อ้วนและอ้วนลงพุง
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อ้วนและอ้วนลงพุง

อ้วนและอ้วนลงพุง
พญ. วรรณี นิธิยานันท์

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  • Full Name Full Name Comment goes here.
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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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อ้วนและอ้วนลงพุง Document Transcript

  • 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. ‹»¦¸¡¦ ‡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. 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. «»£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. ‡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. 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·¤
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  • 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. 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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  • 13. 7 14. Borer KT, Wuorinen E, Ku K, Burant C. Appetite responds to changes in meal content, whereas ghrelin, leptin, and insulin track changes in energy availability. J Clin Endocrinol Metab 2009; 94: 2290-8. 15. Klaus S. Adipose tissue as a regulator of energy balance. Curr Drug Targets 2004; 5: 241- 50. 16. Cypess AM, Kahn CR. The role and importance of brown adipose tissue in energy homeostasis. Curr Opin Pediatr 2010; 22: 478-84. 17. Virtanen K, Lidell M, Orava J, et al. Functional brown adipose tissue in healthy adults. N Engl J Med 2009; 360: 1518-25. 18. Hansen JC, Gilman AP, Odland JØ. Is thermogenesis a significant causal factor in preventing the "globesity" epidemic? Med Hypotheses 2010; 75: 250-6. 19. Blouin K, Boivin A, Tchernof A. Androgens and body fat distribution. J Steroid Biochem Mol Biol 2008; 108: 272-80. 20. Traish AM, Guay A, Feeley R, Saad F. The dark side of testosterone deficiency: I. metabolic syndrome and erectile dysfunction. J Androl 2009; 30: 10-22. 21. Pasquali R. Obesity and androgens: facts and perspectives. Fertil Steril 2006; 85: 1319- 40. 22. Molenaar EA, Massaro JM, Jacques PF, et al. Association of lifestyle factors with abdominal subcutaneous and visceral adiposity: the Framingham Heart Study. Diabetes Care 2009; 32: 505-10. 23. Ferreira MG, Valente JG, Gonçalves-Silva RM, Sichieri R. Alcohol consumption and abdominal fat in blood donors. Rev Saude Publica 2008; 42: 1067-73. 24. Pravdova E, Macho L, Fickova M. Alcohol intake modifies leptin, adiponectin and resistin serum levels and their mRNA expressions in adipose tissue of rats. Endocr Regul 2009; 43: 117-25. 25. Risérus U, Ingelsson E. Alcohol intake, insulin resistance, and abdominal obesity in elderly men. Obesity 2007; 15: 1766-73. 26. Du H, van der A DL, Boshuizen HC, et al. Dietary fiber and subsequent changes in body weight and waist circumference in European men and women. Am J Clin Nutr 2010; 91: 329-36. 27. Romaguera D, Angquist L, Du H, et al. Dietary determinants of changes in waist circumference adjusted for body mass index - a proxy measure of visceral adiposity. PLoS One 2010; 5(7): e11588.
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  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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  • 36. 30 ª¦¦–¸ œ·›·¥µœ´œšr ¦µ¥Šµœ£µ¡¦ª¤Äœž¦³µ„¦„¨»n¤Ä®n ¡ªnµŸ¼oš¸É¤¸Ã¦‡°oªœÁ¡·É¤‡ªµ¤Á­¸É¥Š˜n°„µ¦Á„·—懰ºÉœ ¤µ„…¹Êœ ¤¸„µ¦ž¦³¤µ–‡ªµ¤Á­¸É¥Š­´¤¡´š›r (Relative Risk, RR)1 …°ŠÃ¦‡°oªœ„´ž{®µ­»…£µ¡˜nµŠÇ —´ŠÂ­—ŠÄœ˜µ¦µŠš¸É 1 œ°„‹µ„œ¸Ê ¡‡ªµ¤­´¤¡´œ›r¦³®ªnµŠœÊ宜´„˜´ª (BMI) ¨³°´˜¦µ„µ¦˜µ¥Äœ ¦¼žÂ˜´ª J (J-shaped relationship) ‡º°„¨»n¤ BMI š¸É˜É夵„¤¸°´˜¦µ˜µ¥¤µ„„ªnµ„¨»n¤ BMI ž„˜· ¨³ „µ¦š¸É¥·ÉŠ°oªœ¤µ„ÁšnµÄ—¥·ÉŠÁ¡·É¤°´˜¦µ˜µ¥¤µ„…¹ÊœÁšnµœ´Êœ2 °oªœšÎµÄ®o°µ¥»…´¥‡µ—ÁŒ¨¸É¥¨—¨Š °´˜¦µ˜µ¥š¸É Á¡·É¤…¹Êœ…°ŠŸ¼oš¸É°oªœœ´Êœ ¤¸­µÁ®˜»‹µ„懘nµŠÇ š¸ÉÁ„·—Áž}œŸ¨˜µ¤¤µ Ĝž¦³Áš«­®¦´“°Á¤¦·„µ¡ªnµŸ¼oš¸É¤¸ BMI ž„˜·Â˜n¦°Á°ªÄ®nÁ„·œ Áž¦¸¥Áš¸¥„´Ÿ¼oš¸É¤¸ BMI ¨³¦°Á°ªž„˜· ¤¸°´˜¦µ˜µ¥‹µ„š»„­µÁ®˜» ¦ª¤„´œ­¼Š„ªnµ™¹Š¦o°¥¨³ 203 ˜µ¦µŠš¸É 1. ž{®µ­»…£µ¡š¸É­´¤¡´œ›r„´Ã¦‡°oªœ Á¡·É¤‡ªµ¤Á­¸É¥Š­¼Š(RR > 3) Á¡·É¤‡ªµ¤Á­¸É¥Šžµœ„¨µŠ (RR 2 - 3) Á¡·É¤‡ªµ¤Á­¸É¥Šœo°¥ (RR 1 - 2) æ‡Áµ®ªµœœ·—š¸É 2 懮´ªÄ‹Ã‡Ã¦œµ¦¸É ¤³Á¦ÈŠ (¤³Á¦ÈŠÁ˜oµœ¤ÄœŸ¼o®·Šª´¥ ®¤—ž¦³‹ÎµÁ—º°œ ¤³Á¦ÈŠ¤—¨¼„) ¤³Á¦ÈŠ¨ÎµÅ­oÄ®n æ‡Á„¸É¥ª„´™»ŠœÊε—¸ ‡ªµ¤—´œÃ¨®·˜­¼Š ‡ªµ¤Ÿ·—ž„˜·…°Š±°¦räœÄœ¦³ ­º¡´œ›»r Ņ¤´œÄœÁ¨º°—Ÿ·—ž„˜· 懅o°Á­ºÉ°¤ (Á…nµÂ¨³­³Ã¡„) „¨»n¤°µ„µ¦™»ŠœÊεĜ¦´ŠÅ…n £µª³—ºÊ°°·œŽ¼¨·œ £µª³„¦—¥¼¦·„­¼Š æ‡Á„pµšr ¤¸»˜¦¥µ„ žª—®¨´Š £µª³®µ¥Ä‹¨Îµµ„ Á¡·É¤‡ªµ¤Á­¸É¥Š˜n°„µ¦Á„·—Ÿ¨Âš¦„ Žo°œ‹µ„„µ¦—¤¥µ­¨ £µª³®¥»—®µ¥Ä‹…–³®¨´ šµ¦„Äœ‡¦¦£r¤¸‡ªµ¤Ÿ·—ž„˜· °oªœÂ¨³°oªœ¨Š¡»Š„´­»…£µ¡ °oªœÂ¨³°oªœ¨Š¡»ŠÁž}œ£µª³š¸É¤¸Å…¤´œ­³­¤Äœ¦nµŠ„µ¥¤µ„Á„·œÅž Ņ¤´œš¸É­³­¤ÄœÁŽ¨¨rŅ¤´œ °¥¼nĜ¦¼ž…°ŠÅ˜¦„¨¸ÁŽ°Å¦—r ®¦º° ئ°³Ž·¨„¨¸ÁŽ°¦°¨ (triglyceride ®¦º° triacylglycerol) Áž}œ­nªœÄ®n °oªœÂ¨³°oªœ¨Š¡»Šœ°„‹µ„¤¸‡ªµ¤­´¤¡´œ›r„´Ã¦‡˜nµŠÇ ‹Îµœªœ¤µ„1,4 ¨oª ¥´Š¤¸Ÿ¨„¦³š˜n°­£µ¡ ‹·˜Ä‹ „µ¦­¼Á­¸¥‡ªµ¤ÁºÉ°¤´ÉœÄœ˜œÁ°Š ¨—„µ¦Á®Èœ‡»–‡nµÄœ˜œÁ°Š ž{‹‹´¥Â¨³„¨Å„„µ¦Á„·—æ‡Á®¨nµœ¸Ê ¤¸®¨µ¥°¥nµŠ¦nª¤„´œ (¦¼žš¸É 1) °µ‹ÂnŠÃ¦‡Áž}œ„¨»n¤˜µ¤„¨Å„š¸É­´¤¡´œ›r„´„µ¦Á„·—懗´Šœ¸Ê 1. „¨»n¤Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°—¨³Ã¦‡‹µ„„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤ 2. „¨»n¤Ã¦‡¤³Á¦ÈŠ º··Õè 4
  • 37. 31 3. „¨»n¤Ã¦‡°ºÉœ 4. „¨»n¤ž{®µšµŠ­»…£µ¡‹·˜Â¨³­´Š‡¤ ¦¼žš¸É 1. Ÿ¨…°Š¡§˜·„¦¦¤Á­¸É¥ŠÂ¨³ž{‹‹´¥š¸ÉœÎµÅž­¼n„µ¦Á„·—懰oªœÂ¨³Ã¦‡Á¦ºÊ°¦´Š „¨Å„„µ¦Á„·—懋µ„°oªœÂ¨³°oªœ¨Š¡»Š Ĝ­£µª³ž„˜·ÁŽ¨¨rŅ¤´œšÎµ®œoµš¸ÉÁž}œÂ®¨nŠ­³­¤¡¨´ŠŠµœ ¨³Ÿ¨·˜±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­r (cytokines) Á¡ºÉ°‡ª‡»¤­¤—»¨…°Š¡¨´ŠŠµœ ¦³—´œÊ嘵¨Â¨³Å…¤´œÄœÁ¨º°— œ°„‹µ„œ¸Ê¥´Š¤¸Ÿ¨˜n°¦³ £¼¤·‡»o¤„´œ—oª¥ Á¤ºÉ°ž¦·¤µ–Å…¤´œ­³­¤Äœ¦nµŠ„µ¥¤¸¤µ„Á„·œ ×¥ÁŒ¡µ³°¥nµŠ¥·ÉŠ ­nªœš¸É­³­¤Äœn°Ššo°Š šÎµÄ®o¤¸„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤Â¨³„¨Å„°ºÉœÇ ®¨µ¥°¥nµŠ ‹µ„„µ¦Á¡·É¤…¹Êœ®¦º°¨—¨Š…°Š ±°¦r䜚¸É­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œ ¨³„µ¦Á¡·É¤…¹Êœ…°ŠŽ´¥Ã˜Å‡œ­r (cytokines) ®¨µ¥œ·—š¸É­¦oµŠ‹µ„ÁŽ¨¨r Ņ¤´œŽ¹ÉŠ¤¸Ÿ¨Â˜„˜nµŠ„´œ (˜µ¦µŠš¸É 2) ŗo„n Ÿ¨˜n°ž¦·¤µ–°µ®µ¦š¸É„·œ ž¦·¤µ–…°ŠÅ…¤´œÄœ¦nµŠ„µ¥ ž¦³­·š›·£µ¡…°Š°·œŽ¼¨·œ (°·œŽ¼¨·œž¦³­·š›·£µ¡—o°¥¨Š‡º°¤¸£µª³—ºÊ°°·œŽ¼¨·œ) Á¤Âš°¨·Ž¹É¤…°ŠÅ…¤´œ ¦³®¨°—Á¨º°— ‡ªµ¤—´œÃ¨®·˜ „µ¦­¨µ¥…°Š¨·É¤Á¨º°—5 懚¸ÉÁ„·—­´¤¡´œ›r„´°oªœÂ¨³°oªœ¨Š¡»ŠÁ„·— ‹µ„„¨Å„¡ºÊœ“µœ‡º° £µª³—ºÊ°°·œŽ¼¨·œ Ÿ¨…°Š±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­rš¸ÉÁŽ¨¨rŅ¤´œŸ¨·˜ ¦nª¤„´ „¦³ªœ„µ¦°´„Á­ (inflammation) š¸ÉÁ„·—°¥nµŠ˜n°ÁœºÉ°ŠÄœÁœºÊ°Á¥ºÉ°˜nµŠÇ 懰oªœ „¨»n¤°µ„µ¦°oªœ¨Š¡»Š („¨»n¤°µ„µ¦Á¤Âš°¨·‡, Metabolic syndrome) ¡‡ªµ¤Ÿ·—ž„˜· 3 Ĝ 5 ‡ªµ¤Ÿ·—ž„˜·š¸É¡ - °oªœ¨Š¡»Š - ¦³—´œÊ嘵¨Ÿ·—ž„˜· - ‡ªµ¤—´œÃ¨®·˜Ÿ·—ž„˜· - Triglyceride ­¼Š - HDL-C ˜Éεž{‹‹´¥Á­¸É¥Š—oµœ ¡§˜·„¦¦¤­»…£µ¡ x …µ—„·‹„¦¦¤šµŠ„µ¥ x ¦·Ã£‡°µ®µ¦¤µ„ Á„·œ x ¦·Ã£‡°µ®µ¦ ¡¨´ŠŠµœ­¼Š ¤¸Å…¤´œ œÊ嘵¨ ¨³Á„¨º°­¼Š x ­¼»®¦¸É x —ºÉ¤­»¦µ Ÿ¨š¸ÉÁ„·—˜µ¤¤µ æ‡Á¦ºÊ°¦´Š˜nµŠÇ Ánœ - 懮¨°—Á¨º°—®´ªÄ‹ - 懮¨°—Á¨º°—Äœ ­¤°Š˜¸ - 懮¥»—®µ¥Ä‹…–³ ®¨´ - 懤³Á¦ÈŠµŠœ·— - 懄¦³—¼„¨³…o° ž{‹‹´¥Á­¸É¥Šš¸ÉŤn ­µ¤µ¦™Â„oŅŗo x °µ¥» x Á¡« x ¡´œ›»„¦¦¤
  • 38. 32 ˜µ¦µŠš¸É 2. ±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­r­nªœ®œ¹ÉŠš¸ÉŸ¨·˜‹µ„ÁŽ¨¨rŅ¤´œÂ¨³Ÿ¨„¦³šš¸ÉÁ„·—…¹Êœ5 ±°¦räœ / Ž´¥Ã˜Å‡œ­r Ÿ¨„¦³šš¸ÉÁ„·—…¹Êœ Leptin Control appetite, food intake, energy balance Adiponectin Insulin resistance, inflammation Resistin Insulin resistance, inflammation Visfastin Insulin resistance Cholesteryl ester transfer protein (CETP) Lipid metabolism Lipoprotein lipase (LPL) Lipid metabolism Hormone sensitive lipase (HSL) Lipid metabolism Adipocyte fatty acid-binding protein 4 (A-FABP4, aP2) Lipid metabolism Perilipin Lipid metabolism Angiotensin II (AT II) Blood pressure Angiotensin converting enzyme (ACE) Blood pressure Angiotensinogen Blood pressure tumor necrosis factor-alpha (TNF-D) Inflammation interleukin-6 (IL-6), Inflammation C-reactive protein (CRP) Inflammation Macrophage chemo attractant protein-1 (MCP-1) Macrophage attraction Intercellular adhesion molecule-1 (ICAM-1) Macrophage attraction Plasminogen activator inhibitor-1 (PAI-1) Fibrinolysis ÁŽ¨¨rŅ¤´œŸ¨·˜±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­r‹Îµœªœ¤µ„ (˜µ¦µŠš¸É 2) Ánœ Á¨Èž˜·œ (leptin) °³—·Ãž ÁœÈ‡˜·œ (adiponectin), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-D) ¨³°ºÉœÇ ¤¸…o°¤¼¨ ‹µ„„µ¦«¹„¬µÁ„¸É¥ª„´šµšÂ¨³®œoµš¸É…°Š±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­rÁ®¨nµœ¸Ê š´ÊŠÄœ£µª³ž„˜·Â¨³„µ¦ Á„·—æ‡Á¡·É¤¤µ„…¹Êœ Á¨Èž˜·œ5,6 Áž}œÁž}žÅš—r±°¦räœ ­nŠ­´µ–š¸É­¤°Š‡ª‡»¤‡ªµ¤°¥µ„°µ®µ¦ ¨³‡ª‡»¤ ‡ªµ¤­¤—»¨…°Š¡¨´ŠŠµœ Á—È„š¸É…µ—Á¨Èž˜·œ‹³Á„·—懰oªœ¦»œÂ¦ŠÅ—o ¡ªnµÁŽ¨¨rŅ¤´œ…œµ—Ä®n­¦oµŠ Á¨Èž˜·œ¤µ„…¹Êœ ‡œ°oªœ‹¹Š¤¸¦³—´Á¨Èž˜·œ­¼Š ÁºÉ°ªnµÁ„·—‹µ„¤¸£µª³—ºÊ°˜n°Á¨Èž˜·œ šÎµÄ®oŤn­µ¤µ¦™¥´¥´ÊŠ „µ¦„·œ°µ®µ¦ Á¨Èž˜·œšÎµÄ®o¤¸„µ¦­³­¤Å…¤´œÁ¡·É¤…¹Êœ °°„§š›·Íš¸ÉŘ ¦³®¨°—Á¨º°—¨³®´ªÄ‹ ¨³ °ª´¥ª³°ºÉœ °³—·ÃžÁœÈ‡˜·œ5,7 ¤¸Ÿ¨šÎµÄ®o„µ¦˜°­œ°Š˜n°°·œŽ¼¨·œ¤¸ž¦³­·š›·£µ¡—¸…¹Êœ ¦³—´°³—·ÃžÁœÈ‡˜·œ ĜÁ¨º°—¤¸‡ªµ¤­´¤¡´œ›rŸ„Ÿ´œ„´ž¦·¤µ–Å…¤´œš¸É­³­¤Äœn°Ššo°Š ÁŽ¨¨rŅ¤´œš¸É¤¸…œµ—Ä®n­¦oµŠ°³—· ÞÁœÈ‡˜·œœo°¥¨Š ‹¹ŠÁ„·—Ÿ¨˜¦Š…oµ¤‡º°„µ¦˜°­œ°Š˜n°°·œŽ¼¨·œ—o°¥¨Š œ°„‹µ„œ¸Ê °³—·ÃžÁœÈ‡˜·œ¤¸ §š›·Í˜oµœ„¦³ªœ„µ¦°´„Á­ ˜oµœ„µ¦Á„·—®¨°—Á¨º°——ŠÂ…ÈŠ˜¸˜´œ ˜oµœ„µ¦Á„·—‡ªµ¤—´œÃ¨®·˜Á¡·É¤ ­¼Š…¹Êœ ˜oµœ„µ¦Á„·— oncogenic cell
