susceptibility to infection ¨³ neonatal death ŗo Ž¹ÉŠ‹³˜°­œ°ŠÅ—o—¸˜o°Š„µ¦Ä®o glucocorticoid replacement ˜nĜš¸É­»—‹³Á„·—懰oªœ¦»œÂ¦Š ˜µ¤¤µ‹µ„„µ¦„·œ¤µ„Á„·œ (hyperphagia) ×¥‹³¤¸£µª³°oªœÂ¤o‹³…µ— glucocorticoid Ž¹ÉŠÁž}œ£µª³š¸É ¤´„‹³šÎµÄ®oœÊ宜´„˜´ª¨—¨Š ¨´„¬–³ÁŒ¡µ³…°Š‡œš¸É¤¸Ã¦‡œ¸Ê ‡º° ¤¸ isolated ACTH deficiency, hyperphagia ¨³ severe early-onset obesity 7. POMC haploinsufficiency ¡ªnµ‡œš¸É…µ— POMC allele 1 ˜´ª „ȚεĮoÁ„·—懰oªœÅ—o ×¥¤¸ point mutation Ĝ POMC ¦ª¤š´ÊŠ mutation Ĝ D ¨³ E-MSH 8. POMC mutations affecting specific melanocortin peptides 8.1 missense mutations š¸Éޤ¸Ÿ¨˜n° POMC gene š¸ÉŞ encode melanocortin peptide Á„·—Áž}œ E-MSH / E-endorphin fusion protein Ş‹´„´ melanocortin 4 receptor (MC4R) ˜nŞ activate receptor ŗoŤn—¸ °µ‹šÎµÄ®oÁ„·—‡ªµ¤Á­¸É¥ŠÄœ„µ¦Á„·—懰oªœ­¼Š…¹Êœ ˜nŤn highly penetrant ‹œšÎµÄ®oÁ„·—懰oªœ„¦¦¤¡´œ›»r 8.2 Herterozygous of missense variant in the region encoding E-MSH, Tyr 221 Cys šÎµÄ®oŞ activate ¨³‹´„´ MC4R Ťn—¸ (Á„·— MC4R deficiency) Á—È„‹³¤¸ hyperphagia ¨³Á¡·É¤
  32. 32. 26 linear growth ­—Šªnµ E-MSH ¤¸šµšÄœ„µ¦‡ª‡»¤‡ªµ¤­¤—»¨…°Š¡¨´ŠŠµœ Ž¹ÉŠ„µ¦Ä®o E-MSH analogue Ĝ®œ¼š—¨°ŠÅ—ož¦³Ã¥œr ¨³°µ‹œÎµ¤µÄož¦³Ã¥œrĜ‡œš¸É…µ— E-MSH ŗo 9. Genetic variation at the POMC locus and common obesity ǦäΤ 2p22 Ž¹ÉŠÁž}œ˜ÎµÂ®œnŠš¸É­¦oµŠ POMC gene ¤¸šµš˜n° common obesity ¨³ obesity-related traits ¤¸®¨´„“µœªnµ¤¸‡ªµ¤­´¤¡´œ›r„´œ¦³®ªnµŠ¦³—´…°Š leptin Ĝ„¦³Â­Á¨º°— „´ 2p22 ¨³¡ªnµ POMC gene ¤¸šµšÄœ„µ¦‡ª‡»¤­¤—»¨¡¨´ŠŠµœ…°Š¤œ»¬¥r „µ¦¤¸‡ªµ¤Ÿ·—ž„˜· …°Š POMC locus °µ‹šÎµÄ®oÁ­¸É¥Š˜n°„µ¦Á„·—懰oªœ ×¥ŸnµœšµŠ gene-environment interaction 10. Mulation in prohormone convertase1 (PC1) PC1 ¨³ PC2 ¡Å—oĜ neuroendocrine tissue ¨³šÎµŠµœÃ—¥šÎµÄ®o peptide ˜nµŠÇ active Ánœ proinsulin, proglucagon ¨³ POMC PC1 ‹³™¼„­¦oµŠÃ—¥Áž}œ inactive precursor ‹µ„œ´Êœ™¼„ autocatalytic Ä®oÁ„·—Áž}œ active 66-kDa isoform š¸É­³­¤ÅªoĜ mature secretory granules ‡œš¸É¤¸ compound heterozygote PC1 mutation šÎµÄ®oŤn­µ¤µ¦™Á„·— maturation …°Š inactive propeptide form of PC1 Ÿ¼ožiª¥‹³¤µ—oª¥ severe early-onset obesity, hypogonadotropic hypogonadism, postprandial hypoglycemia, hypocortisolemia ¨³ impaired processing POMC ¨³ proinsulin ¨³°µ‹¤¸ small intestinal dysfunction —´Š˜µ¦µŠš¸É 3 ˜µ¦µŠš¸É 3. ­—Š¨´„¬–³Â¨³‡ªµ¤Ÿ·—ž„˜·…°Š Prohormone Convertase-1 (PC-1) deficiency Clinical features Affected prohormone conversion Obesity Hypogonadotropic hypogonadism Hypoadrenalism Reactive hypoglycemia/impaired glucose tolerance Intestinal malabsorption POMC-MSH ProGnRH-GnRH POMC-ACTH Proinsulin-insulin Proglucagon-GLP1 and GLP2 11. Human MC4R deficiency mutations Ĝ MC4R Ĝ¤œ»¬¥ršÎµÄ®oÁ„·—懰oªœ„¦¦¤¡´œ›»r ×¥¤¸°»´˜·„µ¦–r…°Š„µ¦Á„·— MC4R mutation 0.5% ĜŸ¼oÄ®n°oªœ ‹œ™¹Š 6% ĜÁ—È„š¸É°oªœ¦»œÂ¦Š Ĝ°´Š„§¬Â¨³¥»Ã¦ž¡ªnµ 1-2.5% …°Š‡œš¸É¤¸—´œ¸¤ª¨„µ¥ >30 „„./¤2 ‹³¤¸ mutation Ĝ MC4R ¥ºœ¥´œªnµ MC4R deficiency Áž}œ®œ¹ÉŠÄœÃ¦‡°oªœ„¦¦¤¡´œ›»rš¸É¡Å—on°¥š¸É­»— ×¥ homozygotes ‹³°oªœ¤µ„„ªnµ heterozygotes ‡œš¸É¤¸Ã¦‡œ¸Ê‹³¤¸£µª³ hyperphagia ˜´ÊŠÂ˜n°µ¥»…ªže ¦„ ¤¸„µ¦Á¡·É¤ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥ ¨³Á¡·É¤¤ª¨„¨oµ¤ÁœºÊ° ¨³‡ªµ¤®œµÂœnœ…°Š„¦³—¼„‹œ—¼Áž}œ ‡œÃ‡¦ŠÄ®n ‹³¤¸ linear growth Á¦Èª¤µ„Äœª´¥Á—È„ šÎµÄ®o˜´ª­¼Š„ªnµ‡œš´ÉªÅž ‹µ„„µ¦¤¸¦³—´ fasting insulin ­¼Š„ªnµÁ—È„š¸É°µ¥» Á¡« ¨³—´œ¸¤ª¨„µ¥š¸ÉÁšnµ„´œ ÁœºÉ°Š‹µ„¤¸ hyperinsulinemia ˜n°µ„µ¦ ˜nµŠÇ ‹³—¸…¹ÊœÁ¤ºÉ°°µ¥»¤µ„…¹Êœ
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