  • 39. 33 „¨»n¤Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°—¨³Ã¦‡‹µ„„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤ ‡ªµ¤Ÿ·—ž„˜·š¸É¤´„¡¦nª¤„´°oªœÂ¨³°oªœ¨Š¡»Š‡º° ¦³—´œÊ嘵¨ÄœÁ¨º°—­¼Š…¹Êœ ‡ªµ¤—´œÃ¨®·˜ ­¼Š…¹Êœ ¨³¦³—´Å…¤´œÄœÁ¨º°—Ÿ·—ž„˜· „µ¦¡‡ªµ¤Ÿ·—ž„˜·Á®¨nµœ¸Ê¦nª¤„´œÄœ»‡‡¨Ä—Á¦¸¥„ªnµ»‡‡¨œ´Êœ Áž}œ „¨»n¤°µ„µ¦°oªœ¨Š¡»Š ®¦º° „¨»n¤°µ„µ¦Á¤Âš°¨·‡ (metabolic syndrome) Á„–”r„µ¦ª·œ·‹Œ´¥„¨»n¤ °µ„µ¦Á¤Âš°¨·‡8 ‡º° ¡‡ªµ¤Ÿ·—ž„˜· 3 °¥nµŠ®¦º°¤µ„„ªnµ‹µ„ 5 °¥nµŠ˜n°Åžœ¸Ê¦nª¤„´œ 1. ¦°Á°ªÁšnµ„´®¦º°¤µ„„ªnµ 90 ÁŽœ˜·Á¤˜¦ÄœŸ¼oµ¥ ®¦º° 80 ÁŽœ˜·Á¤˜¦ÄœŸ¼o®·Š 2. ‡ªµ¤—´œÃ¨®·˜ •130/85 ¤¤.ž¦°š ®¦º°Áž}œ‡ªµ¤—´œÃ¨®·˜­¼Š ®¦º°¦´¥µ¦´„¬µ°¥¼n 3. ¦³—´ triglyceride ĜÁ¨º°—­¼Š •150 ¤„./—¨. 4. ¦³—´ HDL-C ĜÁ¨º°—˜Éε <40 ¤„./—¨.ĜŸ¼oµ¥ ®¦º° <50 ¤„./—¨.ĜŸ¼o®·Š 5. ¦³—´œÊ嘵¨ÄœÁ¨º°—…–³°—°µ®µ¦˜°œÁoµ •100 ¤„./—¨. ®¦º°Áž}œÁµ®ªµœœ·—š¸É 2 ®¦º°¦´¥µ¦´„¬µ°¥¼n „µ¦­Îµ¦ª‹­»…£µ¡ž¦³µœÅš¥že 2552 ¡ªnµ‡œÅš¥¦o°¥¨³ 21.1 ¤¸„¨»n¤°µ„µ¦Á¤Âš°¨·‡9 ¡¤µ„Äœ„¨»n¤°µ¥» 60-79 že ¨³¡ÄœŸ¼o®·Š¤µ„„ªnµŸ¼oµ¥ (¦¼žš¸É 2) Áž}œš¸Éš¦µ„´œ—¸ªnµ¦³—´œÊ嘵¨ ĜÁ¨º°—­¼Š ‡ªµ¤—´œÃ¨®·˜­¼Š ¨³¦³—´Å…¤´œÄœÁ¨º°—Ÿ·—ž„˜· Áž}œž{‹‹´¥Á­¸É¥Š­Îµ‡´…°Š„µ¦Á„·—®¨°— Á¨º°——ŠÂ…ÈŠ˜¸Â¨³°»—˜´œ Ž¹ÉŠšÎµÄ®oÁ„·—æ‡Äœ¦³®´ªÄ‹Â¨³®¨°—Á¨º°—˜µ¤¤µ Ÿ¼oš¸ÉÁž}œ„¨»n¤°µ„µ¦Á¤ š°¨·‡Á­¸É¥Š˜n°„µ¦Á„·—懦³®´ªÄ‹Â¨³®¨°—Á¨º°—­¼Š…¹Êœ ÁœºÉ°Š‹µ„¤¸ž{‹‹´¥Á­¸É¥Š®¨µ¥°¥nµŠ°¥¼n ¦nª¤„´œ10 ¡ªnµ‡œÅš¥š¸ÉÁž}œ„¨»n¤°µ„µ¦Á¤Âš°¨·‡¤¸°´˜¦µ„µ¦Á„·—懮¨°—Á¨º°—®´ªÄ‹­¼Š…¹Êœ11 ¦¼žš¸É 2. °´˜¦µž¦³µ„¦Åš¥°µ¥» 15 že…¹ÊœÅžš¸É¤¸„¨»n¤°µ„µ¦Á¤Âš°¨·‡ (metabolic syndrome) „µ¦Á„·—¦³—´œÊ嘵¨ÄœÁ¨º°—Ÿ·—ž„˜· Ÿ¼oš¸É¤¸Å…¤´œ­³­¤Äœ¦nµŠ„µ¥ž¦·¤µ–¤µ„ ‹³¡Å…¤´œ­³­¤ÄœÁŽ¨¨rœ·—°ºÉœš¸ÉŤnčnÁŽ¨¨rŅ¤´œ ‡º° „¨oµ¤ÁœºÊ°¨µ¥ ˜´ ¨³°ª´¥ª³°ºÉœ Á¦¸¥„ªnµÅ…¤´œ­³­¤Ÿ·—š¸É (ectopic fat) Ņ¤´œÅ—°³Ž·¨„¨¸ÁŽ°¦°¨
  • 40. 34 (diacylglycerol) š¸É­³­¤¤µ„ÄœÁŽ¨¨r„¨oµ¤ÁœºÊ°¨µ¥Áž}œ°¸„Á®˜»®œ¹ÉŠ…°Š£µª³—ºÊ°°·œŽ¼¨·œ10,12 „µ¦š¸É¤¸ „¦—Å…¤´œ°·­¦³ (free fatty acid ®¦º° non-esterified fatty acid) Ĝ„¦³Â­Á¨º°—­¼Š Áž}œ˜oœ„εÁœ·—…°Š £µª³—ºÊ°°·œŽ¼¨·œ „¦—Å…¤´œ°·­¦³Å—o‹µ„„µ¦­¨µ¥ triacylglycerol š¸É­³­¤ÄœÁŽ¨¨rŅ¤´œ ®¦º°‹µ„„µ¦ „·œ°µ®µ¦Å…¤´œ­¼Š Á¤ºÉ°Á…oµ­¼n„¦³Â­Á¨º°—‹³Åž¥´ŠÁŽ¨¨r…°Š°ª´¥ª³˜nµŠÇ š¸ÉÁŽ¨¨r„¨oµ¤ÁœºÊ°¨µ¥„¦—Å…¤´œ °·­¦³¥´¥´ÊŠ„µ¦œÎµ„¨¼Ã‡­Á…oµ­¼nÁŽ¨¨rÁœºÉ°Š‹µ„˜´ªœÎµ„¨¼Ã‡­ (glucose transporter 4) œo°¥¨Š ¨³¨— „¦³ªœ„µ¦ÁŸµŸ¨µ„¨¼Ã‡­ÄœÁŽ¨¨r Ĝ…–³š¸É„¦³ªœ„µ¦°È°„Ž·Á—´Éœ (oxidaton) ĜÁŽ¨¨r„¡¦n°Š Ťn­µ¤µ¦™Á˜·¤„¦—Å…¤´œ°·­¦³Ä®o diacylglycerol Áž¨¸É¥œÁž}œ triacylglycerol ŗo ž¦·¤µ– diacylglycerol š¸É¤¸¤µ„šÎµÄ®oÁ„·—£µª³—ºÊ°°·œŽ¼¨·œ Ÿ¨‡º°„¨oµ¤ÁœºÊ°¨µ¥Äo„¨¼Ã‡­œo°¥¨Š ¦nª¤„´ ˜´œÎµ „¦—Å…¤´œ°·­¦³Åž­¦oµŠÁž}œ„¨¼Ã‡­Â¨³­nŠÁ…oµ­¼n„¦³Â­Á¨º°— Ÿ¨¦ª¤‡º°¦³—´œÊ嘵¨ÄœÁ¨º°—­¼Š…¹Êœ °µ‹ „¨nµªÅ—oªnµÁ„·—£µª³Å…¤´œÁž}œ¡·¬ (lipotoxicity)12 Ĝ¦³¥³˜oœ ¸˜oµÁŽ¨¨r…°Š˜´°n°œ‹³Ÿ¨·˜°·œŽ¼¨·œ Á¡·É¤…¹ÊœÁ¡ºÉ°Â„oŅ£µª³—ºÊ°°·œŽ¼¨·œ ž¦³„°„´ÁŽ¨¨rŅ¤´œ­¦oµŠ±°¦r䜰³—·ÃžÁœÈ‡˜·œœo°¥¨Š šÎµÄ®o „µ¦˜°­œ°Š˜n°°·œŽ¼¨·œ„¡¦n°Š¦»œÂ¦Š…¹Êœ ™oµ­£µª³œ¸Ê—εÁœ·œ˜n°Åž Á­¦·¤—oª¥„¦³ªœ„µ¦°´„Á­ ‹µ„ inflammatory cytokines IL-6, TNF-D ¨³°ºÉœÇ š¸ÉÁŽ¨¨rŅ¤´œ­¦oµŠÁ¡·É¤…¹Êœ ‹³šÎµÄ®o‹Îµœªœ¸˜oµ ÁŽ¨¨r¨—¨Š˜n°ÁœºÉ°Š ‹œÄœš¸É­»—Á„·—æ‡Áµ®ªµœ˜µ¤¤µ (¦¼žš¸É 3) ¦¼žš¸É 3. ‡ªµ¤Ÿ·—ž„˜·šµŠÁ¤Âš°¨·‡š¸É¡Äœ£µª³°oªœÂ¨³°oªœ¨Š¡»Š beta-cell failure Diabetes Food muscle insulin resistance hepatic insulin resistance insulin secretion FFA Fat cell insulin resistance Glucose uptake and oxidation Dyslipidemia Adiponectin Resistin TNF-Į, IL-6 pancreas Hepatic glucose output & VLDL
  • 41. 35 „µ¦Á„·—¦³—´Å…¤´œÅ˜¦„¨¸ÁŽ°Å¦—rĜÁ¨º°—­¼ŠÂ¨³¦³—´Á°—¸Â°¨‡°Á¨­Á˜°¦°¨˜Éε Ĝ£µª³ž„˜·„µ¦­¨µ¥Å…¤´œÁž}œ„¦—Å…¤´œ°·­¦³°µ«´¥Á°ÈœÅŽ¤rŨÁž­ÄœÁŽ¨¨rŅ¤´œ (adipocyte lipase) ×¥„¦³ªœ„µ¦ hydrolysis13 °·œŽ¼¨·œšÎµ®œoµš¸É¥´¥´ÊŠÁŽ¨¨rŅ¤´œÅ¤nÄ®o­¨µ¥Å…¤´œÁž}œ„¦— Ņ¤´œ°·­¦³ £µª³—ºÊ°°·œŽ¼¨·œšÎµÄ®o„µ¦¥´¥´ÊŠÅ¤n¤¸ž¦³­·š›·£µ¡ œ°„‹µ„œ¸Ê ±°¦räœ glucocorticoids, ­µ¦Â‡š·‡°¨µ¤¸œ (catecholamines) „¦³˜»oœ„µ¦­¨µ¥Å…¤´œÁž}œ„¦—Å…¤´œ°·­¦³Ã—¥Ÿnµœ¦¸ÁŽÈžÁ˜°¦r (lipolytic beta-adrenergic receptors) ¨³ natriuretic peptides ­µ¤µ¦™„¦³˜»oœ„µ¦­¨µ¥Å…¤´œÁž}œ „¦—Å…¤´œ°·­¦³ ×¥Ÿnµœ cGMP-dependent pathway13,14 „¦—Å…¤´œ°·­¦³š¸ÉÁ¡·É¤…¹Êœ‹³™¼„˜´œÎµÅž ­¦oµŠ°–¼Å…¤´œª¸Á°¨—¸Á°¨ (very low density lipoprotein, VLDL)14,15 Áž}œŸ¨Ä®o¦³—´Å˜¦„¨¸ÁŽ°Å¦—rĜ Á¨º°—­¼Š…¹Êœ (¦¼žš¸É 3) „¦–¸š¸É„¦—Å…¤´œ°·­¦³¤¸ž¦·¤µ–­¼Š¤µ„ …œµ—…°Š VLDL ‹³Ä®n…¹Êœ ÁœºÉ°Š‹µ„Äœ VLDL ¤¸Å˜¦„¨¸ÁŽ°Å¦—rž¦·¤µ–­¼Š Ĝ„¦³Â­Á¨º°— Á°ÈœÅŽ¤rŨÁž­ (lipoprotein lipase) ‹µ„ÁŽ¨¨rŸœ´Š®¨°—Á¨º°——Š °¥ (Á°Èœ כ¸Á¨¸É¥¨ÁŽ¨¨r, endothelial cells) ‹³¥n°¥­¨µ¥„¦—Å…¤´œ°·­¦³°°„‹µ„°–¼ VLDL „¨µ¥Áž}œ VLDL remnant £µª³—ºÊ°°·œŽ¼¨·œšÎµÄ®oÁ°ÈœÅŽ¤rŨÁž­šÎµŠµœ„¡¦n°Š ž¦³„°„´ VLDL ¤¸…œµ—Ä®nšÎµÄ®o VLDL remnant ¤¸ž¦·¤µ–ئ„¨¸ÁŽ°Å¦—r­¼Š ×¥°µ«´¥ cholesteryl ester transfer protein (CETP) ‹³ ¤¸„µ¦Â¨„Áž¨¸É¥œ cholesterol ester Ĝ°–¼ Á°—¸Â°¨ (HDL, high density lipoprotein) „´ ئ„¨¸ÁŽ° Ŧ—rĜ°–¼ VLDL remnant ‹µ„œ´ÊœÁ°ÈœÅŽ¤rŨÁž­š¸É˜´ (hepatic lipase) ‹³­¨µ¥Å˜¦„¨¸ÁŽ°Å¦—r‹µ„ HDL ¨³ VLDL remnant šÎµÄ®o…œµ—°–¼Á¨È„¨Š Áž}œŸ¨Ä®o¦³—´ Á°—¸Â°¨ ‡°Á¨­Á˜°¦°¨ ĜÁ¨º°—˜Éε VLDL remnant ®¦º° LDL (low density lipoprotein) ¤¸…œµ—Á¨È„ (small density LDL)12 š´ÊŠ­°ŠÁ¦nŠ ®¦º°„¦³˜»oœ„¦³ªœ„µ¦Á„·—®¨°—Á¨º°——ŠÂ…ÈŠ˜¸˜´œ ‹µ„„µ¦¤¸‡°Á¨­Á˜°¦°¨­³­¤ÄœŸœ´Š®¨°— Á¨º°——Š°¥nµŠ¦ª—Á¦Èª5,12 —´Šœ´Êœ £µª³—ºÊ°°·œŽ¼¨·œš¸É¤¸¦³—´Å˜¦„¨¸ÁŽ°Å¦—rĜÁ¨º°—­¼Š ¨³Á°—¸Â°¨ ‡°Á¨­Á˜°¦°¨ ĜÁ¨º°—˜Éε ×¥š¸É¦³—´ °¨—¸Â°¨ ‡°Á¨­Á˜°¦°¨ °µ‹ž„˜·®¦º°­¼Š ‹¹Š™º°Áž}œ£µª³ Ņ¤´œÄœÁ¨º°—Ÿ·—ž„˜·š¸ÉÁ­¸É¥Š˜n°„µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— „µ¦Á„·—‡ªµ¤—´œÃ¨®·˜Ÿ·—ž„˜· Ĝ‡œ°oªœ¡ªnµ­¤—»¨…°ŠÁ„¨º°Â¨³œÊε (salt-fluid homeostasis) ¨³‡ªµ¤˜¹Š˜´ª…°Š®¨°— Á¨º°— (vascular tone) Ÿ·—ž„˜· šÎµÄ®o‡ªµ¤—´œÃ¨®·˜­¼Š…¹Êœ °´œÁž}œŸ¨‹µ„„µ¦„¦³˜»oœ¦³ renin- angiotensin-aldosterone ×¥ angiotensin ¨³ angiotensin converting enzyme š¸ÉÁ¡·É¤…¹Êœ ¨³ ¦³—´Á¨Èž˜·œš¸É­¼Š¤µ„5,15 ±°¦räœ aldosterone ¨³°·œŽ¼¨·œš¸É¤¸¦³—´­¼Š…¹ÊœÄœ‡œ°oªœ„¦³˜»oœ epithelial sodium channel (ENaC) ĜÁŽ¨¨r collecting duct …°ŠÅ˜16 ¨³¦³—´Á¨Èž˜·œš¸É­¼Š¤µ„šÎµÄ®o Na+ /K+ - ATPase Á¡·É¤…¹Êœ5 ­nŠŸ¨Ä®o¤¸„µ¦Á„ȝ„´„Á„¨º°ÃŽÁ—¸¥¤¤µ„…¹Êœ œ°„‹µ„œ¸Ê ¦³—´ÃžÂ˜­ÁŽ¸É¥¤¨—˜É娊16 šÎµÄ®ož¦·¤µ– epithelial nitric oxide synthase (eNOS) ¨³ nitric oxide (NO) ¨—¨Š ®¨°—Á¨º°—‹¹Š ˜¹Š˜´ª¤µ„…¹Êœ ¦nª¤„´¤¸ sympathetic overactivity Ÿ¨¦ª¤‡º°‡ªµ¤—´œÃ¨®·˜­¼Š…¹Êœ ¨³šoµ¥­»—Á„·—æ‡ ‡ªµ¤—´œÃ¨®·˜­¼Š˜µ¤¤µ
  • 42. 36 „µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— ÁŽ¨¨rŅ¤´œ­¦oµŠ macrophage chemo attractant protein-1 ¨³ intercellular adhesion molecule-1 —¹Š—¼— macrophage Á…oµ¤µ°¥¼n¦°Ç ×¥ macrophage Á®¨nµœ¸ÊÁ­¦·¤„µ¦­¦oµŠŽ´¥Ã˜Å‡œ­r ®¨µ¥œ·—š¸ÉÁŽ¨¨rŅ¤´œ­¦oµŠ…¹Êœ°¥¼n¨oª ‹¹Š¤¸„µ¦„¦³˜»oœ„¦³ªœ„µ¦°´„Á­ (inflammation) ĜÁœºÊ°Á¥ºÉ° ˜nµŠÇ °¥nµŠ˜n°ÁœºÉ°Š ¦nª¤„´ plasminogen activator inhibitor-1 š¸ÉÁ¡·É¤…¹Êœ ¨³‡ªµ¤Ÿ·—ž„˜·…°Š®¨°— Á¨º°— ž¦³„°„´¦³—´Å…¤´œÄœÁ¨º°—Ÿ·—ž„˜· ¦³—´œÊ嘵¨ÄœÁ¨º°—­¼Š®¦º°Áµ®ªµœ ¨³‡ªµ¤—´œ è®·˜­¼Š šÎµÄ®oÁ„·—®¨°—Á¨º°——Š˜¸Â…Ȋ¨³°»—˜´œ Ĝš¸É­»—Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— ŗo„n „µ¦Á„·— 懮´ªÄ‹Œ´¡¨´œ (acute coronary syndrome) 懄¨oµ¤ÁœºÊ°®´ªÄ‹˜µ¥ °´¤¡§„¬r °´¤¡µ˜ (¦¼žš¸É 4) œ°„‹µ„ž{‹‹´¥š¸É„¨nµª…oµŠ˜oœÂ¨oª „µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°—¥´Š¤¸ž{‹‹´¥Á­¸É¥Š®¦º°Á®˜»°ºÉœ¦nª¤—oª¥ Ánœ „µ¦­¼»®¦¸É Ťn°°„„ε¨´Š„µ¥ ‡ªµ¤Ÿ·—ž„˜·šµŠ¡´œ›»„¦¦¤ °µ¥»š¸É¤µ„…¹Êœ ¦¼žš¸É 4. £µª³°oªœ„´„µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°—¨³Ã¦‡‹µ„„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤ Adipocytes excess lipid accumulation NEFA, IL-6 TNF -D Resistin Adiponectin Adipose Glucose uptake and oxidation, glycogen deposition Muscle HGO, VLDL ( sdLDL) HDL, CRP Fibrinogen PAI-1 Liver NO-mediated Vasorelaxation Adhesion molecules TNF-D, IL-6 PAI-1 Endothelium Aggregation Platelets Genetic Susceptibility Environmental Factors increased NEFA Hormones Cytokines Insulin Resistance Inflammatory State Proliferation Tissue Injury Dysglycemia DyslipidemiaVasculopathy DiabetesHypertension NAFLDCKD Cardiovascular Diseases other risk factors / causes
  • 43. 37 „µ¦Á„·—懰ºÉœ‹µ„„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤ 懋µ„„µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·Ž¹É¤š¸É¡ ŗo„n æ‡Å…¤´œ¡°„˜´ (Non-alcoholic fatty liver disease, NAFLD) 懅°Š™»ŠœÊε—¸ æ‡Å˜Á¦ºÊ°¦´Š Free fatty acid ž¦·¤µ–­¼Šš¸ÉŸnµœ¤µÄœ®¨°—Á¨º°——ε¡°¦r˜´¨Á…oµ­¼n˜´Ã—¥˜¦Š15,17 šÎµÄ®o¤¸Å…¤´œ ­³­¤ÄœÁŽ¨¨r˜´¤µ„…¹Êœ˜µ¤¦³¥³Áª¨µ Ž¹ÉŠÄœ¦³¥³˜oœ­µ¤µ¦™„¨´‡ºœ­¼nž„˜·Å—o®µ„ž¦·¤µ–Å…¤´œ¨—¨Š „µ¦¡Å…¤´œ­³­¤ÄœÁŽ¨¨r˜´œo°¥„ªnµ¦o°¥¨³ 30 ™º°ªnµ¤¸Å…¤´œ¡°„˜´Á¨È„œo°¥ ™oµ¡Á„·œ¦o°¥¨³ 60 ™º°ªnµ¤¸Å…¤´œ¡°„˜´¦»œÂ¦Š Ž¹ÉŠ‹³Áž¨¸É¥œ­£µ¡Áž}œÃ¦‡ Ĝ¦³¥³˜oœ‡º° ˜´°´„Á­ (non-alcoholic steatohepatitis, NASH) ˜n°¤µÁ„·—¡´ŠŸº— (fibrosis) Ĝ˜´¤µ„…¹Êœ „¨µ¥Áž}œÃ¦‡˜´Â…ÈŠ (cirrhosis) Ž¹ÉŠ Ĝš¸É­»—°µ‹Á„·—¤³Á¦ÈŠ˜´˜µ¤¤µ £µª³—ºÊ°°·œŽ¼¨·œÂ¨³„µ¦¤¸ free fatty acid ž¦·¤µ–­¼ŠÄœÁŽ¨¨r˜´šÎµÄ®o„¦³ªœ„µ¦°È°„Ž·Á—´Éœ Ņ¤´œ—o°¥­¤¦¦™£µ¡ Ņ¤´œ‹¹Š­³­¤ÄœÁŽ¨¨r˜´¤µ„…¹ÊœÇ ¨³¥´ŠšÎµÄ®o¤¸ free radials Á„·—…¹Êœ‹Îµœªœ ¤µ„17 ¦nª¤„´„µ¦Áž¨¸É¥œÂž¨Š…°Š±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­rš¸É­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œÄœ¨´„¬–³Á—¸¥ª„´ „µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— ‹¹ŠÁ„·—¡¥µ›·­£µ¡—´Š„¨nµª…oµŠ˜oœ (¦¼žš¸É 4) œ°„‹µ„œ¸Ê ž¦·¤µ–Å…¤´œš¸É­³­¤¤µ„Äœ™»ŠœÊε—¸ šÎµÄ®oÁ„·—£µª³ cholecystosteatosis ¨³Ã¦‡ ™»ŠœÊε—¸°´„Á­ (steatocholecystitis) ™»ŠœÊε—¸°´„Á­Á¦ºÊ°¦´Š (chronic acalculous cholecystitis)18 š¸É˜´ °n°œÁ„·—­£µª³œ¸ÊŗoÁnœ„´œ æ‡Å˜Á¦ºÊ°¦´Š (chronic kidney disease, CKD) ¤¸‡ªµ¤­´¤¡´œ›r„´£µª³°oªœ ÁºÉ°ªnµ„µ¦Á„·—æ‡ ŘÁ¦ºÊ°¦´ŠÁ¦·É¤‹µ„ £µª³—ºÊ°°·œŽ¼¨·œ ¨³ renin-angiotensin-aldosterone system š¸É™¼„„¦³˜»oœšÎµÄ®o¤¸ „µ¦Á„ȝ„´„ÃŽÁ—¸É¥¤¤µ„…¹Êœ ¤¸ž¦·¤µ–­µ¦œÊεÁ¡·É¤…¹Êœ19 šÎµÄ®o„µ¦„¦°ŠŸnµœ®œnª¥„¦°ŠÃ„¨Á¤¦¼¨´­ (glomerulus) …°ŠÅ˜¤¸ž¦·¤µ–­¼Š (high glomerular filtration rate, GFR) ˜n°¤µ¤¸„µ¦Áž¨¸É¥œÂž¨Šš¸É ®œnª¥„¦°ŠÃ„¨Á¤¦¼¨´­ ¤¸„µ¦Á¡·É¤‹ÎµœªœÁŽ¨¨r¤¸ÂŽŠÁ‹¸¥¨ (proliferation of mesangial cells) ¤¸„µ¦ ¦´ÉªÅ®¨…°Š°´¨¼¤·œ®¦º°Ãž¦˜¸œ°°„¤µ„´ž{­­µª³ (albuminuria or proteinuria) ž¦³„°„´„µ¦¤¸ sympathetic over-activity ¤¸„µ¦Áž¨¸É¥œÂž¨Š…°Š±°¦r䜚¸É­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œ ¨³Ž´¥Ã˜Å‡œ­rš¸É ÁŽ¨¨rŅ¤´œ­¦oµŠ‹Îµœªœ¤µ„‹¹ŠÁ„·—¡¥µ›·­£µ¡°¥nµŠ˜n°ÁœºÉ°ŠÂ¨³Á„·—æ‡Å˜Á¦ºÊ°¦´Š…¹Êœ19,20 „¦–¸š¸É¤¸ æ‡Áµ®ªµœ®¦º°‡ªµ¤—´œÃ¨®·˜­¼Š¦nª¤—oª¥„µ¦Áž¨¸É¥œÂž¨Š‹³Á„·—Á¦Èª…¹ÊœÂ¨³°µ‹¦»œÂ¦Š20 „¨»n¤Ã¦‡¤³Á¦ÈŠ …o°¤¼¨‹µ„„µ¦«¹„¬µÃ—¥˜·—˜µ¤„¨»n¤š¸É¤¸ž{®µ°oªœ¡ªnµ ¤¸‡ªµ¤­´¤¡´œ›r„´¤³Á¦ÈŠ®¨µ¥œ·— (˜µ¦µŠš¸É 3)21,22 ¡ªnµ¤¸‡ªµ¤Â˜„˜nµŠ¦³®ªnµŠÁ¡« ¨³¤³Á¦ÈŠµŠœ·—¤¸‡ªµ¤­´¤¡´œ›r„´ÁºÊ°µ˜· Ánœ ¤³Á¦ÈŠ¨ÎµÅ­oÄ®n, ¤³Á¦ÈŠÁ˜oµœ¤, ¤³Á¦ÈŠ˜n°¤¨¼„®¤µ„ ¡Äœ‡œÂ™Á°Á¸¥-žŽ·¢d„¤µ„„ªnµ22 Ÿ¼oš¸É¤¸ž{®µ°oªœ˜´ÊŠÂ˜nÁ—È„®¦º°ª´¥¦»nœ˜n°ÁœºÉ°Š™¹Šª´¥Ÿ¼oÄ®n¤¸‡ªµ¤Á­¸É¥Š˜n°„µ¦Á„·—¤³Á¦ÈŠ23 ÁºÉ°ªnµ £µª³°oªœÁž}œž{‹‹´¥š¸ÉšÎµÄ®oÁ­¸É¥Š˜n°„µ¦Á„·—¤³Á¦ÈŠ‹µ„ž¦·¤µ–¡¨´ŠŠµœÂ¨³Å…¤´œš¸É„·œ¤µ„Á„·œ ×¥°µ‹ ¤¸­µ¦„n°¤³Á¦ÈŠžœÁžg°œÄœ°µ®µ¦—oª¥ ¦nµŠ„µ¥…µ—„µ¦‡»o¤„´œÁœºÉ°Š‹µ„Ťn°°„„ε¨´Š„µ¥ ¨³ÁŽ¨¨r Ņ¤´œš¸É¤¸Å…¤´œ¤µ„­¦oµŠ­µ¦Ž¹ÉŠ­µ¤µ¦™„¦³˜»oœ„µ¦Á„·—¤³Á¦ÈŠ®¨µ¥°¥nµŠ24,25 œ°„‹µ„œ¸Ê £µª³°oªœ¥´Š
  • 44. 38 ­nŠÁ­¦·¤„µ¦Á˜·Ã˜ „µ¦Â¡¦n„¦³‹µ¥…°Š¤³Á¦ÈŠ ¨³„µ¦„¨´Áž}œŽÊ宨´Š„µ¦¦´„¬µ25 ž{‹‹»´œ¤¸‡ªµ¤ Á…oµÄ‹Á„¸É¥ª„´ž{‹‹´¥Â¨³„¨Å„š¸ÉšÎµÄ®oÁ„·—¤³Á¦ÈŠ®¨µ¥œ·—Äœ‡œ°oªœÁ¡·É¤…¹Êœ17,25-27 ˜µ¦µŠš¸É 3. ¤³Á¦ÈŠš¸É¡­´¤¡´œ›r„´Ÿ¼oš¸É¤¸£µª³°oªœ Á¡« ˜ÎµÂ®œnŠ®¦º°œ·—¤³Á¦ÈŠ ‡ªµ¤Á­¸É¥Š­´¤¡´š›r (RR): 1.35-1.90 ‡ªµ¤Á­¸É¥Š­´¤¡´š›r (RR): 1.05-1.34 ®·Š ¤³Á¦ÈŠÁ¥ºÉ°»¤—¨¼„, ¤³Á¦ÈŠ™»ŠœÊε—¸ ¤³Á¦ÈŠÁ˜oµœ¤, ¤³Á¦ÈŠ…°Š˜´°n°œ µ¥ ¤³Á¦ÈŠÁ¤¨µÃœ¤nµ (malignant melanoma), ¤³Á¦ÈŠ¨ÎµÅ­oÄ®n­nªœž¨µ¥ (rectum), non- Hodgkin lymphoma ®·ŠÂ¨³µ¥ ¤³Á¦ÈŠÁŽ¨¨r˜´ (HCC), ¤³Á¦ÈŠ®¨°— °µ®µ¦ ¤³Á¦ÈŠ…°ŠÅ˜, ¤³Á¦ÈŠ¨ÎµÅ­oÄ®n, ¤³Á¦ÈŠ˜n°¤›´¥ ¦°¥—r, ¤³Á¦ÈŠÁ¤È—Á¨º°—…µª, Multiple Myeloma RR = Relative Risk; HCC = hepatocellular carcinoma ž{‹‹´¥Á­¸É¥Šš´ÉªÅž…°Š¤³Á¦ÈŠÁ˜oµœ¤‡º° °µ¥» Á¡«®·Š ¦³¥³Áª¨µš¸É¦´®¦º°­´¤Ÿ´­Á°­Ã˜¦Á‹œ ž¦³ª´˜·‡¦°‡¦´ªÁž}œ¤³Á¦ÈŠÁ˜oµœ¤ ž¦³ª´˜·Áž}œÃ¦‡Á˜oµœ¤œ·—°ºÉœ°¥¼nÁ—·¤ ±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­rš¸É ÁŽ¨¨rŅ¤´œ­¦oµŠ®¨µ¥œ·— Áž}œž{‹‹´¥š¸É¡ªnµ­´¤¡´œ›r„´„µ¦Á„·—¤³Á¦ÈŠÁ˜oµœ¤ (˜µ¦µŠš¸É 4)25 ˜µ¦µŠš¸É 4. Áž¦¸¥Áš¸¥±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­rš¸É¡Äœ£µª³°oªœÂ¨³¤³Á¦ÈŠÁ˜oµœ¤ ±°¦räœ/Ž´¥Ã˜Å‡œ­r £µª³°oªœ ¤³Á¦ÈŠÁ˜oµœ¤ ®¨nŠš¸É¤µ Plasminogen activator inhibitor-1 (PAI-1) Breast epithelial cells, endothelial cells, smooth muscles, adipocytes Urokinase plasminogen activator (uPA) unknown Tumor cells, epithelial cells, uPA receptor (uPAR) unknown Monocytes, neutrophils, epithelial cells, tumor cells Tumor necrosis factor-alpha (TNF-D) Macrophages, adipocytes, lymphocytes Aromatase Breast epithelial cells, adipocytes Leptin Adipocytes Adiponectin Adipocytes Peroxisome proliferator-activated receptor- gamma (PPAR-J) Adipocytes, tumor cells Omega-3 fatty acid (Z-3 FA) Diet Omega-6 fatty acid (Z-6 FA) Diet
  • 45. 39 ¡ªnµ stromal cells š¸É°¥¼nĜÁœºÊ°Á¥ºÉ°Å…¤´œ (adipose tissue) Ÿ¨·˜Á°ÈœÅŽ¤r°³Ã¦¤µÁ˜­ (aromatase) šÎµÄ®o¤¸Á°­Ã˜¦Á‹œÄœÁ˜oµœ¤Á¡·É¤…¹Êœ25 Á°­Ã˜¦Á‹œÁž}œ­µ¦„n°„µ¦Áž¨¸É¥œÂž¨Š (mitogen) …°ŠÁŽ¨¨r˜n°¤œÊ圤 (mammary tissue) ž¦³„°„´ Á¨Èž˜·œš¸É¤¸¦³—´­¼ŠÄœ‡œ°oªœšÎµÄ®o¤¸„µ¦Á‡¨ºÉ°œ (motility) …°ŠÁŽ¨¨rÁ¡·É¤…¹ÊœÂ˜nÁŽ¨¨r­¼­¨µ¥ (apoptosis) œo°¥¨Š Ĝ…–³š¸É°³—·ÃžÁœÈ‡˜·œŽ¹ÉŠ­nŠŸ¨˜¦Š …oµ¤„¨´¨—¨Š Ž´¥Ã˜Å‡œ­rš¸É­¦oµŠ‹µ„ÁŽ¨¨rŅ¤´œšÎµÄ®oÁ„·—„¦³ªœ„µ¦°´„Á­ œ°„‹µ„œ¸Ê ¡ªnµÁ¨Èž ˜·œ¤¸‡»–­¤´˜·„¦³˜»oœÁŽ¨¨r˜n°¤œÊ圤š¸É¤¸Á°­Ã˜¦Á‹œ¦¸ÁŽÈžÁ˜°¦r°´¨¢iµ (estrogen receptor-Į positive cells)26 ž{‹‹´¥Á®¨nµœ¸Ê¦nª¤„´œšÎµÄ®oÁ„·—„µ¦Áž¨¸É¥œÂž¨ŠÁž}œÁŽ¨¨r¤³Á¦ÈŠÂ¨³„µ¦Á¡·É¤‹ÎµœªœÁŽ¨¨r—oª¥ Peroxisome proliferator-activated receptor-gamma (PPAR-J) ¡Å—oĜÁŽ¨¨rŅ¤´œ Áž}œ nuclear receptor Á¤ºÉ°„¦³˜»oœ‹³¤¸„µ¦­¦oµŠ transcription factors š¸É¤¸Ÿ¨šÎµÄ®o„µ¦˜°­œ°Š˜n°°·œŽ¼¨·œ —¸…¹Êœ ÁŽ¨¨rŅ¤´œ¦´„¦—Å…¤´œ°·­¦³—¸…¹Êœ ¨³¤¸ adipocyte differentiation ˜n„µ¦Áž¨¸É¥œÂž¨Š…°ŠŽ´¥ ØҜ­r¤¸‡ªµ¤Âž¦ž¦ªœ Ánœ plasminogen activator inhibitor-1 °µ‹¨—¨Š®¦º°Á¡·É¤…¹Êœ ¡ PPAR- J ĜÁŽ¨¨r¤³Á¦ÈŠ®¨µ¥œ·—25 „µ¦„¦³˜»oœ PPAR-J š¸É¡ÄœÁŽ¨¨r¤³Á¦ÈŠÁ®¨nµœ¸ÊÁ„·—„µ¦˜°­œ°Šš¸É Á¸É¥ŠÁœ‹µ„ž„˜· šÎµÄ®o¤¸„µ¦Á¡·É¤ cell cycle ¦nª¤„´„¨Å„°ºÉœ Ánœ urokinase plasminogen activator, plasminogen activator inhibitor-1 ¨³°ºÉœÇ šÎµÄ®oÁŽ¨¨r¤¸„µ¦Á¡·É¤‹Îµœªœ „µ¦Á‡¨ºÉ°œ…°Š ÁŽ¨¨r°°„‹µ„š¸ÉšÎµÄ®o¤³Á¦ÈŠÂ¡¦n„¦³‹µ¥ ¨³„µ¦„¨´Áž}œ¤³Á¦ÈŠŽÊε (¦¼žš¸É 5) ­µ¦š¸É­µ¤µ¦™„¦³˜»oœ PPAR-J ŗo Ánœ ¥µ„¨»n¤ thiazolidinedione, omega-3 fatty acid, omega-6 fatty acid ¦¼žš¸É 5. „µ¦Á„·—¤³Á¦ÈŠÁ˜oµœ¤Ÿnµœ Peroxisome proliferator-activated receptor- gamma (PPAR-J) ¨³„¨Å„˜nµŠÇ25
  • 46. 40 „¨»n¤Ã¦‡°ºÉœ „¨»n¤Ã¦‡°ºÉœš¸É­´¤¡´œ›r„´°oªœÂ¨³°oªœ¨Š¡»Š ŗo„n 懅o° 懅°Š¦³šµŠÁ—·œ®µ¥Ä‹ „µ¦ Áž¨¸É¥œÂž¨Š…°Š¦³±°¦räœÂ¨³­º¡´œ›»r 懅o° ¤¸…o°¤¼¨Á¡·É¤…¹ÊœÁž}œ¨Îµ—´™¹Š‡ªµ¤­´¤¡´œ›r…°Š£µª³°oªœ„´Ã¦‡…o°Á­ºÉ°¤ (osteoarthritis) ¨³ 懅o°°´„Á­Á„pµšr (gouty arthritis) ž{‹‹´¥Á­¸É¥Š…°Š osteoarthritis š¸Éš¦µ¤µœµœÂ¨oª‡º° °µ¥»š¸É¤µ„…¹Êœ Á¡«®·Š £µª³°oªœ ¨³ ¦Š„—°´— (mechanical stress) ÁºÉ°ªnµ joint mal-alignment °µ‹Áž}œ°¸„ž{‹‹´¥®œ¹ÉŠš¸É­nŠÁ­¦·¤Ä®oÁ„·— osteoarthritis28 œ°„‹µ„œ¸Ê ‹µ„ genome-wide linkage scan nŠ¸Êªnµœ chromosome 2q ¤¸ gene š¸É ­nŠÁ­¦·¤Ä®oÁ„·— osteoarthritis 懅o° osteoarthritis Á„·—‹µ„„µ¦Á­ºÉ°¤ (degeneration) …°Š articular cartilage ž¦³„°„´ ¤¸‡ªµ¤„¡¦n°Š…°Š„µ¦Žn°¤ÂŽ¤ ¨³¤¸„¦³ªœ„µ¦°´„Á­¦nª¤—oª¥ „µ¦Á¡·É¤…¹Êœ…°ŠÁ¨Èž˜·œ ¦¸Ž·­˜·œ ¨³°³—·ÃžÁœÈ‡˜·œš¸É¨—¨Š ¦ª¤š´ÊŠŽ´¥Ã˜Å‡œ­r®¨µ¥°¥nµŠš¸ÉÁ¡·É¤…¹Êœ‹µ„£µª³°oªœ šÎµÄ®o„¦³ªœ„µ¦ °´„Á­Á¦ºÊ°¦´ŠÁ¡·É¤…¹Êœ˜n°ÁœºÉ°Š Áž}œ„µ¦Á­¦·¤Á¡·É¤Á˜·¤„µ¦Á­ºÉ°¤…°Š articular cartilage28-30 Ĝ‡œ°oªœ¡ªnµ¦³—´„¦—¥¼¦·‡ÄœÁ¨º°—­¼Š…¹Êœ ÁœºÉ°Š‹µ„„µ¦…´„¦—¥¼¦·‡…°ŠÅ˜¨—¨Š­´¤¡´œ›r„´ „µ¦—¼—„¨´ÃŽÁ—¸É¥¤š¸ÉÁ¡·É¤…¹ÊœÂ¨³£µª³—ºÊ°°·œŽ¼¨·œ31 ¤¸„µ¦«¹„¬µÂ­—ŠÄ®oÁ®ÈœªnµÄœ articular cartilage ¤¸ glucose transporter 9 (GLUT 9) Ž¹ÉŠšÎµ®œoµš¸ÉœÎµœÊ嘵¨¢¦»p„Ø­ ¨³„¦—¥¼¦·‡Á…oµ­¼nÁŽ¨¨r32 „¦— ¥¼¦·‡š¸É­³­¤Á¡·É¤ž¦·¤µ–¤µ„Áž}œ˜oœÁ®˜»…°Š„µ¦Á„·—懅o°°´„Á­Á„pµšr 懦³šµŠÁ—·œ®µ¥Ä‹ ‡œ°oªœ¤¸ž{®µ¦³šµŠÁ—·œ®µ¥Ä‹ÁœºÉ°Š‹µ„ 2 ž{‹‹´¥®¨´„‡º° „µ¦Á¡·É¤…¹Êœ…°ŠÁœºÊ°Á¥ºÉ°Å…¤´œ ¨³„¦³ªœ„µ¦°´„Á­Á¦ºÊ°¦´Šš¸ÉÁ„·—‹µ„„µ¦Áž¨¸É¥œÂž¨Š…°Š Á¨Èž˜·œ °³—·ÃžÁœÈ‡˜·œ ¨³Ž´¥Ã˜Å‡œ­r °ºÉœÇ š¸ÉŸ¨·˜Ã—¥ÁŽ¨¨rŅ¤´œ33 ÁºÉ°ªnµ„¦³ªœ„µ¦°´„Á­Áž}œž{‹‹´¥®¨´„ æ‡Â¨³ž{®µš¸É¡Å—o„n „µ¦ ®¥»—®µ¥Ä‹…–³®¨´ (obstructive sleep apnea) „µ¦®µ¥Ä‹Áµ˜ºÊœ (hypoventilation syndrome) ž°—°´„Á­°»—„´ÊœÁ¦ºÊ°¦´Š (chronic obstructive pulmonary disease) „µ¦°´„Á­…°Šž°— ®°®º—34,35 ž{®µ‹µ„„µ¦—¤¥µ­¨Â¨³¢gœ˜´ª36 ץ懰oªœÁž}œ˜oœÁ®˜»…°Šž{®µÁ®¨nµœ¸Ê¨³/®¦º°šÎµÄ®ož{®µ Á®¨nµœ¸Êšª¸‡ªµ¤¦»œÂ¦Š…¹Êœ „µ¦Áž¨¸É¥œÂž¨Š…°Š¦³±°¦räœÂ¨³­º¡´œ›»r ž{®µ…°Š¦³±°¦räœÂ¨³­º¡´œ›»r¡Äœ‡œ°oªœ¦»œÂ¦Š (BMI •30 „„./¤.2 ) Áž}œ­nªœÄ®n ĜŸ¼o®·Š¡ž{®µÅ—o®¨µ¥°¥nµŠ37,38 ŗo„n 1. ž¦³‹ÎµÁ—º°œÅ¤n­¤ÉεÁ­¤° ®¦º°œo°¥¨Š ®¦º°…µ—ž¦³‹ÎµÁ—º°œ ‹µ„„µ¦š¸É¦³—´±°¦räœÁ¡« ¨—¨ŠÁž}œŸ¨‹µ„„µ¦˜„Å…n (ovulation) œo°¥¨Š®¦º°Å¤n¤¸„µ¦˜„Å…n 2. ¤¸»˜¦¥µ„ ÁœºÉ°Š‹µ„ž{®µ„µ¦ {Š˜´ª…°ŠÅ…nš¸ÉŸ­¤Â¨oª (fertilized ovum) „´Ÿœ´Š¤—¨¼„ „µ¦Á‹¦·…°ŠŸœ´Š¤—¨¼„ŤnÁž}œÅž˜µ¤¦³¥³‡¦¦£r ®¦º°Å¤n¤¸„µ¦˜„Å…n ‡ªµ¤Ÿ·—ž„˜·œ¸Ê
  • 47. 41 œ°„‹µ„Áž}œŸ¨‹µ„„µ¦¨—¨Š…°Š±°¦räœÁ¡«Â¨oª °µ‹¤¸Ÿ¨‹µ„¦³—´Á¨Èž˜·œš¸É­¼Š¤µ„—oª¥38 3. …–³˜´ÊŠ‡¦¦£r¤¸Ÿ¨˜n°„µ¦˜´ÊŠ‡¦¦£r¨³šµ¦„ Ĝ¤n¤¸Ã°„µ­Á„·—£µª³‡¦¦£rÁž}œ¡·¬ (pre- eclampsia, eclampsia) Áµ®ªµœ…–³˜´ÊŠ‡¦¦£r šoŠ»˜¦39 4. ¤¸ž{®µ…–³‡¨°— ž{®µÄœŸ¼oµ¥‡º°¤¸»˜¦¥µ„Áž}œ®¨´„ Áž}œŸ¨‹µ„„µ¦Áž¨¸É¥œÂž¨Š…°Š¦³—´±°¦räœÁ¡« ¤¸ erectile dysfunction and reduced semen quality40 ĜÁ—È„šÎµÄ®oÁž}œ®œ»n¤­µªÁ¦Èª (early onset puberty) ž¦³‹ÎµÁ—º°œÅ¤n­¤ÉεÁ­¤° ¨³Á„·—™»ŠœÊεĜ¦´ŠÅ…n (polycystic ovarian syndrome)41 „¨»n¤ž{®µšµŠ­»…£µ¡‹·˜Â¨³­´Š‡¤ „µ¦«¹„¬µµªÂ‡œµ—µ°µ¥» 15 že…¹ÊœÅž‹Îµœªœ 36,984 ‡œ ¡ž{®µšµŠ­»…£µ¡‹·˜¤µ„…¹ÊœÄœ ‡œ°oªœ (adjusted odds ratio = 1.22-1.58) ¡ÄœŸ¼o®·ŠÁž}œ­nªœÄ®n ž{®µÂ¨³Ã¦‡š¸É¡‡º°42 1. depression 2. mania 3. panic attacks 4. social phobia 5. agoraphobia without panic disorder 6. anxiety disorder 7. suicidal ideation and suicide attempts ¤¸®¨´„“µœÁºÉ°Å—oªnµ Á¨Èž˜·œ­nŠ­´µ–„ε„´¦³ž¦³­µš­nªœ„¨µŠ ¤¸Ÿ¨¨— motivation ¨³ mood Á„·—£µª³Ž¹¤Á«¦oµ (depression)43 ¥µš¸ÉčoÎµ´—¦´„¬µž{®µÂ¨³Ã¦‡šµŠ‹·˜¤¸­nªœšÎµÄ®oœÊ宜´„ Á¡·É¤Å—o ‡œš¸É°oªœ¤µ„°µ‹Á„·—ž¤—o°¥ šÎµÄ®oÂ¥„˜´ª°°„‹µ„­´Š‡¤ Á‡¨ºÉ°œÅ®ª¨Îµµ„ ®¨´Å¤n­œ·š ¤¸ ž{®µšµŠ­»…£µ¡ šÎµÄ®o‡»–£µ¡¸ª·˜Á¨ª¨Š Ÿ¼o®·Š¤¸ž{®µ¤µ„„ªnµµ¥44,45 ­¦»ž °oªœÂ¨³°oªœ¨Š¡»Š­nŠŸ¨Ä®oÁ„·—ž{®µ­»…£µ¡š¸É®¨µ„®¨µ¥ ž{®µš¸ÉÁ„·—­´¤¡´œ›r„´ž¦·¤µ– Ņ¤´œ­nªœÁ„·œš¸É­³­¤ÄœÁœºÊ°Á¥ºÉ°Å…¤´œ £µª³—ºÊ°°·œŽ¼¨·œ ¦³—´°³—·ÃžÁœÈ‡˜·œš¸É¨—¨Š „µ¦Á¡·É¤…¹Êœ…°Š Á¨Èž˜·œÂ¨³Ž´¥Ã˜Å‡œ­r®¨µ¥°¥nµŠš¸É„¦³˜»oœ„¦³ªœ„µ¦°´„Á­Á¦ºÊ°¦´ŠÁž}œ®¨´„ Á­¦·¤—oª¥‡ªµ¤Ÿ·—ž„˜· Á‹µ³‹Š°ºÉœÇ Ĝ°ª´¥ª³š¸ÉÁ„¸É¥ª…o°Š ¨³ž{‹‹´¥šµŠ¡´œ›»„¦¦¤ Ĝ¦³¥³¥µªÁ„·—Áž}œÃ¦‡Á¦ºÊ°¦´Šš¸É˜o°Š„µ¦ „µ¦—¼Â¨¦´„¬µ°¥nµŠ˜n°ÁœºÉ°Š Áž}œ£µ¦³šµŠÁ«¦¬“„·‹Â¨³­´Š‡¤Äœ„µ¦—¼Â¨¦´„¬µÃ¦‡°oªœÃ—¥˜¦ŠÂ¨³Ã¦‡ Á¦ºÊ°¦´Šš¸ÉÁ„·—˜µ¤¤µ
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  • 51. 45 ª¦¦–¸ œ·›·¥µœ´œšr žµ‹¦¸¥r °´—»¨¨µ„µŽ·¤ °oªœÂ¨³°oªœ¨Š¡»Šœ°„‹µ„¤¸‡ªµ¤­´¤¡´œ›r„´Ã¦‡¤µ„¤µ¥Â¨oª¥´Š¤¸Ÿ¨„¦³š—oµœ°ºÉœÇ ŗo„n1 ­¤¦¦™£µ¡ ž¦³­·š›·£µ¡„µ¦šÎµŠµœ ‡»–£µ¡¸ª·˜ „µ¦Á„·—š»¡¨£µ¡Â¨³Á­¸¥¸ª·˜„n°œª´¥°´œ‡ª¦ Ÿ¨„¦³š…°ŠÃ¦‡°oªœ®¦º°°oªœ¨Š¡»Š˜n°­»…£µ¡ ‹µ„„µ¦«¹„¬µ‡ªµ¤»„…°Š£µª³œÊ宜´„Á„·œÂ¨³°oªœ…°Š„¨»n¤ž¦³Áš«š¸É¤¸¦µ¥Å—ožµœ„¨µŠÂ¨³ ˜Éε (middle– and low–income countries) Ĝ£¼¤·£µ‡Á°Á¸¥ÂžŽ·¢d„ (Asia-Pacific region) ‹Îµœªœ 14 ž¦³Áš«‹µ„š´ÊŠ®¤— 40 ž¦³Áš«…°Š£¼¤·£µ‡œ¸Ê ¦ª¤š´ÊŠž¦³Áš«Åš¥2 ×¥¦ª¦ª¤…o°¤¼¨ÄœnªŠ¦³®ªnµŠ že 1993–2004 …°Š„µ¦«¹„¬µÄœÂ˜n¨³ž¦³Áš« ¡‡nµ Population Attributable Fractions (PAFs) ‹µ„ £µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ °¥¼nĜnªŠ¦o°¥¨³ 0.8–9.2 ­Îµ®¦´°´˜¦µ˜µ¥‹µ„懮´ªÄ‹Ã‡Ã¦œµ¦¸É ¡ ¦o°¥¨³ 0.2–2.9 ­Îµ®¦´°´˜¦µ˜µ¥‹µ„ hemorrhagic stroke ¨³ ¡¦o°¥¨³ 0.9–10.2 ­Îµ®¦´°´˜¦µ ˜µ¥‹µ„æ‡ ischemic stroke (¦¼žš¸É 1) ¦¼žš¸É 1. ­—Š Population attributable fractions …°ŠÃ¦‡®´ªÄ‹Ã‡Ã¦œµ¦¸É æ‡ hemorrhagic stroke ¨³ ischemic stroke š¸ÉÁ„¸É¥ªÁœºÉ°Š¤µ‹µ„£µª³œÊ宜´„Á„·œÂ¨³°oªœ …°Šž¦³Áš«Äœ £¼¤·£µ‡Á°Á¸¥ÂžŽ·¢d„2 º··Õè 5
  • 52. 46 ¤¸Šµœª·‹´¥Â­—Šªnµ¦°Á°ªÂ¨³‡ªµ¤°oªœ­´¤¡´œ›r„´„µ¦˜µ¥‹µ„š»„­µÁ®˜»Äœš´ÊŠ­°ŠÁ¡«3,4 „µ¦«¹„¬µ£µ¦³Ã¦‡Ã—¥Äo„µ¦­¼Á­¸¥že­»…£µª³ (Disability Adjusted Life Years, DALYs) Ž¹ÉŠ¦ª¤„µ¦ Á­¸¥¸ª·˜„n°œª´¥°´œ‡ª¦ (Years of Life Lost, YLLs) ¨³„µ¦­¼Á­¸¥‡»–£µ¡¸ª·˜‹µ„Á‹Èžiª¥®¦º° š»¡¡¨£µ¡ (Years Lost due to Disability, YLDs) Ĝž¦³Áš«š¸É¡´•œµÂ¨oª¡ªnµÁ„·—‹µ„ »®¦¸É °¨„°±°¨r ‡ªµ¤—´œÃ¨®·˜­¼Š Ņ¤´œ‡°Á¨­Á˜°¦°¨ÄœÁ¨º°—­¼Š ¨³£µª³œÊ宜´„Á„·œ5 „µ¦­¼Á­¸¥že­»… £µª³ (DALYs) …°Š‡œÅš¥Äœže ¡.«. 2542 ‹µ„懘·—˜n° æ‡Å¤n˜·—˜n° ¨³„µ¦µ—Á‹È ¦ª¤Â¨oª¤¸ „µ¦­¼Á­¸¥ 5.6 ¨oµœže­»…£µª³ÄœŸ¼oµ¥ ¨³ 3.9 ¨oµœže­»…£µª³ÄœŸ¼o®·Š ץ懚¸ÉÁž}œ­µÁ®˜»…°Š„µ¦ Á­¸¥¸ª·˜ 10 °´œ—´Â¦„š¸É¤¸­nªœÁ„¸É¥ª…o°Š„´„µ¦¦·Ã£‡š¸ÉŤnÁ®¤µ³­¤š´ÊŠÄœÁ¡«µ¥Â¨³Á¡«®·Š ŗo„n 懮¨°—Á¨º°—­¤°Š æ‡Áµ®ªµœ ¨³Ã¦‡®´ªÄ‹…µ—Á¨º°— ®µ„¡·‹µ¦–µ®¦º°‹ÎµÂœ„˜µ¤ž{‹‹´¥Á­¸É¥Š ­»…£µ¡š¸ÉšÎµÄ®oÁ„·—„µ¦­¼Á­¸¥že­»…£µª³Â¨³Á„¸É¥ª…o°Š„´„µ¦¦·Ã£‡ ‡º° 懰oªœÂ¨³œÊ宜´„Á„·œ ‡ªµ¤—´œÃ¨®·˜­¼Š Ņ¤´œ‡°Á¨­Á˜°¦°¨ÄœÁ¨º°—­¼Š „µ¦¦·Ã£‡Ÿ´„¨³Ÿ¨Å¤oŤnÁ¡¸¥Š¡° ¦ª¤š´ÊŠ°°„ „ε¨´Š„µ¥Å¤nÁ¡¸¥Š¡° (¦¼žš¸É 2) Ĝže ¡.«. 2547 „µ¦­¼Á­¸¥že­»…£µª³…°Š‡œÅš¥­¼Š…¹ÊœÁž}œ 5.7 ¨oµœže ­»…£µª³ÄœŸ¼oµ¥ ¨³ 4.2 ¨oµœže­»…£µª³ÄœŸ¼o®·Š ×¥­µÁ®˜»‹µ„懘·—˜n°¨—¨Š ˜n‹µ„æ‡Å¤n˜·—˜n° Á¡·É¤…¹Êœ6 ¦¼žš¸É 2. ­µÁ®˜»…°Š„µ¦­¼Á­¸¥Â¨³ž{‹‹´¥Á­¸É¥Š…°Š‡œÅš¥Äœže ¡.«. 2542 ‹µ„¦µ¥Šµœ…°Š WHO ‹Îµœªœ…°Šž¦³µ„¦š¸É¤¸œÊ宜´„Á„·œÂ¨³°oªœš´ÉªÃ¨„œ´Êœ ‹³Á¡·É¤…¹Êœ™¹Š 1.5 ¡´œ¨oµœ‡œÄœže 20151 ™oµÂœªÃœo¤¥´Š‡ŠÁž}œÁnœœ¸Ê ‡µ—ªnµ­µÁ®˜»„µ¦˜µ¥°´œ—´ 1 …°Šž¦³µ„¦ ‹Îµœªœ¤µ„„ªnµ 17 ¨oµœ¸ª·˜š´ÉªÃ¨„Á„·—‹µ„懮´ªÄ‹Â¨³®¨°—Á¨º°— Áž}œŸ¨‹µ„懰oªœÂ¨³œÊ宜´„
  • 53. 47 Á„·œŽ¹ÉŠÁž}œž{‹‹´¥Á­¸É¥Š­Îµ‡´š¸ÉÁ¡·É¤¤µ„…¹Êœ ¦ª¤š´ÊŠž¦³Áš«Åš¥—oª¥ ‹µ„„µ¦ª·Á‡¦µ³®r…o°¤¼¨‹ÎµœªœÂ¨³ °´˜¦µ˜µ¥—oª¥Ã¦‡Å¤n˜·—˜n°š¸ÉÁž}œž{®µ­µ›µ¦–­»…­Îµ‡´…°Šž¦³Áš« ŗo„n 懮´ªÄ‹Â¨³®¨°—Á¨º°— 懇ªµ¤—´œÃ¨®·˜­¼Š 懮´ªÄ‹…µ—Á¨º°— 懮¨°—Á¨º°—­¤°Š (°´¤¡§„¬r °´¤¡µ˜) æ‡Áµ®ªµœ ¨³ °»´˜·Á®˜»‹µ„„µ¦‹¦µ‹¦šµŠ„ ¨³‹µ„¦µ¥Šµœ­™·˜·­µ›µ¦–­»… ¡.«. 2540 - 2549 ¡ªnµ‹ÎµœªœÂ¨³ °´˜¦µ˜µ¥—oª¥Ã¦‡¤³Á¦ÈŠÂ¨³Ã¦‡®´ªÄ‹…µ—Á¨º°— ¤¸ÂœªÃœo¤Á¡·É¤­¼Š…¹ÊœÁnœÁ—¸¥ª„´œ —´Š…o°¤¼¨˜µ¤˜µ¦µŠš¸É 1-2 ¨³¦¼žš¸É 3-4 ˜µ¦µŠš¸É 1. ‹Îµœªœ„µ¦˜µ¥ —oª¥Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— 懇ªµ¤—´œÃ¨®·˜­¼Š 懮´ªÄ‹…µ—Á¨º°— 懮¨°—Á¨º°—­¤°Š æ‡Áµ®ªµœ 懤³Á¦ÈŠ „µ¦µ—Á‹ÈÂ¨³°»´˜·Á®˜»‹µ„„µ¦ ‹¦µ‹¦šµŠ„ že ¡.«. 2540-2549 CVD 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 58,531 52,376 42,288 32,331 34,903 32,896 40,090 39,554 36,771 34,106 HT 2,054 2,029 2,987 3,403 3,912 3,213 3,402 2,491 2,452 2,363 IHD 1,870 2,199 4,849 6,251 7,683 9,011 12,005 11,066 11,627 12,163 Stroke 5,962 4,283 6,631 8,260 11,309 13,427 18,332 19,265 15,719 12,921 DM 4,512 4,837 7,000 7,558 8,173 7,383 6,663 7,665 7,371 7,486 Cancer 26,237 29,812 36,091 39,480 42,497 45,834 49,682 50,818 50,622 52,062 Injury 37,188 30,412 39,101 41,032 40,010 42,805 45,119 44,196 35,818 37,433 RTI 12,832 7,839 11,315 12,936 12,722 13,354 12,811 12,340 11,041 10,421 ˜µ¦µŠš¸É 2. °´˜¦µ˜µ¥ ˜n°ž¦³µ„¦ 100,000 —oª¥Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— 懇ªµ¤—´œÃ¨®·˜­¼Š 懮´ªÄ‹…µ—Á¨º°— 懮¨°—Á¨º°—­¤°Š æ‡Áµ®ªµœ 懤³Á¦ÈŠ „µ¦µ—Á‹ÈÂ¨³°»´˜·Á®˜»‹µ„ „µ¦‹¦µ‹¦šµŠ„ že ¡.«.2540-2549 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 CVD 98.6 85.6 68.7 52.3 56.2 52.6 63.7 63.3 59.12 54.5 HT 3.4 3.3 4.9 5.5 6.3 5.1 5.4 4.0 3.94 3.8 IHD 3.2 3.6 7.9 10.1 12.4 14.4 19.1 17.7 18.69 19.4 Stroke 10.1 7 10.8 13.4 18.2 21.5 29.1 30.8 25.27 20.6 DM 7.5 7.9 11.4 12.2 13.2 11.8 10.6 12.3 11.85 12.0 Cancer 43.4 48.7 58.6 63.9 68.4 73.3 78.9 81.3 81.4 83.1 Injury 61.5 41.7 63.5 66.4 64.4 68.4 71.7 70.7 57.6 59.8 RTI 21.2 12.8 18.4 20.9 20.5 21.3 20.4 19.7 17.8 16.6 š¸É¤µ : ­Îµœ´„œÃ¥µ¥Â¨³¥»š›«µ­˜¦r ­Îµœ´„Šµœž¨´—„¦³š¦ªŠ­µ›µ¦–­»… ¦ª¦ª¤Ã—¥ : „¨»n¤­nŠÁ­¦·¤­œ´­œ»œª·µ„µ¦ ­Îµœ´„æ‡Å¤n˜·—˜n° „¦¤‡ª‡»¤Ã¦‡ CVD: 懮´ªÄ‹Â¨³®¨°—Á¨º°—; HT: 懇ªµ¤—´œÃ¨®·˜­¼Š; IHD: 懮´ªÄ‹…µ—Á¨º°—; Stroke: 懮¨°—Á¨º°—­¤°Š; DM: æ‡Áµ®ªµœ; Cancer: 懤³Á¦ÈŠ; Injuries: „µ¦µ—Á‹È; RTI: °»´˜·Á®˜»‹µ„„µ¦‹¦µ‹¦šµŠ„
  • 54. 48 0 20 40 60 80 100 120 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 CVD Cancer Injury RTI š¸É¤µ : ­Îµœ´„œÃ¥µ¥Â¨³¥»š›«µ­˜¦r ­Îµœ´„Šµœž¨´—„¦³š¦ªŠ­µ›µ¦–­»… ¦ª¦ª¤Ã—¥ : „¨»n¤­nŠÁ­¦·¤­œ´­œ»œª·µ„µ¦ ­Îµœ´„æ‡Å¤n˜·—˜n° „¦¤‡ª‡»¤Ã¦‡ ¦¼žš¸É 3. °´˜¦µ˜µ¥ ˜n°ž¦³µ„¦ 100,000 ‡œ —oª¥„¨»n¤Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— 懤³Á¦ÈŠ „µ¦µ—Á‹ÈÂ¨³°»´˜·Á®˜»‹µ„„µ¦‹¦µ‹¦šµŠ„ že ¡.«. 2540-2549 0 5 10 15 20 25 30 35 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 HT IHD Stroke DM š¸É¤µ : ­Îµœ´„œÃ¥µ¥Â¨³¥»š›«µ­˜¦r ­Îµœ´„Šµœž¨´—„¦³š¦ªŠ­µ›µ¦–­»… ¦ª¦ª¤Ã—¥ : „¨»n¤­nŠÁ­¦·¤­œ´­œ»œª·µ„µ¦ ­Îµœ´„æ‡Å¤n˜·—˜n° „¦¤‡ª‡»¤Ã¦‡ ¦¼žš¸É 4. °´˜¦µ˜µ¥ ˜n°ž¦³µ„¦ 100,000 ‡œ 懇ªµ¤—´œÃ¨®·˜­¼Š 懮´ªÄ‹…µ—Á¨º°— æ‡ ®¨°—Á¨º°—­¤°Š ¨³Ã¦‡Áµ®ªµœže ¡.«. 2540-2549 Ÿ¨„¦³š…°Š£µª³°oªœÂ¨³œÊ宜´„Á„·œ˜n°Á«¦¬“„·‹Â¨³­´Š‡¤ £µ¦³Ã¦‡—´Š„¨nµª…oµŠ˜oœ ¤¸‡ªµ¤­´¤¡´œ›r„´¦³—´…°Š„µ¦¡´•œµž¦³Áš«—oª¥ ×¥ÁŒ¡µ³Äœ „¨»n¤ž¦³Áš« middle–income š¸É¤¸„µ¦Áž¨¸É¥œÂž¨ŠšµŠ¦³µ—ª·š¥µ £µ¦³Ã¦‡š¸É­Îµ‡´…°Šž¦³Áš«¤¸ „µ¦Áž¨¸É¥œÂž¨Š‹µ„懘·—˜n°Åž­¼næ‡Å¤n˜·—˜n° š¸É¤¸­µÁ®˜»Á„¸É¥ª…o°Š„´ª·™¸„µ¦—εÁœ·œ¸ª·˜Â¨³ ¡§˜·„¦¦¤„µ¦¦·Ã£‡š¸ÉÁž¨¸É¥œÂž¨ŠÅž ˜´ª°¥nµŠÁnœ ž¦³Áš«Åš¥6 £µª³°oªœ‹´—ªnµÁž}œž{‹‹´¥Á­¸É¥Šš¸É
  • 55. 49 ­Îµ‡´°¥nµŠ®œ¹ÉŠÄœ„µ¦Á„·—£µ¦³Ã¦‡š¸É‹³­nŠŸ¨Á­¸¥˜n°­»…£µ¡°œµ¤´¥Â¨³Á«¦¬“„·‹…°Šž¦³Áš« Ÿ¨„¦³ššµŠÁ«¦¬“„·‹ÂnŠÅ—oÁž}œ 3 ¦³—´7 ¦³—´»‡‡¨ ‡nµÄo‹nµ¥—oµœ­»…£µ¡ šÎµÄ®oÁ­¸¥Ã°„µ­Äœ®¨µ¥—oµœ Ánœ „µ¦Á…oµšÎµŠµœ ¦³—´­™µœž¦³„°„µ¦®¦º°Ÿ¼o‹oµŠ „µ¦­¼Á­¸¥Ÿ¨Ÿ¨·˜‹µ„ž¦³­·š›·£µ¡„µ¦šÎµŠµœÂ¨³„µ¦ ®¥»—Šµœ ‡nµÄo‹nµ¥„µ¦ž¦³„´œ­»…£µ¡ ‡nµÄo‹nµ¥Äœ„µ¦¦´„¬µ¡¥µµ¨ „µ¦Äo¦·„µ¦—oµœ­»…£µ¡ ¦³—´šo°Š™·ÉœÂ¨³ž¦³Áš« „µ¦‹´—š¦´¡¥µ„¦Äœ„µ¦¦´„¬µ¡¥µµ¨ ‡nµ—Á¥ šÎµÄ®o¤¸£µ¦³—oµœ Šž¦³¤µ–­¼ŠÄœÂ˜n¨³že ­¤¦¦™£µ¡Â¨³ž¦³­·š›·£µ¡„µ¦šÎµŠµœ „µ¦«¹„¬µ‡œ°Á¤¦·„´œ 80,261 ‡œÄœže ‡.«. 19948 ¡ªnµ ž{®µ­»…£µ¡š¸É­´¤¡´œ›r„´°oªœšÎµ Ä®o˜o°Š®¥»—Šµœ 39.2 ¨oµœª´œ ¦´„µ¦¦´„¬µ˜´ªÄœÃ¦Š¡¥µµ¨ 89.5 ¨oµœª´œ ¡Â¡š¥r 62.6 ¨oµœ‡¦´ÊŠ ¨³˜o°Š‹Îµ„´—„·‹„¦¦¤ 239 ¨oµœª´œ „µ¦«¹„¬µšµŠ¦³µ—ª·š¥µ…°Š Tucker & Freidman9 Ĝže ‡.«. 1998 ¡ªnµ¡œ´„Šµœš¸É°oªœ‹³¤¸Ã°„µ­…µ—Šµœ¦³¥³¥µª (®¥»—Šµœ t7 ª´œÁœºÉ°Š¤µ‹µ„‡ªµ¤Á‹Èžiª¥ ĜnªŠ¦³®ªnµŠ 6 Á—º°œš¸ÉŸnµœ¤µ) ™¹Š 1.7 Ášnµ ¨³¤¸„µ¦…µ—Šµœ¦³¥³žµœ„¨µŠ (®¥»—Šµœ 3-6 ª´œ ÁœºÉ°Š¤µ‹µ„‡ªµ¤Á‹Èžiª¥ÄœnªŠ 6 Á—º°œš¸ÉŸnµœ¤µ) ­¼Š 1.6 Ášnµ œ°„‹µ„œ¸Ê µ¥Â¨³®·Š°oªœš¸ÉÁ…oµšÎµŠµœ‹³°¥¼nĜ­™µœž¦³„°„µ¦š¸É¤¸Ã‡¦Š„µ¦ž¦³„´œ­»…£µ¡ ¡œ´„Šµœ (employment-based health insurance)10 ¡œ´„Šµœš¸É°oªœ¦»œÂ¦Š (BMI •40 „„./¤.2 ) ¤¸ª´œ…µ— Šµœ¤µ„„ªnµ¡œ´„ŠµœÅ¤n°oªœž¦³¤µ– 13 Ášnµ ¨³¤¸„µ¦Á¦¸¥„¦o°Š‡nµ—Á¥¤µ„„ªnµ¡œ´„ŠµœÅ¤n°oªœ®œ¹ÉŠ Ášnµ˜´ª11 „µ¦Äo¦·„µ¦—oµœ­»…£µ¡ µ¥Â¨³®·Šš¸É°oªœ¤¸„µ¦Äo¦·„µ¦—oµœ­»…£µ¡˜nµŠÇ ŗo„n „µ¦¡Â¡š¥rš´ÉªÅž „µ¦¡Â¡š¥r ÁŒ¡µ³šµŠ „µ¦¡Â¡š¥rŒ»„ÁŒ·œ „µ¦˜¦ª‹‡oœÁ¡ºÉ°ª·œ·‹Œ´¥ ¨³„µ¦Á…oµ¦´„µ¦¦´„¬µÄœÃ¦Š¡¥µµ¨ ¦ª¤š´ÊŠ‡nµÄo‹nµ¥Äœ„µ¦¦´„¬µ ¤µ„„ªnµ„¨»n¤š¸ÉŤn°oªœ°¥nµŠ¤¸œ´¥­Îµ‡´šµŠ­™·˜·12 ‡nµÄo‹nµ¥ Á¤ºÉ°¡·‹µ¦–µ™¹Š˜oœš»œšµŠÁ«¦¬“„·‹ (economic costs) …°ŠÃ¦‡°oªœ ­®¦´“°Á¤¦·„µ¤¸„µ¦ ž¦³¤µ–„µ¦–rŪoÁž}œ¦o°¥¨³ 6.8 …°Š‡nµÄo‹nµ¥šµŠ—oµœ­»…£µ¡š´ÊŠ®¤— ‡·—Áž}œ˜oœš»œ…°Š£µª³ œÊ宜´„Á„·œÂ¨³°oªœÄœÂ˜n¨³žež¦³¤µ– 122.9 ¡´œ¨oµœ—°¨¨nµ¦r Ž¹ÉŠ«¼œ¥r‡ª‡»¤Â¨³žj°Š„´œÃ¦‡…°Š ­®¦´“°Á¤¦·„µ (Center for Disease Control and Prevention, CDC) ŗož¦³¤µ–‡nµÄo‹nµ¥šµŠ­»…£µ¡ š¸ÉÁž}œŸ¨¡ªŠ¤µ‹µ„懰oªœÄœže 1998 – 2000 (˜µ¦µŠš¸É 3) Ūo 75 ¡´œ¨oµœ—°¨¨µ¦r ‡·—Áž}œ‡¦¹ÉŠ®œ¹ÉŠ Ĝ¦³„µ¦ÁŠ·œ­µ›µ¦–³ ×¥„¦³‹µ¥°°„Áž}œ„µ¦—¼Â¨­»…£µ¡Äœª´¥Ÿ¼oÄ®nš´ÊŠ®¤—ž¦³¤µ–¦o°¥¨³ 6 ĜǦŠ„µ¦ž¦³„´œ­»…£µ¡¦o°¥¨³ 7 ¨³Ã‡¦Š„µ¦­ª´­—·„µ¦­´Š‡¤¦o°¥¨³ 11 š¸ÉÁ„¸É¥ª…o°Š„´Ã¦‡°oªœ ¤¸ „µ¦ž¦³¤µ–ªnµ ®µ„Ťn¥´¥´ÊŠ„µ¦Á¡·É¤…¹Êœ…°Š£µª³œÊ宜´„Á„·œÂ¨³°oªœ ‡nµÄo‹nµ¥—oµœ­»…£µ¡Äœ„¨»n¤œ¸Ê
  • 56. 50 ‹³Á¡·É¤…¹Êœ®œ¹ÉŠÁšnµ˜´ªš»„ 1 že ‡·—Áž}œž¦³¤µ– 860-950 ¡´œ¨oµœ—°¨¨nµ¦rĜže ‡.«. 2030 ×¥‡·—Áž}œ ¦o°¥¨³ 16-18 …°Š‡nµÄo‹nµ¥šµŠ—oµœ­»…£µ¡š´ÊŠ®¤—13 ˜µ¦µŠš¸É 3. ‡nµÄo‹nµ¥Äœ¦³ž¦³„´œ­»…£µ¡š¸É¤µ‹µ„懰oªœ ž¦³Á£š °´˜¦µ…°ŠÃ¦‡ °oªœ(%) ‡nµÄo‹nµ¥…°ŠÃ¦‡ °oªœ (—°¨¨µ¦r) ‡nµÄo‹nµ¥Äœ„µ¦—¼Â¨ ­»…£µ¡š´ÊŠ®¤—š¸É¤µ ‹µ„懰oªœ(%) ž¦³µœš´ÉªÅž 20 75 ¡´œ¨oµœ 6 ĜǦŠ„µ¦ž¦³„´œ­»…£µ¡ 21 18 ¡´œ¨oµœ 7 ĜǦŠ„µ¦­ª´­—·„µ¦­´Š‡¤ 30 21 ¡´œ¨oµœ 11 ˜oœš»œšµŠÁ«¦¬“„·‹ (Economic costs) …°ŠÃ¦‡°oªœš´ÊŠÄœ­nªœ»‡‡¨Â¨³»¤œ ­µ¤µ¦™ÂnŠ °°„Å—oÁž}œ‡nµÄo‹nµ¥Ã—¥˜¦Š (direct costs) Ž¹ÉŠÁž}œ‡nµÄo‹nµ¥Äœ„µ¦—¼Â¨¦´„¬µ¡¥µµ¨Ÿ¼ožiª¥˜µ¤¦³ ¦·„µ¦­»…£µ¡ š¸ÉÁž}œÃ¦‡˜nµŠÇ š¸É­ºÁœºÉ°Š¤µ‹µ„£µª³°oªœ Ánœ æ‡Áµ®ªµœœ·—š¸É 2 懮´ªÄ‹ æ‡ ‡ªµ¤—´œÃ¨®·˜­¼Š ¨³Ã¦‡¤³Á¦ÈŠ˜nµŠÇ Áž}œ˜oœ ­nªœ‡nµÄo‹nµ¥šµŠ°o°¤®¦º°‡nµÄo‹nµ¥šµŠ­´Š‡¤ (indirect costs ®¦º° social costs) ŗo„n ‡ªµ¤­µ¤µ¦™Äœ„µ¦šÎµŠµœ¨—¨Š°´œÁœºÉ°Š¤µ‹µ„„µ¦Á‹Èžiª¥ ‡ªµ¤ ¡·„µ¦Â¨³„µ¦˜µ¥‹µ„æ‡Á¦ºÊ°¦´Š˜nµŠÇ š¸ÉÁž}œŸ¨­ºÁœºÉ°Š¤µ‹µ„懰oªœ „µ¦ž¦³Á¤·œ‡nµÄo‹nµ¥šµŠ „µ¦Â¡š¥rÁœºÉ°Š¤µ‹µ„懰oªœÄœž¦³Áš«˜nµŠÇ (˜µ¦µŠš¸É 4) ¡¤¸¤¼¨‡nµ­¼Š14 Ĝže ‡.«. 2005 ‡nµÄo‹nµ¥Ã—¥˜¦Š…°ŠŸ¼oš¸ÉœÊ宜´„Á„·œÂ¨³°oªœÄœ°°­Á˜¦Á¨¸¥Á¡·É¤Áž}œ 21 ¡´œ¨oµœ°°­Á˜¦Á¨¸¥—°¨¨nµ¦r15 ˜µ¦µŠš¸É 4. ‡nµÄo‹nµ¥Ã—¥˜¦Š (Direct costs) …°ŠÃ¦‡°oªœ ž¦³Áš« že (‡.«.) ž¦³µ„¦ (¨oµœ‡œ) ‡nµÄo‹nµ¥ (˜n°že) œ·ªŽ¸Â¨œ—r 1996 3.6 135 ¨oµœ NZ$ °°­Á˜¦Á¨¸¥ 1994 18.4 464 ¨oµœ AUD$ ÁœÁ›°¦r¨œ—r 1995 15.7 1 ¡´œ¨oµœ NG  ¦´ÉŠÁ«­ 1995 58.0 12 ¡´œ¨oµœ FF ­®¦´“°Á¤¦·„µ 1998 274.0 51.6 ¡´œ¨oµœ US$ ‡nµÄo‹nµ¥šµŠ„µ¦Â¡š¥rÁœºÉ°Š¤µ‹µ„懰oªœ…°Šž¦³Áš«­®¦´“°Á¤¦·„µÄœ ‡.«. 1998 ¡ªnµ­¼Š ™¹Š 78.5 ¡´œ¨oµœ—°¨¨nµ¦r˜n°že ¨³‡µ—ªnµÄœ ‡.«. 2008 ‹³Á¡·É¤Áž}œ 147 ¡´œ¨oµœ—°¨¨nµ¦r˜n°že16 Ĝ ž¦³Áš«­®¦´“°Á¤¦·„µ ‡nµÄo‹nµ¥…°ŠÃ¦‡š¸É­ºÁœºÉ°Š¤µ‹µ„懰oªœ ¤µ‹µ„‡nµÄo‹nµ¥Ã—¥˜¦Š…°ŠÃ¦‡®´ªÄ‹ ץŤn¦ª¤Ã¦‡®¨°—Á¨º°—­¤°Š˜¸‡·—Áž}œ¦o°¥¨³ 17 ‡nµÄo‹nµ¥Ã—¥˜¦Š…°ŠÃ¦‡…o°Á­ºÉ°¤‡·—Áž}œ 5.3 ¡´œ¨oµœ US$ ¨³Áž}œ‡nµÄo‹nµ¥šµŠ°o°¤ 15.9 ¡´œ¨oµœ—°¨¨nµ¦r ‡nµÄo‹nµ¥Ã—¥˜¦Š…°ŠÃ¦‡™»ŠœÊε—¸‡·—
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  • 58. 52 ¦¼žš¸É 6. ‡nµÄo‹nµ¥šµŠ˜¦ŠÂ¨³šµŠ°o°¤…°ŠÃ¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— ¨³Ã¦‡®¨°—Á¨º°— ­¤°Š˜¸Äœž¦³Áš«­®¦´“°Á¤¦·„µ že 2007 „µ¦«¹„¬µ…°Š­¤µ‡¤„µ¦‹´—„µ¦­»…£µ¡ (The Health Management Associates, HMA) Ĝ ¦´“‡¨·¢°¦rÁœ¸¥ ž¦³Áš«­®¦´“°Á¤¦·„µÄœže 2000 ™¹Š‡nµÄo‹nµ¥šµŠ˜¦ŠÂ¨³šµŠ°o°¤š¸É¤µ‹µ„„µ¦Å¤n¤¸ „·‹„¦¦¤šµŠ„µ¥ £µª³œÊ宜´„Á„·œ ¨³Ã¦‡°oªœ Ĝ£µ¡¦ª¤š´ÊŠ®¤—ž¦³¤µ– 21.7 ¡´œ¨oµœ˜n°že ×¥ Ĝ‹Îµœªœœ¸Êŗo¦ª¤™¹Š‡nµÄo‹nµ¥ÄœšµŠ„µ¦Â¡š¥r (10.2 ¡´œ¨oµœ—°¨¨µ¦r) ‡nµ—Á¥¡œ´„Šµœ (338 ¨oµœ —°¨¨µ¦r) ¨³„µ¦­¼Á­¸¥„ε¨´Š„µ¦Ÿ¨·˜ (11.2 ¡´œ¨oµœ—°¨¨µ¦r) ×¥™oµ‡·—‡nµÄo‹nµ¥ÄœÂ˜n¨³že…°Š„µ¦ …µ—„·‹„¦¦¤šµŠ„µ¥Áž}œ¤¼¨‡nµ 13.3 ¡´œ¨oµœ—°¨¨nµ¦r 懰oªœ 6.4 ¡´œ¨oµœ—°¨¨nµ¦r ¨³£µª³œÊ宜´„ Á„·œ 2.0 ¡´œ¨oµœ—°¨¨nµ¦r (¦¼žš¸É 7) Ž¹ÉŠ‡nµÄo‹nµ¥­nªœÄ®nœ¸Ê‹³­°—š¦„Á…oµÅžÃ—¥Ÿ¼oªnµ‹oµŠš´ÊŠš¸ÉÁž}œ ­nªœ˜´ªÂ¨³­µ›µ¦–³ Ĝ¦¼žÂ…°Š¦³ž¦³„´œ­»…£µ¡Â¨³„µ¦­¼Á­¸¥„ε¨´Š„µ¦Ÿ¨·˜ ‹µ„„µ¦«¹„¬µ œ¸Ê ‡nµÄo‹nµ¥Á®¨nµœ¸Ê‹³Á¡·É¤…¹Êœ¤µ„„ªnµ 28 ¡´œ¨oµœ—°¨¨nµ¦rĜže 2005 ™oµ¥´ŠÅ¤n¤¸„µ¦‹´—„µ¦š¸ÉÁ—È—…µ— ¦¼žš¸É 7. ‡nµÄo‹nµ¥šµŠ˜¦ŠÂ¨³šµŠ°o°¤…°Š„µ¦…µ—„·‹„¦¦¤šµŠ„µ¥ (physical inactivity) 懰oªœ ¨³£µª³œÊ宜´„Á„·œ Ĝ‡¨·¢°¦rÁœ¸¥ že 2000 (Ĝ®œnª¥¡´œ¨oµœ US$)
  • 59. 53 œ°„‹µ„œ¸Ê „µ¦«¹„¬µœ¸Ê¥´ŠÅ—o‡µ—„µ¦–rŪoªnµ ®µ„¤¸„µ¦ž¦´Áž¨¸É¥œÄ®o¤¸„·‹„¦¦¤šµŠ„µ¥Â¨³¤¸ œÊ宜´„š¸É°¥¼nĜÁ„–”rž„˜·Á¡·É¤…¹Êœ¦o°¥¨³ 5 £µ¥Äœ¦³¥³Áª¨µ 5 žeœ´Êœ‹³nª¥¨—‡nµÄo‹nµ¥˜nµŠÇ —´Š„¨nµª …oµŠ˜oœÅ—o¤µ„„ªnµ 6 ¡´œ¨oµœ US$ ¨³™oµ­µ¤µ¦™ž¦´Áž¨¸É¥œÅ—oÁ¡·É¤…¹Êœ¦o°¥¨³ 10 ‹³­µ¤µ¦™nª¥¨— ‡nµÄo‹nµ¥Å—o™¹Š 23 ¡´œ¨oµœ US$ œ´Éœ‡º°™oµ¤¸ 1 ®¦º° 2 ‡œÄœš»„Ç 20 ‡œš¸É¤¸ž{®µœÊ宜´„Á„·œ®¦º° °oªœ­µ¤µ¦™¨—œÊ宜´„×¥¤¸ BMI ĜÁ„–”rš¸Éž„˜·Â¨³¤¸„·‹„¦¦¤šµŠ„µ¥Á¡·É¤¤µ„…¹Êœ„È‹³nª¥Ä®o ­µ¤µ¦™¨—‡nµÄo‹nµ¥—´Š„¨nµªÅ—o°¥nµŠ¤¸œ´¥­Îµ‡´ CDC …°Š­®¦´“°Á¤¦·„µÂœ³œÎµ¤µ˜¦„µ¦žj°Š„´œ£µª³°oªœ¦³—´»¤œ ×¥˜o°Š‡¦°‡¨»¤š¸É oµœ æŠÁ¦¸¥œ ­ªœ­µ›µ¦–³ ¨³š»„‡¦´ªÁ¦º°œÄœ»¤œ17 °¥nµŠÅ¦„Șµ¤ Finkelstein EA ¨³‡–³18 ¡ªnµŸ¨š¸É‡µ—®ª´Š‹µ„„µ¦¨Šš»œÁ¡ºÉ°¨—œÊ宜´„‹³Å¤nÁ„·—…¹ÊœÄœ¦³¥³Áª¨µ­´Êœ‡º° 2 žeš¸É˜·—˜µ¤Ã—¥ ‡nµÄo‹nµ¥šµŠ„µ¦Â¡š¥r ‡nµ¦´„¬µÂŸ¼ožiª¥œ°„ ¨³‡nµ¦´„¬µÂŸ¼ožiª¥Äœ …°ŠŸ¼oš¸É¨—œÊ宜´„¤¸¤¼¨‡nµ œo°¥„ªnµ„¨»n¤š¸ÉœÊ宜´„Ťn¨—˜nŤn¤¸œ´¥­Îµ‡´šµŠ­™·˜· ˜n‡nµÄo‹nµ¥š¸ÉÁž}œ‡nµ¥µœo°¥„ªnµ°¥nµŠ´—Á‹œ —´Šœ´Êœ ®µ„¤¸„µ¦‡ª‡»¤Â¨³žj°Š„´œ£µª³°oªœÂ¨³œÊ宜´„Á„·œ‹³Áž}œ„µ¦¨Šš»œš¸ÉÄ®oŸ¨Äœ„µ¦ ¨—‡nµÄo‹nµ¥˜nµŠÇ Ĝ¦³¥³¥µª19 „µ¦¨Šš»œ‡ª¦‡¦°‡¨»¤š»„—oµœÂ¼¦–„µ¦ (¦¼žš¸É 8) ¦¼žš¸É 8. Ÿ¨š¸Éŗo‹µ„„µ¦¨Šš»œÄœ„µ¦žj°Š„´œ ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ ¨³„µ¦«¹„¬µª·‹´¥Á¡ºÉ° ‡ª‡»¤„µ¦Á„·—懰oªœ Šµœª·‹´¥Äœ°œµ‡˜ ‹ÎµÁž}œ˜o°Š¤¸„µ¦‡Îµœª–‡nµÄo‹nµ¥š¸É˜o°ŠÄo™oµ®µ„Ťn¤¸„µ¦‹´—„µ¦„´Ã¦‡ °oªœš¸ÉÁ¡·É¤‹Îµœªœ…¹ÊœÁ¦ºÉ°¥Ç —´Š˜´ª°¥nµŠÄœ­®¦´“°Á¤¦·„µ š¸ÉčoŠž¦³¤µ–—oµœ­»…£µ¡Á¡·É¤…¹Êœ‹µ„œo°¥ „ªnµ¦o°¥¨³ 5 Ş™¹Š¦o°¥¨³ 15 Ĝže 1990 …°ŠŠž¦³¤µ–¦ª¤š´ÊŠ®¤— ¨³¤¸„µ¦‡µ—ž¦³¤µ–Ūoªnµ‹³ ¤¸Á¡·É¤¤µ„Á„·œ¦o°¥¨³ 25 Ĝže 2006 (¦¼žš¸É 9) o „µ¦‡oœ‡ªoµª·‹´¥šµŠ—oµœ­¦¸¦ª·š¥µÂ¨³¥µ¦´„¬µÃ¦‡°oªœ o „µ¦Ä®o‡ªµ¤¦¼ošµŠ—oµœÃ£œµ„µ¦ o „µ¦­nŠÁ­¦·¤„µ¦°°„„ε¨´Š„µ¥ o „µ¦¨—‡ªµ¤Á‡¦¸¥— o „µ¦­œ´­œ»œ­»…£µ¡‹·˜Ä‹ o „µ¦‹´—„µ¦„´Ã¦‡Å—o—oª¥˜œÁ°Š ‡nµÄo‹nµ¥ „ε¨´Š„µ¦Ÿ¨·˜ „µ¦žj°Š„´œÂ¨³„µ¦Ä®o‡ªµ¤¦¼o
  • 60. 54 ¦¼žš¸É 9. „µ¦Á¡·É¤…¹Êœ…°Š­´—­nªœŠž¦³¤µ–š¸ÉčoĜ¦³¦·„µ¦­»…£µ¡…°Šž¦³Áš«­®¦´“°Á¤¦·„µ Ĝ…–³œ¸ÊÁž}œš¸Éš¦µ„´œ—¸ ™¹Š‡ªµ¤­´¤¡´œ›r¦³®ªnµŠ‡ªµ¤¦»œÂ¦Š…°ŠÃ¦‡°oªœÄœÂ˜n¨³»‡‡¨Â¨³ ‡nµÄo‹nµ¥ÁŒ¨¸É¥Äœ„µ¦—¼Â¨­»…£µ¡ ¦¼žš¸É 10 ­—Š™¹Š‡ªµ¤Â˜„˜nµŠ…°Š‡ªµ¤­´¤¡´œ›r¦³®ªnµŠÃ¦‡°oªœ ¨³Šž¦³¤µ–Äœ„µ¦—¼Â¨­»…£µ¡š´ÊŠ®¤—š¸É˜o°ŠÄoĜ„µ¦¦´„¬µÄœž¦³Áš«­®¦´“°Á¤¦·„µ Ž¹ÉŠÁ¡·É¤‹Îµœªœ …¹Êœ°¥nµŠ´—Á‹œ ‡nµÄo‹nµ¥­nªœÁ„·œÄœ„¨»n¤š¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ¦³—´ 1 œ´Êœ ¤µ„„ªnµ„¨»n¤š¸É °oªœ¦»œÂ¦Š ¦¼žš¸É 10. ‡nµÄo‹nµ¥Äœ¦³—´š¸É˜„˜nµŠ„´œ…°ŠŸ¼oš¸É¤¸œÊ宜´„Á„·œÄœ­®¦´“°Á¤¦·„µ Ĝž¦³Áš«Åš¥ …o°¤¼¨‡ªµ¤­¼Á­¸¥šµŠÁ«¦¬“„·‹Â¨³‡nµÄo‹nµ¥š¸ÉÁ„·—‹µ„懰oªœ¥´ŠÅ¤nž¦µ„’ ¤¸…o°¤¼¨‡nµÄo‹nµ¥„µ¦¦´„¬µÃ¦‡š¸É­´¤¡´œ›r„´Ã¦‡°oªœoµŠ Ánœ æ‡Áµ®ªµœ20 Ĝže 2546 ‡nµ¦´„¬µ Ÿ¼ožiª¥Ã¦‡Áµ®ªµœ Ĝ¨´„¬–³Ÿ¼ožiª¥œ°„Ášnµ„´ 7,487 µš˜n°‡œ˜n°že ™oµÁž}œŸ¼ožiª¥ÄœÁšnµ„´ 42,921 µš˜n°‡œ˜n°‡¦´ÊŠ Ťn¤¸…o°¤¼¨…°Š indirect medical cost …o°¤¼¨‹µ„ǦŠ„µ¦¨Šš³Á¸¥œŸ¼ožiª¥ 懮¨°—Á¨º°—®´ªÄ‹ÁŒ¸¥¡¨´œ (acute coronary syndrome)21 ¡ªnµ‡nµÁŒ¨¸É¥„¨µŠ…°Š‡nµÄo‹nµ¥Äœ
  • 61. 55 „µ¦œ°œÃ¦Š¡¥µµ¨¦´“‹µ„„µ¦¦´„¬µš»„¦¼žÂÁšnµ„´ 47,908 µš ‡nµÄo‹nµ¥Âž¦˜µ¤¨´„¬–³…°Š 懮¨°—Á¨º°—®´ªÄ‹ÁŒ¸¥¡¨´œ Ÿ¼ožiª¥š¸É¡ ST segment elevation ¤¸‡nµÄo‹nµ¥‡nµÁŒ¨¸É¥ 82,848 µš Ÿ¼ožiª¥š¸ÉŤn¡ ST segment elevation ¤¸‡nµÄo‹nµ¥‡nµÁŒ¨¸É¥ 40,531 µš ¨³ Ÿ¼ožiª¥š¸ÉÁž}œ unstable angina ¤¸‡nµÄo‹nµ¥‡nµÁŒ¨¸É¥ 26,116 µš ¡ªnµª·›¸„µ¦¦´„¬µ—oª¥„µ¦Ÿnµ˜´—˜n°®¨°—Á¨º°—¤¸‡nµÄo‹nµ¥ ­¼Š­»—¦µ¥¨³ž¦³¤µ– 203,139 – 223,747 µš ¦°Š¨Š¤µ‡º°„µ¦…¥µ¥®¨°—Á¨º°—¦µ¥¨³ 152,081 – 161,374 µš ¤¸¦µ¥Šµœ„µ¦­¼Á­¸¥Ÿ¨·˜£µ¡‹µ„‡nµ¦´„¬µ¡¥µµ¨ „µ¦˜µ¥Â¨³„µ¦…µ—ŠµœÄœže ¡.«. 2547 ­¼Š™¹Š 61,936 208,287 ¨³ 219,560 ¨oµœµš ˜µ¤¨Îµ—´ (¦ª¤­µ¤—oµœÁšnµ„´ 489,783 ¨oµœµš) 6 °´œÁž}œŸ¨‹µ„懚¸É¤¸£µ¦³Ã¦‡­¼Š 12 °´œ—´˜oœ ŗo„n æ‡Á°—­r/Á°Å°ª¸ ¤³Á¦ÈŠ˜´ Áµ®ªµœ æ‡ Ž¹¤Á«¦oµ °¨„°±°¨r ˜o°„¦³‹„ ®´ªÄ‹…µ—Á¨º°— ®¨°—Á¨º°—­¤°Š ž°—°»—„´ÊœÁ¦ºÊ°¦´Š ˜´Â…ÈŠ …o°Á­ºÉ°¤ ¨³°»´˜·Á®˜»‹¦µ‹¦ ץ懚¸É­´¤¡´œ›r„´Ã¦‡°oªœ´—Á‹œ‡º°Áµ®ªµœ ®´ªÄ‹…µ—Á¨º°— ®¨°—Á¨º°—­¤°Š ¨³…o°Á­ºÉ°¤ ¤¸„µ¦­¼Á­¸¥Ÿ¨·˜£µ¡¦ª¤­µ¤—oµœÁšnµ„´ 156,564 ¨oµœµš®¦º°‡·—Áž}œ¦o°¥¨³ 32 …°Š š´ÊŠ®¤— ×¥­¦»ž £µª³°oªœÂ¨³°oªœ¨Š¡»ŠšÎµÄ®oÁ„·—ž{®µšµŠ—oµœ­»…£µ¡ ¨³Áž}œ£µ¦³šµŠÁ«¦¬“„·‹ ¨³­´Š‡¤ ‹¹ŠÁž}œž¦³Á—Èœ­Îµ‡´ÄœÁ·ŠœÃ¥µ¥š¸É‹³˜o°Š¡·‹µ¦–µÄ®o‡ªµ¤­Îµ‡´ ¨³—εÁœ·œ„µ¦Á¡ºÉ° ‡ª‡»¤Â¨³Â„oŅž{®µ Á°„­µ¦°oµŠ°·Š 1. Kouris-Blazos A, Wahlqvist ML. Health economics of weight management: evidence and cost. Asia Pac J Clin Nutr. 2007; 16 (Suppl 1): 329-38. 2. Asia Pacific Cohort Studies Collaboration. The burden of overweight and obesity in the Asia-Pacific region. Obes Rev 2007; 8: 191-6. 3. Koster A, Leitzmann MF, Schatzkin A, et al. Waist circumference and mortality. Am J Epidemiol 2008; 167: 1465-75. 4. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med 2010; 363: 2211-9. 5. World health Organization. The World Health Report 2002: Reducing risks, promoting healthy life. Geneva, WHO 2002. 6. £¼­·˜ ž¦³‡°Š­µ¥, ª·Ã¦‹œr ˜´ÊŠÁ‹¦·Á­™¸¥¦ ¨³‡–³. ǦŠ„µ¦«¹„¬µª·‹´¥ÂŸœ„µ¦¨Šš»œ—oµœ ­»…£µ¡ ĜŸœ¡´•œµÁ«¦¬“„·‹Â¨³­´Š‡¤Â®nŠµ˜· Œ´š¸É 10 (¡.«. 2550-2554). ­Îµœ´„Šµœ ¡´•œµœÃ¥µ¥­»…£µ¡¦³®ªnµŠž¦³Áš«. œœš»¦¸ 7. Runge CF. Economic consequences of the obese. Diabetes. 2007; 56: 2668-72. 8. Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res 1998; 6: 97-106.
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  • 72. 66 „µ¦ššªœŸ¨„µ¦«¹„¬µª·‹´¥š¸É˜·—˜µ¤Á—È„°oªœÅž¦³¥³¥µª¡ªnµ ‡ªµ¤Á­¸É¥Š…°Š„µ¦¥´Š‡Š °oªœÁ¤ºÉ°Áž}œŸ¼oÄ®nÁ¡·É¤…¹Êœ˜µ¤°µ¥» ®œ¹ÉŠÄœ­µ¤…°ŠÁ—È„š¸É°oªœÄœª´¥„n°œÁ¦¸¥œ ¨³‡¦¹ÉŠ®œ¹ÉŠ…°ŠÁ—È„š¸É °oªœÄœª´¥Á¦¸¥œ‹³¥´Š‡Š°oªœÁ¤ºÉ°Áž}œŸ¼oÄ®n ®µ„¥´Š°oªœÁ¤ºÉ°Áž}œª´¥¦»nœ ¦o°¥¨³ 80 ‹³Áž}œŸ¼oÄ®n°oªœ59 Á—È„š¸É°oªœÄœnªŠ 1-2 že¤¸‡ªµ¤Á­¸É¥Šš¸É‹³°oªœÁ¤ºÉ°Áž}œŸ¼oÄ®nÁž}œ 2 Ášnµ…°ŠÁ—È„ª´¥Á—¸¥ª„´œš¸ÉŤn°oªœ ™oµ ¥´Š‡Š°oªœ™¹Š°µ¥» 3-5 žeð„µ­š¸É‹³Áž}œŸ¼oÄ®n°oªœÁ¡·É¤…¹ÊœÁž}œ 8 Ášnµ60 懰oªœ‹¹ŠÁž}œž{®µÃ£œµ„µ¦š¸É­Îµ‡´…°ŠÁ—È„Åš¥ ‡ªµ¤»„…°Š£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡ °oªœÁ¡·É¤…¹Êœ°¥nµŠ˜n°ÁœºÉ°Š ¨³ž{®µ­»…£µ¡š¸ÉÁž}œŸ¨‹µ„懰oªœ ×¥ÁŒ¡µ³Áµ®ªµœœ·—š¸É 2 š¸É‹³ ˜n°ÁœºÉ°ŠÁž}œž{®µÃ¦‡Å¤n˜·—˜n°Á¦ºÊ°¦´ŠÁ¡·É¤…¹ÊœÄœŸ¼oÄ®n Áž}œ£µ¦³‡nµÄo‹nµ¥—oµœ­»…£µ¡š¸É°µ‹„¦³š˜n° Á«¦¬“„·‹…°Šž¦³Áš« ‹¹Š­¤‡ª¦˜o°ŠÅ—o¦´„µ¦Â„oŅ°¥nµŠ¦¸—nªœ ×¥„µ¦¤¸­nªœ¦nª¤…°Š®¨µ¥ iµ¥š¸É Á„¸É¥ª…o°Š ¼¦–µ„µ¦š»„¦³—´—oª¥¤µ˜¦„µ¦Äœ„µ¦žj°Š„´œ ‡ª‡»¤ ‡´—„¦°ŠÂ¨³Îµ´—¦´„¬µ š¸É ‡¦°‡¨»¤„¨»n¤ž{‹‹´¥—oµœ¡§˜·„¦¦¤„µ¦¦·Ã£‡ „µ¦¤¸„·‹„¦¦¤šµŠ„µ¥ ¨³ž{‹‹´¥Âª—¨o°¤š¸É¤¸Ÿ¨˜n° ¡§˜·„¦¦¤…°Š»‡‡¨ „µ¦Â„ož{®µœÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ¥´Š¤¸‡ªµ¤šoµšµ¥ š¸É˜o°Š¦³ª´ŠÅ¤nÄ®o­nŠŸ¨ ­³šo°œ„¨´Ä®ož{®µÃ£œµ„µ¦¡¦n°Š‹µ„ž{®µ eating disorder Á°„­µ¦°oµŠ°·Š 1. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes 2006; 1: 11-25. 2. de Onis M, Blössner M. Prevalence and trends of overweight among preschool children in developing countries. Am J Clin Nutr 2000; 72: 1032–9. 3. Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. Int J Pediatr Obes 2006; 1: 33-41. 4. Yach D, Stuckler D, Brownell KD. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes. Nature Med 2006; 12: 62-6. 5. ¨´——µ Á®¤µ³­»ª¦¦–, «·¦·„»¨ °·«¦µœ»¦´„¬r, œ·¦µ Á¦º°Š—µ¦„µœœšr, ­»›¦¦¤ œ´œš¤Š‡¨´¥, £´š¦µ ­Šnµ, „´¨¥µ œ·˜·Á¦º°Š‹¦´­, ‹·¦µ¡¦ ¤¡·„»¨, ¨³‡–³ª·‹´¥Ã‡¦Š„µ¦ª·‹´¥¡´•œµ„µ¦Â°Š‡r¦ª¤…°Š Á—È„Åš¥. Á—È„Åš¥ª´œœ¸Ê Áž}œ°¥¼n°¥nµŠÅ¦. ®µ—Ä®n: ¨·¤¦µÁ—°¦r­„µ¦¡·¤¡r‹Îµ„´—; 2547. 6. Mo-suwan L. Childhood Obesity: An Overview. Siriraj Med J 2008; 60: 37-40. 7. Klein S, Romijn JA. Obesity. In: Kronenberg HM MS, Polonsky KS, Larsen PR, (eds). Williams textbook of endocrinology. Philadelphia: Saunders Elsevier; 2008:1563-88. 8. ¨´——µ Á®¤µ³­»ª¦¦–. 懰oªœÄœÁ—È„. Ĝ: œ‡¦´¥ ÁŸºÉ°œž“¤, (¦¦–µ›·„µ¦). Clinical practice guideline. „¦»ŠÁš¡²: ð Á°­ ¡¦·Êœ˜·ÊŠÁ±µ­r; 2545: 45-78.
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  • 78. 72 ަ„¦¤ “APPLES” Ĝž¦³Áš«°´Š„§¬ ަ„¦¤ “Crete” Ĝž¦³Áš«„¦¸Ž Áž}œ˜oœ Ÿ¨„µ¦ª·‹´¥¸Êªnµ ¤µ˜¦„µ¦Ã¦ŠÁ¦¸¥œÄ®oŸ¨­ÎµÁ¦È‹Å¤n­¼Šœ´„¨³¤´„Ťn¥´ÉŠ¥ºœ ¤µ˜¦„µ¦Äœ­™µœž¦³„°„µ¦ (Ž¹ÉŠ‹³¦ª¤ ¦ŠŠµœÁ—È„°µ¥» 15 - <18 že ˜µ¤¡¦³¦µ´´˜·‡»o¤‡¦°ŠÂ¦ŠŠµœ ¡.«. 2541) ŗoŸ¨Äœ„µ¦ž¦´ ¡§˜·„¦¦¤Äœ¦³¥³­´Êœ ˜n¥´Š…µ—Ÿ¨ÄœÂŠn„µ¦¨— BMI ®¦º°¨—°oªœ¨ŠÅ—o ¤µ˜¦„µ¦š¸É¤¸ÂœªÃœo¤ªnµ‹³ ŗoŸ¨‡º°„µ¦—εÁœ·œŠµœÂ¼¦–µ„µ¦Äœ»¤œ (community-level approach) ×¥Áœoœ„µ¦‡ª‡»¤ ž{‹‹´¥Âª—¨o°¤Ÿnµœ„µ¦—εÁœ·œŠµœÂ­®­µ…µ (multidisciplinary approach) ¨³ž¦³­µœŸ¼o¤¸­nªœÅ—o Á­¸¥ (multiple stakeholders) š¸Éž¦´Ä®oÁ®¤µ³„´ª´•œ›¦¦¤šo°Š™·Éœ ˜nŸ¨„µ¦ž¦³Á¤·œ¥´Š¤¸œo°¥Â¨³¥´Š Ťnœnœ°œªnµ¤¸ž¦³­·š›·Ÿ¨Äœ„µ¦‡ª‡»¤Ã¦‡°oªœÄœÁ—È„6 œÃ¥µ¥šµŠÁ¨º°„ (policy options) Ĝ£µª³ž{‹‹»´œ¤¸ž{‹‹´¥ upstream š¸É„ε®œ—¡§˜·„¦¦¤Â¨³£µª³Ã£œµ„µ¦ °µš· œÃ¥µ¥ …œ­nŠ­µ›µ¦–³Â¨³œÃ¥µ¥Ÿ´ŠÁ¤º°Š š¸É¤¸Ÿ¨„¦³š˜n°„µ¦Á¨º°„ª·›¸Á—·œšµŠÂ¨³‡ªµ¤ž¨°—£´¥…°Š ­™µœš¸É­µ›µ¦–³ š¸É­nŠŸ¨˜n°„µ¦¤¸„·‹„¦¦¤šµŠ„µ¥…°ŠÂ˜n¨³‡œ ®¦º° œÃ¥µ¥°µ®µ¦š¸É„ε®œ—œ·— …°ŠŸ¨·˜Ÿ¨Á„¬˜¦­nŠŸ¨˜n°°µ®µ¦ÄœÃ¦ŠÁ¦¸¥œÂ¨³„µ¦¦·Ã£‡°µ®µ¦…°ŠÂ˜n¨³‡œ Ĝ„µ¦Â„ož{®µÃ¦‡ °oªœ‹¹Š˜o°Š‡¦°‡¨»¤š´ÊŠ upstream (socioecology) ×¥„µ¦ž¦´­£µ¡Âª—¨o°¤—oµœ­´Š‡¤ Á«¦¬“„·‹ ¨³„µ¥£µ¡ midstream (lifestyle ®¦º°¦¼žÂ„µ¦—εÁœ·œ¸ª·˜) ×¥„µ¦ž¦´¡§˜·„¦¦¤Ä®o¨—„µ¦ ¦·Ã£‡¡¨´ŠŠµœÂ¨³Á¡·É¤„·‹„¦¦¤šµŠ„µ¥ ¨³ downstream (health service) ×¥„µ¦­œ´­œ»œ„µ¦ Ä®o¦·„µ¦—oµœ­»…£µ¡Â¨³„µ¦—¼Â¨¦´„¬µÃ¦‡ ž¦³­„µ¦–r—εÁœ·œœÃ¥µ¥Â„ož{®µÃ¦‡°oªœ ¡ªnµ¦·„µ¦—oµœ­»…£µ¡Å¤nčnª·›¸š¸É—¸Á­¤°Åž Ĝ„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ œÃ¥µ¥—oµœ°»žšµœ Ánœ œÃ¥µ¥°µ®µ¦Â¨³„µ¦Äo¤µ˜¦„µ¦—oµœ¦µ‡µ „´°µ®µ¦¡¨´ŠŠµœ­¼Š¡ª„°µ®µ¦…¥³ ¨³Ÿ´„Ÿ¨Å¤o „Ȥ¸‡ªµ¤­Îµ‡´Ánœ„´œ ˜nµŠ‡¦´ÊŠ„È°µ‹Á„·—‡ªµ¤ …´—Â¥oŠ¦³®ªnµŠœÃ¥µ¥­µ›µ¦–³—oµœ­»…£µ¡ Ánœ ¨—„µ¦„·œ°µ®µ¦…¥³ „´œÃ¥µ¥—oµœ„µ¦‡oµš¸É ˜o°Š„µ¦„¦³˜»oœ„µ¦¦·Ã£‡°µ®µ¦¡¨´ŠŠµœ­¼Š—´Š„¨nµªÅ—o Haddad7 ŗoÁ­œ°˜´ª°¥nµŠœÃ¥µ¥šµŠÁ¨º°„—oµœ°µ®µ¦ Á¡ºÉ°¨—£µª³Ã£œµ„µ¦Á„·œÂ¨³Ã¦‡ °oªœÂ¨³Ÿ¨„¦³š˜n°£µª³Á«¦¬“„·‹ 1. œÃ¥µ¥—oµœ°»ž­Š‡r (demand-side policy) - ž¦´¦µ‡µ°µ®µ¦¼­»…£µ¡Ä®o˜É優nµ°µ®µ¦š¸ÉšÎµÄ®oÁ­¸É¥Š˜n°£µª³Ã£œµ„µ¦Á„·œ - ‹´—šÎµÂœªšµŠ®¦º°…o°Âœ³œÎµ—oµœ°µ®µ¦Â¨³Ã£œµ„µ¦¦³—´µ˜· - ¤¸Œ¨µ„㍜µ„µ¦š¸É´—Á‹œÁ…oµÄ‹Šnµ¥Á¡ºÉ°Ä®oÁ¨º°„°µ®µ¦­»…£µ¡ - ¦–¦Š‡rÁ¡ºÉ°­¦oµŠ‡ªµ¤˜¦³®œ´„™¹ŠŸ¨Á­¸¥…°Š°µ®µ¦š¸ÉŤn—¸˜n°­»…£µ¡Â¨³Ã¦‡°oªœ - ‡ª‡»¤„·‹„¦¦¤„µ¦˜¨µ—°µ®µ¦š¸ÉŤn—¸˜n°­»…£µ¡š¸É—εÁœ·œ„µ¦„´Á—Ȅ×¥˜¦Š 2. œÃ¥µ¥—oµœ°»žšµœ (supply-side policy) - Á¡·É¤„µ¦¨Šš»œÄœ„µ¦Ÿ¨·˜Ÿ¨…°ŠŸ¨Å¤o¨³Ÿ´„ Á¡ºÉ°Ä®o¦µ‡µ™¼„¨Š - „ε‹´—‡ªµ¤Å—oÁž¦¸¥—oµœ¦µ‡µ…°Š°µ®µ¦Å…¤´œ­¼Š ¨³¨—…o°‹Îµ„´——oµœž¦·¤µ–…°Š °µ®µ¦¼­»…£µ¡
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  • 80. 74 ž{®µÃ¦‡°oªœÄœÁ—È„‹¹Š˜o°ŠÂ…nŠ„´ž{®µ°ºÉœÂ¨³°µ‹Å—o¦´‡ªµ¤­œÄ‹œo°¥ —´ŠÂ­—ŠÄœ¦¼žš¸É 1 ®µ„ ­µ¤µ¦™°›·µ¥Ãœo¤œoµªÄ®o»‡‡¨š¸É¤¸°·š›·¡¨­¼ŠÁ®¨nµœ¸ÊÁ®Èœ‡ªµ¤­Îµ‡´…°Šž{®µÅ—o „È‹³ž¦³­ ‡ªµ¤­ÎµÁ¦È‹Å—oŠnµ¥ Centers for Disease Control …°Š­®¦´“°Á¤¦·„µ8 Á­œ°Ä®o¤¸„µ¦ž¦¹„¬µŸ¼o¤¸­nªœÅ—oÁ­¸¥Äœ „¦³ªœ„µ¦¡´•œµ¤µ˜¦„µ¦šµŠ­µ›µ¦–­»…—oª¥ Ÿ¼o¤¸­nªœÅ—oÁ­¸¥‹³¤¸šµš­Îµ‡´¥·ÉŠÄœ„µ¦Âž¨Ÿ¨ …°ŠÃ‡¦Š„µ¦ Ÿ¼o¤¸­nªœÅ—o­nªœÁ­¸¥š¸É­Îµ‡´¤¸ 3 „¨»n¤‡º° x „¨»n¤š¸ÉÁ„¸É¥ª…o°Š„´„µ¦—εÁœ·œÃ‡¦Š„µ¦ ŗo„n sponsors, collaborators, coalition partners, funding officials, administrators, managers, and staff x „¨»n¤š¸Éŗo¦´Ÿ¨„¦³š‹µ„ǦŠ„µ¦ ŗo„n clients, family members, neighborhood, organizations, academic institutions, elected officials, advocacy groups, professional associations, skeptics, opponents, and staff of related or competing organizations x „¨»n¤š¸ÉčoŸ¨ž¦³Á¤·œ…°ŠÃ‡¦Š„µ¦ (primary users of the evaluation) ¦µ¥Šµœ„µ¦ž¦³»¤Ÿ¼oÁ¸É¥ªµ…°Š°Š‡r„µ¦°œµ¤´¥Ã¨„9 ­¦»žšµš®¨´„…°ŠŸ¼o¤¸­nªœÅ—o­nªœ Á­¸¥Åªoªnµ x ¦´“µ¨‡ª¦¤¸šµšÁž}œŸ¼oœÎµ —εÁœ·œ„µ¦˜·—˜µ¤Á jµ¦³ª´Š ¨³œÎµ¤µ˜¦„µ¦ÅžÄoÄ®o Á®¤µ³­¤„´¦·š x £µ‡ž¦³µœ œ´„ª·µ„µ¦ ¨³£µ‡Á°„œ ¤¸šµšÄœ„µ¦¡´•œµÂ¨³—εÁœ·œ¤µ˜¦„µ¦ ˜·—˜µ¤‡ªµ¤„oµª®œoµ ÁŸ¥Â¡¦n…o°¤¼¨…°Š best practice ¨³­œ´­œ»œÁ¡ºÉ°Ä®oÁ„·—„µ¦ Áž¨¸É¥œÂž¨Š „µ¦„ε®œ—Ážjµ®¤µ¥ (targets) „µ¦„ε®œ—Ážjµ®¤µ¥Áž}œÁ‡¦ºÉ°Š¤º°­Îµ‡´Äœ„µ¦˜·—˜µ¤„µ¦—εÁœ·œŠµœ˜µ¤œÃ¥µ¥Â¨³ ž¦³Á¤·œŸ¨ Crombie ¨³‡–³10 ŗoššªœÁ°„­µ¦œÃ¥µ¥š¸ÉÁ„¸É¥ª…o°Š„´Ã¦‡°oªœ‹µ„ 12 ž¦³Áš« (Australia, Canada, Denmark, England, Ireland, Japan, New Zealand, Northern Ireland, Scotland, Sweden, USA ¨³ Wales) ‹œ™¹Šže ‡.«. 2005 ­¦»žÅ—o—´Šœ¸Ê 1. Ážjµ®¤µ¥—oµœÃ¦‡°oªœ ¤¸ 8 ž¦³Áš«˜´ÊŠÁžjµ®¤µ¥—oµœÃ¦‡°oªœ (˜µ¦µŠš¸É 1) ˜nĜ‹Îµœªœ œ¸Ê¤¸Á¡¸¥Š 4 ž¦³Áš«š¸É„ε®œ—Ážjµ®¤µ¥°¥nµŠÁ‹µ³‹Šªnµ‹³¨—‡ªµ¤»„…°ŠÃ¦‡°oªœÄ®oÁ®¨º°¦o°¥¨³ÁšnµÄ— ­nªœš¸ÉÁ®¨º°Å¤nŗo¦³» 2. Ážjµ®¤µ¥—oµœÃ£œµ„µ¦ ¤¸ 9 ž¦³Áš«š¸É„ε®œ—Ážjµ®¤µ¥—oµœÃ£œµ„µ¦ ŗo„n ž¦³Áš«¸Éž»iœ œ·ªŽ¸Â¨œ—r °´Š„§¬ Å°¦r¨œ—rÁ®œº° ­„p°˜Â¨œ—r °°­Á˜¦Á¨¸¥ Á—œ¤µ¦r‡ ­ª¸Á—œ ¨³ ­®¦´“°Á¤¦·„µ Ážjµ®¤µ¥š¸Éš´ÊŠ 9 ž¦³Áš«„ε®œ—‡º°„µ¦¦·Ã£‡Ÿ´„¨³Ÿ¨Å¤o ¨³­nªœÄ®n¤¸Ážjµ®¤µ¥š¸É Á„¸É¥ª„´­´—­nªœ…°Š¡¨´ŠŠµœš¸Éŗo‹µ„Å…¤´œ (˜µ¦µŠš¸É 2)
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  • 93. 87 œÃ¥µ¥Â¨³¤µ˜¦„µ¦žj°Š„´œÃ¦‡°oªœÄœÁ—È„…°Šž¦³Áš«Åš¥18 Ÿœ¡´•œµÁ«¦¬“„·‹Â¨³­´Š‡¤Â®nŠµ˜· Ĝ°—¸˜ £µª³Ã£œµ„µ¦Á„·œÂ¨³Ã¦‡°oªœÅ¤nŗo¦´„µ¦¦¦‹»ÅªoĜŸœ¡´•œµÁ«¦¬“„·‹Â¨³­´Š‡¤ ®nŠµ˜· ‹¹ŠÅ¤n¤¸„µ¦„ε®œ—œÃ¥µ¥—oµœÃ¦‡°oªœÂ¥„°°„¤µÃ—¥ÁŒ¡µ³ ĜŸœ¡´•œµÁ«¦¬“„·‹Â¨³ ­´Š‡¤Â®nŠµ˜·Œ´š¸É 7 (¡.«. 2535-2539) ¤¸Ážjµ®¤µ¥—oµœ­»…£µ¡ “Ä®ož¦³µœ¤¸­»…£µ¡—¸™oªœ®œoµ Ĝš«ª¦¦¬®œoµ” ¨³ ”¨—£µª³š»¡Ã£œµ„µ¦¦³®ªnµŠ°µ¥» 0-4 že Ĝ¦³—´ 2 ¨³¦³—´ 3” Ÿœ¡´•œµ² Œ´š¸É 8 (¡.«. 2540-2544) Áž}œÂŸœž’·¦¼ž‡ªµ¤‡·—¨³‡»–‡nµÄ®¤n…°Š ­´Š‡¤Åš¥ š¸ÉÁœoœÄ®o “‡œÁž}œ«¼œ¥r„¨µŠ…°Š„µ¦¡´•œµ” ­nŠÁ­¦·¤¦·„µ¦­»…£µ¡°œµ¤´¥Á¡ºÉ°¡´•œµ„µ¦ …°ŠÁ—Ȅ¨³‡»–£µ¡¸ª·˜š¸É—¸…°ŠÂ¤n Ánœ „µ¦Ä®o£¼¤·‡»o¤„´œÃ¦‡ „µ¦°œµ¤´¥Â¤n¨³Á—È„ „µ¦Ä®o°µ®µ¦ Á­¦·¤˜nµŠÇ Áž}œ˜oœ ¨³­nŠÁ­¦·¤„µ¦ÁŸ¥Â¡¦n‡ªµ¤¦¼o¨³­¦oµŠš´«œ‡˜·š¸É™¼„˜o°ŠÂ„nž¦³µœÄ®o¦¼o‹´„„µ¦ ­nŠÁ­¦·¤­»…£µ¡ „µ¦žj°Š„´œÃ¦‡š´ÊŠ…°Š˜œÁ°Š ‡¦°‡¦´ª ¨³ »¤œ ˜¨°—‹œ„µ¦—¼Â¨¦´„¬µÁºÊ°Š˜oœ ­Îµ®¦´Ã¦‡Šnµ¥Ç ¨³„µ¦—¼Â¨Ÿ¼ožiª¥—oª¥Ã¦‡Á¦ºÊ°¦´ŠÄœ»¤œ ž{®µÃ¦‡Á¦ºÊ°¦´ŠÅ¤n˜·—˜n°Á¦·É¤¦¦‹»ÄœÂŸœ¡´•œµ² Œ´š¸É 9 (¡.«. 2545-2549) š¸É¤»nŠ¡´•œµ­¼n “­´Š‡¤š¸ÉÁ…o¤Â…Ȋ¨³¤¸—»¨¥£µ¡” ×¥¥¹— “ž¦´µ…°ŠÁ«¦¬“„·‹¡°Á¡¸¥Š” Ážjµ®¤µ¥ ¨—°´˜¦µ„µ¦ Á‹Èžiª¥—oª¥­µÁ®˜»š¸Éžj°Š„´œÅ—o Ánœ 懮´ªÄ‹ 懤³Á¦ÈŠ °»´˜·Á®˜» Áž}œ˜oœ Ä®ož¦³µœ¤¸„µ¦°°„ „ε¨´Š„µ¥®¦º°Á¨nœ„¸¯µÁ¡·É¤…¹Êœ ¤¸ÂœªšµŠ„µ¦¡´•œµ‡œÄ®o¤¸‡»–£µ¡Â¨³¦¼oÁšnµš´œ„µ¦Áž¨¸É¥œÂž¨Š ×¥ “­nŠÁ­¦·¤­»…£µ¡Â¨³žj°Š„´œÃ¦‡š´ÊŠ—oµœ¦nµŠ„µ¥Â¨³‹·˜Ä‹ ץĮož¦³µœ¤¸„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ ­»…£µ¡Ä®oÁ®¤µ³­¤ ×¥ÁŒ¡µ³¤¸„µ¦¦·Ã£‡š¸É™¼„˜o°ŠÂ¨³¤¸„µ¦°°„„ε¨´Š„µ¥­¤ÉεÁ­¤°” ¨³˜n°ÁœºÉ°Š ™¹ŠÂŸœ¡´•œµÁ«¦¬“„·‹Â¨³­´Š‡¤Â®nŠµ˜·Œ´š¸É 10 (¡.«. 2550-2554) ŗo„ε®œ—Ážjµ®¤µ¥„µ¦¡´•œµ ‡»–£µ¡‡œ Ä®o‡œÅš¥š»„‡œÅ—o¦´„µ¦¡´•œµš´ÊŠšµŠ¦nµŠ„µ¥ ‹·˜Ä‹ ‡ªµ¤¦¼o ‡ªµ¤­µ¤µ¦™ š´„¬³„µ¦ ž¦³„°°µ¸¡Â¨³¤¸‡ªµ¤¤´Éœ‡ŠÄœ„µ¦—ε¦Š¸ª·˜ š´ÊŠœ¸Ê„ε®œ—Ä®o°µ¥»‡µ—®¤µ¥ÁŒ¨¸É¥…°Š‡œÅš¥­¼Š…¹Êœ Áž}œ 80 že ‡ª‡¼n„´¨—°´˜¦µÁ¡·É¤…°Š„µ¦Á‹Èžiª¥—oª¥Ã¦‡š¸Éžj°Š„´œÅ—oĜ 5 °´œ—´Â¦„ ‡º° ®´ªÄ‹ ‡ªµ¤ —´œÃ¨®·˜­¼Š Áµ®ªµœ ®¨°—Á¨º°—­¤°Š ¨³¤³Á¦ÈŠ œÎµÅž­¼n„µ¦Á¡·É¤Ÿ¨·˜£µ¡Â¦ŠŠµœ ¨³¨—¦µ¥‹nµ¥ —oµœ­»…£µ¡…°Š»‡‡¨¨ŠÄœ¦³¥³¥µª œªšµŠ„µ¦¡´•œµ£µ¥Ä˜o¥»š›«µ­˜¦r„µ¦¡´•œµ‡»–£µ¡‡œÂ¨³ ­´Š‡¤Åš¥­¼n­´Š‡¤Â®nŠ£¼¤·ž{µÂ¨³„µ¦Á¦¸¥œ¦¼oĜ¦³¥³ 5 že ĜnªŠÂŸœ¡´•œµ² Œ´š¸É 10 ¦³»ªnµ ­œ´­œ»œÄ®o‡œÅš¥¨— ¨³ Á¨·„¡§˜·„¦¦¤­»n¤Á­¸É¥ŠšµŠ­»…£µ¡ ‡ª‡¼n„´„µ¦—¼Â¨­»…£µ¡š¸ÉÁ®¤µ³­¤ ˜µ¤nªŠª´¥ ¦¼o‹´„„µ¦žj°Š„´œÃ¦‡ÁºÊ°Š˜oœ ¤¸¡§˜·„¦¦¤„µ¦¦·Ã£‡š¸ÉÁ®¤µ³­¤ °°„„ε¨´Š„µ¥°¥nµŠ ­¤ÉεÁ­¤° Á¨nœ„¸¯µ čoÁª¨µªnµŠÄ®oÁž}œž¦³Ã¥œr Á­¦·¤­¦oµŠ‡ªµ¤¦nª¤¤º°…°Š‡¦°‡¦´ªÂ¨³»¤œÄœ„µ¦ ­¦oµŠ­»…£µ¡š¸É—¸Â¨³¡´•œµ­£µ¡Âª—¨o°¤Äœ»¤œÄ®oÁ®¤µ³­¤„´­»…£µ¡¤µ„…¹Êœ29 Ÿœ¡´•œµ­»…£µ¡Â®nŠµ˜· ž{®µ£µª³Ã£œµ„µ¦Á„·œÅ—oÁ¦·É¤¦¦‹»ÄœÂŸœ¡´•œµ­»…£µ¡Â®nŠµ˜·Œ´š¸É 8 ¤¸„µ¦„ε®œ— ˜´ª¸Êª´—­»…£µ¡Ä®oÁ—È„°µ¥» 6-12 že ¤¸£µª³œÊ宜´„Á„·œÂ¨³°oªœÅ¤nÁ„·œ¦o°¥¨³ 10 ¨³¥´Š‡ŠÁžjµ®¤µ¥
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  • 107. 101 ª–·µ „·‹ª¦¡´•œr š‡ªµ¤š¸ÉŗoœÎµÁ­œ°Äœ®œ´Š­º°Á¨n¤œ¸Ê ŗo‹µ„µ¦ššªœœÃ¥µ¥Â¨³¤µ˜¦„µ¦„µ¦žj°Š„´œ £µª³œÊ宜´„Á„·œ 懰oªœÂ¨³°oªœ¨Š¡»Š ˜¨°—¦³¥³Áª¨µ 10 žeš¸ÉŸnµœ¤µ‹œ™¹Šž{‹‹»´œ (¡.«. 2553) …°Šœµœµž¦³Áš«š¸É¤¸ÂœªÃœo¤š¸É¦»œÂ¦Š¤µ„…¹ÊœÅ—o„n ­®¦´“°Á¤¦·„µ ­®¦µ°µ–µ‹´„¦ ¨³°°­Á˜¦Á¨¸¥ Á¡ºÉ°Áž¦¸¥Áš¸¥„´œÃ¥µ¥Â¨³¤µ˜¦„µ¦„µ¦žj°Š„´œ£µª³œÊ宜´„Á„·œ 懰oªœÂ¨³°oªœ¨Š¡»Š…°Š ž¦³Áš«Åš¥ š¸É„ε¨´ŠÁŸ·„´ž{®µš¸Éª·„§˜·Ánœ„´œ ®µ„œÃ¥µ¥Â¨³¤µ˜¦„µ¦…°Šž¦³Áš«Åš¥Å¤n ­µ¤µ¦™®¥»—¥´ÊŠ¡§˜·„¦¦¤Á­¸É¥Šš¸ÉšÎµÄ®oÁ„·—懰oªœÂ¨³°oªœ¨Š¡»ŠÄœŸ¼oÄ®nŗo „È‹³šÎµÄ®oÁ„·—„µ¦ Á‹Èžiª¥ ¡·„µ¦ Á­¸¥¸ª·˜šª¸‡ªµ¤¦»œÂ¦Š…°ŠÃ¦‡„¨oµ¤ÁœºÊ°®´ªÄ‹˜¸˜´œ 懮¨°—Á¨º°—­¤°Š˜¸˜´œ æ‡ ‡ªµ¤—´œÃ¨®·˜­¼Š æ‡Áµ®ªµœ ¨³Ã¦‡¤³Á¦ÈŠµŠœ·—¤µ„¥·ÉŠ…¹Êœ ž¦³Áš«µ˜·‹³¤¸£µ¦³‡nµÄo‹nµ¥ šµŠ—oµœ­»…£µ¡ ¨³„µ¦­¼Á­¸¥šµŠÁ«¦¬“„·‹˜µ¤¤µ°¥nµŠ¤®µ«µ¨ °Š‡r„µ¦°œµ¤´¥Ã¨„ (WHO, 2004)1, 2 ŗo¤¸…o°Á­œ° “¥»š›«µ­˜¦r脗oµœ°µ®µ¦ „·‹„¦¦¤šµŠ „µ¥Â¨³­»…£µ¡” ‡º° „µ¦¦·Ã£‡°µ®µ¦š¸É¤¸ž¦³Ã¥œr˜n°­»…£µ¡ „µ¦¤¸„·‹„¦¦¤šµŠ„µ¥š¸É¡°Á¡¸¥ŠÂ¨³ ­¤ÉεÁ­¤°¦nª¤„´„µ¦‡ª‡»¤»®¦¸É ×¥„µ¦¡´•œµ­£µ¡Âª—¨o°¤š¸ÉÁ„ºÊ°®œ»œž’·´˜·„µ¦š¸É¥´ÉŠ¥ºœÄœ¦³—´ ž{‹Á‹„»‡‡¨ »¤œ ž¦³Áš«Â¨³¦³—´Ã¨„ Ž¹ÉŠ¤¸®¨´„“µœÁ·Šž¦³‹´„¬r ž¦³µœ¥´Š‡Š¤¸­»…£µ¡ …Ȋ¦Š‹œ™¹Š°µ¥»Âž—­·®¦º°Á„oµ­· —oª¥„µ¦¤¸¡§˜·„¦¦¤š¸É­nŠÁ­¦·¤­»…£µ¡Äœ—oµœ˜nµŠÇ °µš· „µ¦ ¦·Ã£‡°µ®µ¦š¸É¤¸ž¦³Ã¥œr˜n°­»…£µ¡ „µ¦¤¸„·‹„¦¦¤šµŠ„µ¥š¸É¡°Á¡¸¥ŠÂ¨³­¤ÉεÁ­¤°3 ˜¨°—‹œ ®¨¸„Á¨¸É¥Š„µ¦­¼»®¦¸É …o°Á­œ°Âœ³ÄœÁ¦ºÉ°Š°µ®µ¦­Îµ®¦´¦³—´ž¦³µ„¦Â¨³ž{‹Á‹„»‡‡¨ ¤¸—´Šœ¸Ê:- 1. šÎµÄ®oÁ„·—‡ªµ¤­¤—»¨…°Š¡¨´ŠŠµœ (energy balance) ¨³œÊ宜´„š¸ÉÁ®¤µ³­¤„´­»…£µ¡ 2. ‹Îµ„´—¡¨´ŠŠµœš¸É‹³Å—o¦´‹µ„Å…¤´œ ¨³Áž¨¸É¥œ„µ¦¦·Ã£‡‹µ„Å…¤´œ°·É¤˜´ª Áž}œÅ…¤´œÅ¤n °·É¤˜´ª ˜¨°—‹œ„µ¦„ε‹´—„¦—Å…¤´œš¦µœ­r 3. Á¡·É¤„µ¦¦·Ã£‡Ÿ´„ Ÿ¨Å¤o ™´ÉªÁ¤¨È—®oŠ Á¤¨È—›´¡º ¨³Ÿ¨Å¤oÁž¨º°„Â…ÈŠ (nuts) 4. ‹Îµ„´—„µ¦¦·Ã£‡œÊ嘵¨ 5. ‹Îµ„´—„µ¦¦·Ã£‡Á„¨º° (ÎÁ—¸¥¤) ĜÁ¦ºÉ°Š„·‹„¦¦¤šµŠ„µ¥ ŗoœ³œÎµÄ®ož{‹Á‹„»‡‡¨¤¸„µ¦Á‡¨ºÉ°œÅ®ªÄœ¦³—´š¸É¡°Á¡¸¥Š˜¨°— ¸ª·˜ °µš· „µ¦¤¸„·‹„¦¦¤šµŠ„µ¥¦³—´žµœ„¨µŠ°¥nµŠ­¤ÉεÁ­¤° °¥nµŠœo°¥ 30 œµš¸Á„º°š»„ª´œnª¥¨— ‡ªµ¤Á­¸É¥Š˜n°Ã¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— Áµ®ªµœ ­Îµ®¦´„µ¦‡ª‡»¤œÊ宜´„‹ÎµÁž}œ˜o°Š¤¸„·‹„¦¦¤š¸É ¤µ„„ªnµœ¸Ê ­£µ¡Âª—¨o°¤š¸ÉÁ°ºÊ°°Îµœª¥„·‹„¦¦¤šµŠ„µ¥„´„µ¦‡¤œµ‡¤ ¦´“µ¨Â¨³°Š‡r„¦ž„‡¦°Š ­nªœšo°Š™·Éœ ‡ª¦¥„¦nµŠœÃ¥µ¥Â¨³‹´—®µ­·ÉŠ‹¼ŠÄ‹Á¡ºÉ°Ä®o¤´ÉœÄ‹ªnµ „µ¦Á—·œ „µ¦…¸É‹´„¦¥µœ ¨³„·‹„¦¦¤ º··Õè 8
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  • 110. 104 Ÿ¨„µ¦­Îµ¦ª‹®¨´Š„µ¦Ä®o‡ªµ¤¦¼o ¡‡ªµ¤Áž¨¸É¥œÂž¨Š…°Š„µ¦¦·Ã£‡ÄœšµŠš¸É¡¹Šž¦³­Š‡r—´Š ˜µ¦µŠš¸É 1 ˜µ¦µŠš¸É 1. ­—ŠÁž°¦rÁŽÈœ˜r„µ¦Áž¨¸É¥œÂž¨Š…°Š„µ¦¦·Ã£‡°µ®µ¦…°Šµª°Á¤¦·„´œ °µ¥» 31-50 že Ĝž{‹‹»´œ ®¨nŠ…o°¤¼¨ : http://www.aplu.org/NetCommunity/Document.Doc?id=2491 „ε®œ—„µ¦Ä®¤n—oµœ°µ®µ¦Á¡ºÉ°„µ¦…´Á‡¨ºÉ°œ¡ºÊœ“µœ­Îµ®¦´„µ¦žj°Š„´œÃ¦‡Â¨³Ã¦‡°oªœ • Ÿ¼o¦´Ÿ·—°„µ¦¦·®µ¦‹´—„µ¦Ä®¤n ž¦³„°—oª¥ - DHHS - USDA - šÎµÁœ¸¥…µªÃ—¥ Michelle Obama • ®œ´Š­º°Á¨n¤Ä®¤n ž¦³„°—oª¥ - „ε®œ—„µ¦žj°Š„´œÁ¦ºÉ°Š°µ®µ¦ž¨°—£´¥ ㍜µ„µ¦ ¨³­»…£µ¡ - „µ¦Âš¦„ÂŽŠ…°Š¦´“µ¨/„‘®¤µ¥š¸É„oŅž{®µÅ—o­³—ª„¤µ„š¸É­»— - …¥µ¥„ε®œ—„µ¦—oµœ°µ®µ¦ šo°Š™·Éœ ¨³ °°¦r„µœ·‡ œÃ¥µ¥¨nµ­»—…°Š Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services 8 Á­œ° “Healthy People 2010 and Steps to a Healthier US: Leading Prevention” (¦¼žš¸É 3) ×¥¤¸ª´˜™»ž¦³­Š‡r‡º° • Á¡·É¤­´—­nªœŸ¼oÄ®nš¸É­µ¤µ¦™¦³»£µª³œÊ宜´„˜œÁ°Šªnµ Ÿ°¤ œÊ宜´„ž„˜· ®¦º°œÊ宜´„Á„·œ ŗo™¼„˜o°Š
  • 111. 105 • Á­œ°…o°¤¼¨: National Health and Nutrition Examination Survey • Á¡·É¤‹Îµœªœž¦³µ„¦š¸ÉÁ…oµÄ‹™¹Šž{‹‹´¥Á­¸É¥Š—oµœ­»…£µ¡š¸É­´¤¡´œ›r„´£µª³œÊ宜´„Á„·œÂ¨³ 懰oªœ • Á¡·É¤‹Îµœªœ»‡¨µ„¦šµŠ„µ¦Â¡š¥rš¸Éž¦³­Ÿ¨­ÎµÁ¦È‹Äœ„µ¦¨—œÊ宜´„Å—o 5-10% • Á­œ°…o°¤¼¨: National Survey of Energy Balance-related Care among Primary Care Physicians Build a Healthier Nation Focus on Prevention National Objectives RelationshipRelationship ¦¼žš¸É 3. ­—Š‡ªµ¤­´¤¡´œ›r Healthy People 2010, Healthier US, Steps to a Healthier US Á¡ºÉ°œÎµÅž­¼n„µ¦žj°Š„´œÃ¦‡°oªœ ®¨nŠ…o°¤¼¨ : http://www.healthpeople.gov. ž¦³Á—ÈœÁœºÊ°®µÄœ„µ¦žj°Š„´œÃ¦‡Â¨³Ã¦‡°oªœ¤¸¦µ¥¨³Á°¸¥—˜µ¤˜µ¦µŠš¸É 2 ˜µ¦µŠš¸É 2. ž¦³Á—ÈœÁœºÊ°®µÄœ„µ¦žj°Š„´œÃ¦‡Â¨³Ã¦‡°oªœ ž¦³Á—Èœ®µ¦º° ¤µ˜¦„µ¦ „‘®¤µ¥ ž¦³Á—Èœ®´ª…o°Á¦ºÉ°Š ž¦³Á—Èœ®µ¦º° ž¦³Á—ÈœÁŒ¡µ³ (The radar screen) • ž’·¦¼ž¦³„µ¦—¼Â¨—oµœ­»…£µ¡ • Child Nutrition Reauthorization • Menu Labeling • œªšµŠ„µ¦ž’·´˜·—oµœ°µ®µ¦ že 2553 (Dietary Guidelines 2010) • „µ¦¨—ÃŽÁ—¸¥¤ÄœŸ¨·˜£´–”r°µ®µ¦ • Œ¨µ„œŽ°Š°µ®µ¦ • Œ¨µ„­—Š‡nµÂ‡¨°¦¸ • Œ¨µ„­—Š‡nµœÊ嘵¨ • 懰oªœÄœÁ—È„ •  f„ž’·´˜·„µ¦˜¨µ——oµœ°µ®µ¦ Áœoœ„¨»n¤Á—È„ • £µ¬¸ Á‡¦ºÉ°Š—ºÉ¤/°µ®µ¦š¸É¤¸‡»–‡nµ˜Éε • Tiers for MyPyramid •¨—œÊεÁºÉ°¤¢¦»p‡Ã˜­‹µ„…oµªÃ¡— Ĝ °µ®µ¦ •‡ª‡»¤­´—­nªœ°µ®µ¦ •„¦—Å…¤´œš¦µœ­r ¨³°·É¤˜´ª •Á¤¨È—›´¡º/Ä¥°µ®µ¦ •ÁœoœÁ¦ºÉ°Š°µ®µ¦ °°¦r„µœ·‡, °µ®µ¦ šo°Š™·Éœ, °µ®µ¦Å¤nž¦¦¼ž •¤µ˜¦“µœÃ£œµ„µ¦Â®nŠµ˜·
  • 112. 106 ž¦³Áš«­®¦µ°µ–µ‹´„¦ ¦´“µ¨°´Š„§¬Å—o‹´—šÎµ Foresight Programme9 Á¤ºÉ°ª´œš¸É 17 ˜»¨µ‡¤ 2550 Á¡ºÉ°‹´—šÎµ ª·­´¥š´«œr„µ¦…´Á‡¨ºÉ°œ¦°Š¦´Ã¦‡°oªœÄœ°œµ‡˜°¸„ 40 že…oµŠ®œoµ čoª·›¸šµŠ—oµœª·š¥µ«µ­˜¦rÁž}œ ¡ºÊœ“µœ ×¥ššªœš‡ªµ¤ª·µ„µ¦ ªµŠ£µ¡‹Îµ¨°Š™¹ŠÂœªÃœo¤Â¨³„µ¦…´Á‡¨ºÉ°œšµŠ­´Š‡¤…°Š Ÿ¨„¦³š…°ŠÃ¦‡°oªœ (Áš‡ÃœÃ¨¥¸ „µ¦—¼Â¨—oµœ­»…£µ¡ ®¨nŠ¡¨´ŠŠµœ ¨³­´Š‡¤) ¨³šÎµ mapping ž{‹‹´¥š¸É¤¸°·š›·¡¨˜n°¡¨´ŠŠµœ­¤—»¨š´ÊŠž{‹Á‹„»‡‡¨ ¨³ž¦³µ„¦ (¦¼žš¸É 4) ¦¼žš¸É 4. ­—Šž{‹‹´¥—oµœ˜nµŠÇ ¨³¦µ¥¨³Á°¸¥—Äœ„µ¦‹´—„µ¦ž{®µÃ¦‡°oªœ ®¨nŠ…o°¤¼¨: Karen Lock. Developing policy to tackle childhood obesity: international lessons. London School of Hygiene and Tropical Medicine presented at Bangkok on Jan 31 2009. Á¤ºÉ°Á—º°œ¤„¦µ‡¤ 2551 ž¦³Áš«°´Š„§¬Å—o„ε®œ—¥»š›«µ­˜¦r…°Š¦´“µ¨10,11 “Healthy Weight, Healthy Lives” Áž}œ‡¦´ÊŠÂ¦„š¸É¤¸Ãž¦Â„¦¤˜n°­¼o„´Ã¦‡°oªœÂ¨³­œ´­œ»œž¦³µœÄ®o¤¸œÊ宜´„ š¸É—¸Á¡ºÉ°­»…£µ¡ ץčoŠž¦³¤µ– 372 ¨oµœž°œ—rĜ„µ¦—εÁœ·œ¥»š›«µ­˜¦rœ¸ÊŤnœo°¥„ªnµ 3 že č ­´¨´„¬–r ªnµ change for life
  • 113. 107 „µ¦¦–¦Š‡rž¦³µ­´¤¡´œ›rÁ¦ºÉ°Š Change4Life Á¦·É¤ Start4Life ‡º° „¨»n¤š¸É 1 ¡n°Â¤n¤º°Ä®¤nš¸É¤¸ Á—È„°n°œ „¨»n¤š¸É 2 ¡n°Â¤nš¸É¤¸¨¼„°µ¥» 1-4 že Á¦·É¤Á¤ºÉ°že 2551 „¨»n¤š¸É 3 ‡¦°‡¦´ªš¸É¤¸¨¼„°µ¥» 5-11 že Á¦·É¤ Á—º°œ¤„¦µ‡¤ 2552 ¨³ „¨»n¤š¸É 4 ¦–¦Š‡rĜ„¨»n¤Ÿ¼oÄ®nÁ¦·É¤ ª´œš¸É 23 „»¤£µ¡´œ›r 2553 čo keyword “Swap It, Don’t Stop It” Change4Life Áž}œ„µ¦Á‡¨ºÉ°œÅ®ªšµŠ­´Š‡¤Ã—¥¤¸‹»—¤»nŠ®¤µ¥š¸É‹³žj°Š„´œž¦³µœ‹µ„„µ¦¤¸ £µª³œÊ宜´„Á„·œ ¦·Á¦·É¤Ä®o¤¸„µ¦„·œš¸É—¸…¹ÊœÂ¨³Á‡¨ºÉ°œÅ®ª¤µ„…¹Êœ šÎµ„µ¦˜¨µ—­ºÉ°­µ¦™¹Š‡ªµ¤ ¦´Ÿ·—°…°Š¦´“µ¨˜n°„µ¦Á¡·É¤…¹Êœ…°ŠÃ¦‡°oªœ „µ¦¦–¦Š‡r¤¸‹»—¤»nŠ®¤µ¥š¸É‹³­¦oµŠ„¦³Â­Ä®oÁ„·—„µ¦ Á‡¨ºÉ°œÅ®ªšµŠ­´Š‡¤ Ä®oš»„Ç „¨»n¤ ¦´“µ¨ ›»¦„·‹ Ÿ¼oÁ¸É¥ªµ—oµœ­µ›µ¦–­»… charities æŠÁ¦¸¥œ ‡¦°‡¦´ª ®¦º°»‡‡¨ ¤¸‡ªµ¤­œÄ‹Äœ„µ¦š¸É‹³žj°Š„´œÃ¦‡°oªœ „¨ª·›¸Áœoœž¦³Á—Èœ 5 …o° ‡º° 1. „µ¦¡´•œµÂ¨³„µ¦Á‹¦·Á˜·Ã˜š¸É¤¸­»…£µ¡—¸…°ŠÁ—È„ 2. „µ¦­nŠÁ­¦·¤šµŠÁ¨º°„°µ®µ¦Á¡ºÉ°­»…£µ¡ 3. ­¦oµŠ„·‹„¦¦¤šµŠ„µ¥Á…oµ­¼nª·™¸¸ª·˜ 4. ­¦oµŠ­·ÉŠ‹¼ŠÄ‹Á¡ºÉ°­»…£µ¡š¸É—¸„ªnµ 5. Ä®o‡ÎµÂœ³œÎµÂ¨³­œ´­œ»œÁž}œ¦µ¥»‡‡¨ š¸É¤¸ž¦³­·š›·Ÿ¨™oµž¦³µœ¤¸œÊ宜´„Á„·œ®¦º°°oªœ „¨»n¤š¸É 4 ¦–¦Š‡rĜ„¨»n¤Ÿ¼oÄ®n Á¦·É¤Á¤ºÉ°ª´œš¸É 23 „»¤£µ¡´œ›r 2553 čo keyword “Swap It, Don’t Stop It” ×¥ Department of Health ¡·¤¡r¨³ÁŸ¥Â¡¦n Ÿnœ¡´ ¨³ online ¡§˜·„¦¦¤ 6 …o° š¸É ‹³™¼„ž¦´Áž¨¸É¥œ£µ¥Ä˜o…o°®oµ¤…°Š 'swaps' ‡º° 1. Plate swap 2. Swap for 5 a day 3. Swap to get you up and about 4. Snack swap 5. Fiber swap 6. Drink swap
  • 114. 108 ˜´ª°¥nµŠ…°Š Plate swap ‡º° portion swap ­µ¤µ¦™nª¥„´œÅ¤nÄ®o„·œ‹œÅ—o¦´Â‡¨°¦¸¤µ„Á„·œÅž Swap for 5 a day ‡º°„µ¦¦¼o‹´„„·œŸ´„¨³Ÿ¨Å¤oÄ®oŗoª´œ¨³ 5 ­nªœ ­Îµ®¦´Ÿ¼oÄ®n Ÿ´„¨³Ÿ¨Å¤o 1 ­nªœ ®œ´„ž¦³¤µ– 80 „¦´¤ Swap to get you up and about Á¡ºÉ°Ä®o¤¸„µ¦Á‡¨ºÉ°œÅ®ªÁ¡·É¤…¹ÊœÄœÂ˜n¨³ª´œ ×¥œ´‹Îµœªœ„µ¦ Á‡¨ºÉ°œÅ®ªš´ÊŠ®¤— œ´ÉŠÄ®oœo°¥¨Š Á‡¨ºÉ°œÅ®ªÄ®o¤µ„…¹Êœ ¤¸„·‹„¦¦¤šµŠ„µ¥®œ´„žµœ„¨µŠ ­´ž—µ®r¨³ 5 ‡¦´ÊŠÇ ¨³ 30 œµš¸ ¨³¤¸„µ¦°°„„ε¨´Š°¥nµŠœo°¥ 10 œµš¸˜n°‡¦´ÊŠÁ¡ºÉ°Ä®o®´ªÄ‹Á˜oœÂ¦Š…¹Êœ ž°—šÎµŠµœ ®œ´„…¹Êœ 5 A DAY What’s it all about?
  • 115. 109 ˜´ª°¥nµŠ Snack swap, Drink swap ®¨nŠ…o°¤¼¨: http://www.nhs.uk/Change4Life/Pages/Partners.aspx, ¨³ http://www.dh.gov.uk/change4Life. ž¦³Áš«°°­Á˜¦Á¨¸¥ œÃ¥µ¥Á¦ºÉ°Š£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ ¨Šœµ¤¦´¦°Š ×¥ 48th RACGP Council12 Á¤ºÉ° ª´œš¸É 26 „¦„‘µ‡¤ 2549 ¤¸„µ¦ÂnŠ„¨»n¤ž¦³µ„¦Â¨³„ε®œ—ÂœªšµŠž’·´˜·…°ŠÂ˜n¨³„¨»n¤ (˜µ¦µŠš¸É 3)
  • 116. 110 ˜µ¦µŠš¸É 3. „¨»n¤ž¦³µ„¦Â¨³ÂœªšµŠž’·´˜·…°ŠÂ˜n¨³„¨»n¤ 榚¸É¤¸‡ªµ¤Á­¸É¥ŠÁž}œÃ¦‡°oªœš¸É¤¸ £µª³Âš¦„Žo°œ œªšµŠž’·´˜· ‡ªµ¤™¸É ‡ªµ¤Á­¸É¥Šžµœ„¨µŠ µª°°­Á˜¦Á¨¸¥š»„‡œ ž¦³Á¤·œ BMI ¨³¦°ªŠÁ°ªÄœ„¨»n¤°µ¥» 18 že …¹ÊœÅž Á—Ȅ¨³ª´¥¦»nœ ž¦³Á¤·œÃ—¥Äo „¦µ¢ BMI ˜n°°µ¥»¡¦o°¤š´ÊŠÄ®o‡ªµ¤¦¼o—oµœÃ£œµ„µ¦ ¨³„·‹„¦¦¤šµŠ„µ¥ š»„ 2 že ‡ªµ¤Á­¸É¥ŠÁ¡·É¤…¹Êœ x µª°³°¦·‹·œ ¨³ Torres Strait Island x Ÿ¼ožiª¥Áµ®ªµœ®¦º°Ã¦‡®¨°—Á¨º°—®´ªÄ‹ ¨³­¤°Š æ‡Á„µ˜r 懘´ 懜·ÉªÄœ™»Š œÊε—¸ ž¦³Á¤·œ BMI ¨³¦°ªŠÁ°ªÄœ„¨»n¤°µ¥» 18 že …¹ÊœÅž ¡¦o°¤š´ÊŠÄ®o‡ªµ¤¦¼o—oµœÃ£œµ„µ¦Â¨³ „·‹„¦¦¤šµŠ„µ¥Áž}œ¦µ¥»‡‡¨ š»„ 1 že ‡ªµ¤Á­¸É¥Šš¸É¦³»´—ªnµÁž}œÃ¦‡°oªœ x Ÿ¼ožiª¥š¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³Áž}œÃ¦‡°oªœ ž¦³Á¤·œœÊ宜´„¨³¦°ªŠÁ°ª ¡¦o°¤š´ÊŠªµŠ Ÿœ„µ¦‹´—„µ¦—oµœœÊ宜´„ š»„ 6 Á—º°œ œÃ¥µ¥Â¨³¤µ˜¦„µ¦„µ¦žj°Š„´œ£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ …°Š NSW Government ‡¦°‡¨»¤ž¦³µ„¦š»„°µ¥» (Preventing Overweight in Children, Young People & their Families 2009-2011)13 Á¤ºÉ°Á—º°œ¡§«‹·„µ¥œ ¡.«. 2551 ¦´“ NSW °œ»¤´˜·Šž¦³¤µ– $448 ¨oµœ­Îµ®¦´ÂŸœ 4 že ¨³ $872 ¨oµœ­Îµ®¦´ÂŸœ 6 že ×¥ 2 že¦„ (¡.«. 2552-2553) Áž}œÂŸœ¡´•œµÁ¡·É¤­´—­nªœŸ¼oÄ®n ¨³Á—È„Ä®o¤¸œÊ宜´„˜´ªš¸ÉÁ®¤µ³­¤ ¨³žj°Š„´œ„µ¦Á¡·É¤…¹Êœ…°ŠŸ¼ožiª¥Áµ®ªµœ¦µ¥Ä®¤n ×¥Á¡·É¤°´˜¦µ „µ¦Á‡¨ºÉ°œÅ®ª¦nµŠ„µ¥Â¨³„µ¦„·œ°µ®µ¦Á¡ºÉ°­»…£µ¡…°Š»¤œ Ÿœž’·´˜·„µ¦Å—oÁ­œ°ž¦³Á—Èœ­Îµ‡´ 5 ž¦³„µ¦ š¸É¦³»‡ªµ¤­ÎµÁ¦È‹„µ¦Áž¨¸É¥œÂž¨Š…°Š»¤œ ¨³»‡‡¨Äœ—oµœ¡§˜·„¦¦¤Â¨³šµŠÁ¨º°„Á¡ºÉ°­»…£µ¡ ץčo„¨¥»š›rÄ®o»¤œÁ…oµÄ‹™¹Š­µÁ®˜»Â¨³‡ªµ¤ Á­¸É¥Šš¸É­´¤¡´œ›r„´‡ªµ¤°oªœÄ®o¤µ„…¹Êœ Á¡ºÉ°Ä®oÁ„·—„µ¦Áž¨¸É¥œÂž¨Š—oµœ¡§˜·„¦¦¤„µ¦¦·Ã£‡Ÿ´„¨³ Ÿ¨Å¤oÁ¡·É¤…¹Êœ ¤¸„·‹„¦¦¤šµŠ„µ¥ Á—·œÂ¨³Á‡¨ºÉ°œÅ®ªÁ¡·É¤…¹Êœ ¨—„µ¦¦·Ã£‡°µ®µ¦—o°¥‡»–‡nµš¸ÉÄ®o ¡¨´ŠŠµœ­¼Š ¨³Á‡¦ºÉ°Š—ºÉ¤š¸ÉÄ®o‡ªµ¤®ªµœ ¨³¦¼oª·›¸š¸É‹³nª¥žj°Š„´œ‡ªµ¤°oªœÅ—o˜´ÊŠÂ˜nÁœ·ÉœÇ ¡¦o°¤š´ÊŠ „µ¦nª¥Á®¨º°„¨»n¤š¸É¤¸œÊ宜´„˜´ªÁ„·œÂ¨³°oªœÂ¨oª—oª¥ Ž¹ÉŠ “The Hon Nathan Rees MP, Premier ŗo „¨nµªªnµ Á…µÅ—oÁ jµ¤°ŠÄœ“µœ³¦´“ „»Â‹­Îµ‡´ ‡º° Ÿ¼o¤¸­nªœÅ—o­nªœÁ­¸¥‹µ„£µ‡°»˜­µ®„¦¦¤Â¨³»¤œ ŗo¦nª¤¤º°š¸É‹³Á­œ°ž¦³Á—Èœ­»…£µ¡š¸É­Îµ‡´œ¸Ê” Ÿœž’·´˜·„µ¦­Îµ‡´¤¸ 5 ž¦³Á—Èœ—´Šœ¸Ê (¦¼žš¸É 5) 1. „¦³‹µ¥…nµª­µ¦Äœ»¤œ – ­¦oµŠ‡ªµ¤˜¦³®œ´„—oª¥Âœª„µ¦˜¨µ—Á¡ºÉ°­´Š‡¤ ¨³­œ´­œ»œ š¦´¡¥µ„¦žj°Š„´œ‡ªµ¤°oªœ
  • 117. 111 2. °µ®µ¦Á¡ºÉ°­»…£µ¡ – …´Á‡¨ºÉ°œÄ®o¤¸šµŠÁ¨º°„°µ®µ¦Á¡ºÉ°­»…£µ¡ 3. ª·™¸¸ª·˜š¸É¤¸¸ª·˜¸ªµ – Ä®o¤¸„µ¦°°„„ε¨´Š„µ¥Äœª·™¸¸ª·˜ 4. „¸¯µÂ¨³Ã‡¦Š­¦oµŠ – ‹´—Ä®o¤¸Ãž¦Â„¦¤„·‹„¦¦¤šµŠ„µ¥Â¨³­·ÉŠ°Îµœª¥‡ªµ¤­³—ª„ ­œ´­œ»œ„µ¦°°„„ε¨´Š„µ¥ 5. žj°Š„´œÂ¨³Ä®o¦·„µ¦ – ­œ´­œ»œ„µ¦Áž¨¸É¥œÂž¨Š¡§˜·„¦¦¤»‡‡¨ ¦¼žš¸É 5. œªž’·´˜·Á¡ºÉ°„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ ®¨nŠ…o°¤¼¨: http://www.health.nsw.gov.au ž¦³Áš«Åš¥ Ÿœ¥»š›«µ­˜¦r­»…£µ¡—¸ª·™¸¸ª·˜Åš¥ ¡.«.2550-2559 (Thailand Healthy Lifestyle Strategic Plan)14 Áž}œÂŸœ¥»š›«µ­˜¦r¦³—´µ˜·Á¡ºÉ°ÄoÁž}œ„¦°¸Êš·«šµŠ„µ¦¡´•œµÄœ„µ¦­¦oµŠª·™¸¸ª·˜¡°Á¡¸¥Š …°Š‡œÅš¥ Áž}œª·™¸¸ª·˜š¸É¨—Á­¸É¥Š ¨—æ‡ ¨—£µª³Âš¦„Žo°œ ¨—„µ¦˜µ¥ ¨³¨—£µ¦³‡nµÄo‹nµ¥‹µ„ 懚¸ÉÁ„·—‹µ„¡§˜·„¦¦¤š¸ÉŤnÁ®¤µ³­¤ ¦·Ã£‡Á„·œ …µ—„µ¦°°„„ε¨´Š„µ¥ Á„·—£µª³Á‡¦¸¥—®µšµŠ°°„ ×¥„·œ ­¼»®¦¸É —ºÉ¤­»¦µ šÎµÄ®o¤¸£µª³œÊ宜´„Á„·œÂ¨³°oªœ Áž}œ­µÁ®˜»®¨´„­Îµ‡´šÎµÄ®oÁ„·—æ‡Å¤n˜·—˜n° Á¦ºÊ°¦´Š®¦º°Á¦¸¥„ªnµÃ¦‡ª·™¸¸ª·˜ ŗo„næ‡Áµ®ªµœ 懇ªµ¤—´œÃ¨®·˜­¼Š 懮´ªÄ‹ 懮¨°—Á¨º°—­¤°Š ¨³Ã¦‡¤³Á¦ÈŠ Ž¹ÉŠÅ—o„ε®œ—懚¸Éžj°Š„´œÅ—o 5 懜¸Ê Áž}œÁžjµ®¤µ¥®¨´„…°Š„µ¦¡´•œµÄœÂŸœ¡´•œµ Á«¦¬“„·‹Â¨³­´Š‡¤Â®nŠµ˜· Œ´š¸É 10 ¡.«. 2550-2554 ¨³ÂŸœ¡´•œµ­»…£µ¡Â®nŠµ˜·Œ´š¸É 10 —oª¥
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  • 119. 113 ¦¼žš¸É 6. ­—Š¦·šÂª—¨o°¤Â¨³ª·™¸¸ª·˜š¸É¨—Á­¸É¥Š ¨—æ‡ ¨³£´¥‡»„‡µ¤­»…£µ¡ ®¨nŠ…o°¤¼¨: ­Îµœ´„œÃ¥µ¥Â¨³¥»š›«µ­˜¦r „¦³š¦ªŠ­µ›µ¦–­»…. Ÿœ¥»š›«µ­˜¦r­»…£µ¡—¸ª·™¸¸ª·˜ Ś¥ ¡.«.2550-2559. ‡ªµ¤­ÎµÁ¦È‹ ¤µ˜¦„µ¦Â¨³œÃ¥µ¥…°Šœµœµž¦³Áš« ŗo¤»nŠÄ®oÁ„·—‡ªµ¤­ÎµÁ¦È‹Äœž¦³Á—Èœ˜nµŠÇ š¸É¤¸‡ªµ¤ ‡¨oµ¥‡¨¹Š„´œ —´Šœ¸Ê x ¤µ˜¦„µ¦­nŠÁ­¦·¤Ã£œµ„µ¦š¸ÉÁ®¤µ³­¤„´„¨»n¤°µ¥»˜nµŠÇ ¨³„µ¦°°„„ε¨´Š„µ¥ x „µ¦Ä®o‡ªµ¤¦¼oŸnµœ­ºÉ°­µ¦¤ª¨œš´ÊŠšµŠ„µ¦°°„°µ„µ« ­ºÉ°¡·¤¡r ¨³°°œÅ¨œr x ¦–¦Š‡r ž¦³µ­´¤¡´œ›r Ä®o‡ªµ¤¦¼o ­¦oµŠ‡ªµ¤˜¦³®œ´„ Á¡ºÉ°¤»nŠÄ®oÁ„·—„µ¦ž¦´Áž¨¸É¥œ ¡§˜·„¦¦¤„µ¦­¦oµŠÁ­¦·¤­»…£µ¡—oª¥„µ¦¦·Ã£‡°µ®µ¦š¸ÉÁž}œž¦³Ã¥œr˜n°­»…£µ¡ ¨³„µ¦ Á‡¨ºÉ°œÅ®ª°°„¦Š/°°„„ε¨´Š„µ¥°¥nµŠ˜n°ÁœºÉ°ŠÄœš»„„¨»n¤ª´¥ ¨³Á jµ¦³ª´Š‡ª‡»¤£µª³ °oªœ¨Š¡»Š x Ÿ¨´„—´œ‹´—Ä®o¤¸Ãž¦Â„¦¤„·‹„¦¦¤šµŠ„µ¥Â¨³­·ÉŠ°Îµœª¥‡ªµ¤­³—ª„ ­œ´­œ»œ„µ¦°°„ „ε¨´Š„µ¥ x …°‡ªµ¤¦nª¤¤º°£µ‡°»˜­µ®„¦¦¤°µ®µ¦Ä®o‡ªµ¤¦nª¤¤º° Ÿ¨·˜°µ®µ¦š¸É¤¸ž¦³Ã¥œr˜n° ­»…£µ¡ªµŠ‹Îµ®œnµ¥šo°Š˜¨µ—Äœ¦µ‡µš¸ÉÁ®¤µ³­¤ ¦ª¤š´ÊŠ¤¸Œ¨µ„°µ®µ¦š¸É°„¦µ¥¨³Á°¸¥— ‡¦™oªœ (food labeling) x ¤µ˜¦„µ¦šµŠ„‘®¤µ¥Äœ„µ¦‡ª‡»¤„µ¦Ä®o…o°¤¼¨œŒ¨µ„°µ®µ¦ „¨Å„„µ¦˜¨µ— „µ¦­ºÉ°­µ¦ž¦³µ­´¤¡´œ›r „µ¦‡ª‡»¤„ε„´ °»ž­Š‡r - Ÿ¨Ÿ¨·˜„µ¦Á„¬˜¦ (Ÿ´„¨³Ÿ¨Å¤o) - ­™µœž¦³„°„µ¦ (°µ®µ¦Â¨³Á‡¦ºÉ°Š—ºÉ¤) °»žšµœ („µ¦Á…oµ™¹Š) - ž¦·¤µ–/‡»–£µ¡ - ¡§˜·„¦¤„µ¦¦·Ã£‡ ž{‹‹´¥Âª—¨o°¤ - ǦŠ­¦oµŠšµŠ­´Š‡¤ ‡ªµ¤Áž}œÁ¤º°Š - Áš‡ÃœÃ¨¥¸ - ǦŠ­¦oµŠÁ«¦¬“„·‹ „µ¦‡oµ¦³®ªnµŠž¦³Áš« „µ¦œÎµÁ…oµ/­nŠ°°„ £µª³š»¡Ã£œµ„µ¦ …°ŠÂ¤n¨³Á—È„ £µª³œÊ宜´„Á„·œÂ¨³°oªœ æ‡Å¤n˜·—˜n°Á¦ºÊ°¦´Š®¦º° 懪·™¸¸ª·˜ „µ¦°°„„ε¨´Š„µ¥ ŤnÁ¡¸¥Š¡° Ťn­¤—»¨ Ÿ¨„¦³šÁ·Š­»…£µª³Â¨³Á«¦¬“„·‹
  • 120. 114 °»ž­¦¦‡˜n°¤µ˜¦„µ¦Â¨³œÃ¥µ¥„µ¦žj°Š„´œÃ¦‡°oªœ x ž{‹‹´¥­·ÉŠÂª—¨o°¤š¸ÉÁž¨¸É¥œÂž¨Š ¤¸Ÿ¨Ä®o¤¸ª·™¸¸ª·˜Áž¨¸É¥œÅž‹œÁ„·—£µª³Á­¸É¥Š˜n°Ã¦‡°oªœ x „µ¦Ã‰¬–µ…°Š…Á‡¸Ê¥ª °µ®µ¦ž¦³Á£š¢µ­˜r¢¼j— …œ¤°„¦°² š¸É°»—¤—oª¥ÂžjŠœÊ嘵¨ ¨³Å…¤´œš¸ÉšÎµ„µ¦˜¨µ—šµŠš¸ª¸ x „µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ Ánœ „µ¦¦·Ã£‡ „µ¦‹´—„µ¦„´‡ªµ¤Á‡¦¸¥— „µ¦°°„„ε¨´Š„µ¥ Ž¹ÉŠÅ—oŸ¨˜ÉεĜ¦³¥³¥µª Á°„­µ¦°oµŠ°·Š 1. WHO. Global Strategy on Diet, Physical Activity and Health. Geneva, World Health Organization, 2004. 2. „°Š°°„„ε¨´Š„µ¥Á¡ºÉ°­»…£µ¡ „¦¤°œµ¤´¥. ¥»š›«µ­˜¦r脗oµœ°µ®µ¦ „·‹„¦¦¤šµŠ„µ¥Â¨³ ­»…£µ¡. 抡·¤¡r°Š‡r„µ¦­ŠÁ‡¦µ³®rš®µ¦Ÿnµœ«¹„, Á¤¬µ¥œ 2550. 3. WHO. Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization, 2003 (WHO Technical Report Seies, No. 916). 4. Leona Cuttler, et al. Child and Adult Obesity in Ohio: 2008 Ohio Family Health Survey. The Center for Child Health and Policy at Rainbow Babies & Children’s Hospital, Case Western Reserve Univ. 5. CDC Division. Recognizes Innovative Obesity Prevention and Control Initiatives with Weight of the Nation Awards. Press Release July 29, 2009. 6. The New York Academy of Medicine. NYAM’s support of governor paterson’s five-point obesity prevention plan. Retrived June 10, 2010 from, http://www.nyam.org. 7. Mary McPhail Gray. USDA 2010 . Retrived June 10, 2010 from, http://www.aplu.org/NetCommunity/Document.Doc?id=2491 8. Disease Prevention and Health Promotion U.S. Department of Health and Human Services. Healthy People 2010 and Steps to a HealthierUS: Leading Prevention Retrived June 10, 2010 from, http://www.healthpeople.gov. 9. Karen Lock. Developing policy to tackle childhood obesity: international lessons. London School of Hygiene and Tropical Medicine presented at Bangkok Jan 31 2009. 10. Change4Life. Retrived June 10, 2010 from, http://www.nhs.uk/Change4Life/Pages/Partners.aspx, http://www.dh.gov.uk/change4Life. 11. DH. Change4Life one year on Retrived June 10, 2010 from, www.dh.gov.uk/publications.
  • 121. 115 12. The Royal Australian College. General Practitioners’ position on obesity and weight management. Guidelines for preventive activities in general practice (red book) and Smoking, Nutrition, Alcohol and Physical activity: a population health guide to behavioral risk factors in general practice (SNAP guide). 13. NSW Department of Health. NSW government plan for preventing overweight and obesity in children, young people & their families 2009-2011. June 2009, Retrived June 10, 2010 from http://www.health.nsw.gov.au. 14. ­Îµœ´„œÃ¥µ¥Â¨³¥»š›«µ­˜¦r „¦³š¦ªŠ­µ›µ¦–­»…. Ÿœ¥»š›«µ­˜¦r­»…£µ¡—¸ª·™¸¸ª·˜Åš¥ ¡.«. 2550-2559.
  • 122. 116 ‹»¦¸¡¦ ‡Šž¦³Á­¦·“ £µª³œÊ宜´„Á„·œ °oªœÂ¨³°oªœ¨Š¡»ŠÁž}œž{®µ­µ›µ¦–­»…­Îµ‡´…°Šž¦³Áš«Åš¥Äœ…–³œ¸Êš¸É ˜o°Š„µ¦„µ¦—¼Â¨°¥nµŠÁ¦nŠ—nªœ Á¡ºÉ°¨—Ÿ¨„¦³šš´ÊŠšµŠ—oµœ­»…£µ¡ ‡¦°‡¦´ª ­´Š‡¤ ¨³Á«¦¬“„·‹ ‹µ„‡nµÄo‹nµ¥Äœ„µ¦¦´„¬µ¡¥µµ¨Ã¦‡Âš¦„Žo°œš¸ÉÁ¡·É¤…¹Êœ š´ÊŠ‡nµÄo‹nµ¥šµŠ˜¦ŠÂ¨³šµŠ°o°¤ °oªœÂ¨³ °oªœ¨Š¡»ŠÁž}œŸ¨¨´¡›r…°Šž’·­´¤¡´œ›rš¸ÉŽ´Žo°œ¦³®ªnµŠ¡´œ›»„¦¦¤„´­·ÉŠÂª—¨o°¤ ­nŠŸ¨Ä®oÁ„·—‡ªµ¤Å¤n ­¤—»¨¦³®ªnµŠ„µ¦¦´¡¨´ŠŠµœ (energy intake) ®¦º°„µ¦¦·Ã£‡°µ®µ¦ „´„µ¦Äo¡¨´ŠŠµœ (energy expenditure) ®¦º°„µ¦Á‡¨ºÉ°œÅ®ª…°Š¦nµŠ„µ¥1 ¡ªnµª·™¸¸ª·˜—´ÊŠÁ—·¤ Ánœ „µ¦Á¨¸Ê¥Š¨¼„—oª¥œ¤Â¤n°¥nµŠ œo°¥ 6 Á—º°œ Áž}œž{‹‹´¥žj°Š„´œ£µª³°oªœ ‡ªµ¤œnµÁºÉ°™º°…°Š®¨´„“µœš¸ÉÁ„¸É¥ª…o°Š„´‡ªµ¤­´¤¡´œ›r …°Šž{‹‹´¥š¸É¤¸Ÿ¨˜n°°oªœÂ¨³°oªœ¨Š¡»Š­¦»žÅªoĜ˜µ¦µŠš¸É 1 ˜µ¦µŠš¸É 1. ­¦»ž‡ªµ¤œnµÁºÉ°™º°…°Š®¨´„“µœš¸ÉÁ„¸É¥ª…o°Š„´‡ªµ¤­´¤¡´œ›r…°Šž{‹‹´¥Á­¸É¥Š˜n°£µª³ œÊ宜´„Á„·œ °oªœÂ¨³°oªœ¨Š¡»Š1 ‡ªµ¤ œnµÁºÉ°™º° ¨—‡ªµ¤Á­¸É¥Š Ťn¤¸ ‡ªµ¤­´¤¡´œ›r Á¡·É¤‡ªµ¤Á­¸É¥Š ÁºÉ°™º°Å—o - ¤¸„µ¦Á‡¨ºÉ°œÅ®ª¦nµŠ„µ¥­¤ÉεÁ­¤° - ¦´ž¦³šµœ°µ®µ¦š¸É¤¸„µ„Ä¥ Á¡·É¤…¹Êœ - „µ¦šÎµŠµœœ´ÉŠÇœ°œÇ - ¦´ž¦³šµœ°µ®µ¦š¸É¤¸¡¨´ŠŠµœ¤µ„ ¨³¤¸­µ¦°µ®µ¦˜Éε ‡n°œ…oµŠ œn - ­·ÉŠÂª—¨o°¤ÄœoµœÂ¨³Ã¦ŠÁ¦¸¥œš¸É ­nŠÁ­¦·¤Ä®oÁ—È„Á¨º°„¦´ž¦³šµœ °µ®µ¦š¸É¤¸ž¦³Ã¥œr - „µ¦Á¨¸Ê¥Š¨¼„—oª¥œ¤Â¤n - „µ¦Â…nŠ…´œšµŠ˜¨µ—°¥nµŠÁ…o¤…oœ …°Š¦oµœ°µ®µ¦‹µœ—nªœ (fast food) - „µ¦¦·Ã£‡ Á‡¦ºÉ°Š—ºÉ¤š¸É¤¸œÊ嘵¨ ¨³ œÊεŸ¨Å¤oÁ¡·É¤…¹Êœ - Á«¦¬“µœ³šµŠ­´Š‡¤˜Éε (Ĝž¦³Áš« ¡´•œµÂ¨oª ×¥ÁŒ¡µ³Á¡«®·Š) Áž}œÅžÅ—o - °µ®µ¦š¸É¤¸—´œ¸œÊ嘵¨ (glycaemic index) ˜Éε ž¦·¤µ–Þ¦˜¸œ Ĝ°µ®µ¦ - …œµ— …°Š®œnª¥¦·Ã£‡(portion size) …°Š°µ®µ¦¤¸ž¦·¤µ–¨³…œµ— Ä®n…¹Êœ - „µ¦¦´ž¦³šµœ°µ®µ¦œ°„oµœ Á¡·É¤…¹Êœ - ÂŸœ„µ¦¦´ž¦³šµœ°µ®µ¦š¸É°— °µ®µ¦°¥nµŠÁ…o¤Šª— ¨³µŠnªŠ …µ—„µ¦¥´¥´ÊŠ„µ¦„·œ …o°¤¼¨Å¤n Á¡¸¥Š¡° - ¦´ž¦³šµœ°µ®µ¦n°¥ ®¨µ¥¤ºÊ° - °¨„°±°¨r º··Õè 9
  • 123. 117 ž¦³Ã¥œrš¸Éŗo¦´˜n°­»…£µ¡ (Health benefits) ‹µ„„µ¦‡ª‡»¤œÊ宜´„ Ÿ¼oš¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³°oªœ ‡ª¦Å—o¦´‡ÎµÂœ³œÎµÄ®o¤¸„µ¦‡ª‡»¤œÊ宜´„˜´ª®¦º°¨—œÊ宜´„ ÁœºÉ°Š‹µ„£µª³œÊ宜´„Á„·œÂ¨³°oªœ­´¤¡´œ›r„´„µ¦Á¡·É¤‡ªµ¤Á­¸É¥Š˜n°„µ¦Á„·—æ‡Â¨³„µ¦Á­¸¥¸ª·˜ ‹µ„ ®¨µ¥„µ¦«¹„¬µ2 ­—ŠÄ®oÁ®ÈœªnµœÊ宜´„˜´ªš¸É¨—¨Šž¦³¤µ–¦o°¥¨³ 10 œ°„‹µ„nª¥¨—°´˜¦µ˜µ¥Å—o ¤µ„„ªnµ¦o°¥¨³ 20 ¨oª ¥´Š­nŠŸ¨Ä®ož{‹‹´¥Á­¸É¥Š˜n°„µ¦Á„·—懚¸É­´¤¡´œ›r„´Ã¦‡°oªœ¨—¨Š —´Š˜µ¦µŠš¸É 2 ˜µ¦µŠš¸É 2. Ÿ¨š¸Éŗo¦´‹µ„„µ¦¨—œÊ宜´„¦o°¥¨³ 10 …°ŠœÊ宜´„Á¦·É¤˜oœ °´˜¦µ˜µ¥ °´˜¦µ˜µ¥¦ª¤¨—¨Š ¤µ„„ªnµ¦o°¥¨³ 20 °´˜¦µ˜µ¥š¸É­´¤¡´œ›r„´Áµ®ªµœ¨—¨Š ¤µ„„ªnµ¦o°¥¨³ 30 °´˜¦µ˜µ¥š¸É­´¤¡´œ›r„´Ã¦‡°oªœ¨—¨Š ¤µ„„ªnµ¦o°¥¨³ 40 ‡ªµ¤—´œÃ¨®·˜ ‡nµ‡ªµ¤—´œÃ¨®·˜˜´ªœ (systolic pressure) ¨³˜´ª¨nµŠ (diastolic pressure ) ¨—¨Š 10 ¤¤.ž¦°š Áµ®ªµœ ‡nµ¦³—´œÊ嘵¨ÄœÁ¨º°—(Fasting plasma glucose: FPG) ¨—¨Š¦o°¥¨³ 50 Ņ¤´œ Ņ¤´œ¦ª¤¨—¨Š¦o°¥¨³ 10 Ņ¤´œ LDL ¨—¨Š¦o°¥¨³ 15 ئ„¨¸ÁŽ°Å¦—r ¨—¨Š¦o°¥¨³ 30 Ņ¤´œ HDL Á¡·É¤…¹Êœ¦o°¥¨³ 8 ‹µ„„µ¦«¹„¬µ®¨µ¥­™µ´œ ¡ªnµ„µ¦¨—œÊ宜´„¨ŠÁ¡¸¥Š¦o°¥¨³ 5-10 …°ŠœÊ宜´„Á¦·É¤˜oœ ­nŠŸ¨Ä®o¦³—´‡ªµ¤—´œÃ¨®·˜ ¦³—´œÊ嘵¨ÄœÁ¨º°—¨—¨Š ¨³¦³—´Å…¤´œÄœÁ¨º°——¸…¹ÊœÁnœÁ—¸¥ª„´œ Blackburn G3 ¡ªnµœÊ宜´„š¸É¨—¨ŠÁ¡¸¥Š¦o°¥¨³ 5.8 ¤¸‡ªµ¤­´¤¡´œ›r„´‡nµÅ…¤´œ¦ª¤š¸É¨—¨Š ¦o°¥¨³ 16 ¦³—´ HDL-‡°Á¨­Á˜°¦°¨ Á¡·É¤…¹Êœ¦o°¥¨³ 18 ¨³ ¦³—´ LDL-‡°Á¨­Á˜°¦°¨ ¨—¨Š¦o°¥¨³ 12 ­°—‡¨o°Š„´„µ¦«¹„¬µ…°Š Ditschunheit HH ¨³‡–³4 š¸É¡ªnµ Ÿ¼ožiª¥°oªœš¸É¤¸‡nµ¦³—´Å…¤´œÄœ Á¨º°—­¼ŠÂ¨³­µ¤µ¦™¨—œÊ宜´„¨ŠÅ—o¦o°¥¨³ 7.6 ¤¸‡nµ¦³—´Å…¤´œ¦ª¤ ئ„¨¸ÁŽ°Å¦—r ¨³ VLDL ¨—¨Š °¥nµŠ¤¸œ´¥­Îµ‡´ Wing RR ¨³‡–³5 ŗo«¹„¬µŸ¼oš¸É¤¸Ã¦‡°oªœ¦nª¤„´£µª³Áµ®ªµœ‹Îµœªœ 114 ¦µ¥ ®¨´Š‹µ„š¸É ŗočoަ„¦¤¨—œÊ宜´„—oª¥„µ¦Ä®o‡ÎµÂœ³œÎµ—oµœ°µ®µ¦ °°„„ε¨´Š„µ¥ ¨³„µ¦ž¦´Áž¨¸É¥œ ¡§˜·„¦¦¤ Áž}œÁª¨µ 1 že ¡ªnµŸ¼oš¸É¤¸œÊ宜´„¨—¨Š¦o°¥¨³ 5 -10 ‹µ„œÊ宜´„Á—·¤‹³¤¸‡nµ¦³—´œÊ嘵¨ ÁŒ¨¸É¥­³­¤ (HbA1c) ¨—¨Š°¥nµŠ¤¸œ´¥­Îµ‡´ ¨³¤¸¦³—´œÊ嘵¨ÄœÁ¨º°—…–³°—°µ®µ¦ (FPG) ¦³—´ °·œŽ¼¨·œ ئ„¨¸ÁŽ°Å¦—r ¨³ HDL–‡°Á¨­Á˜°¦°¨ —¸…¹Êœ ‹µ„„µ¦«¹„¬µ¤µ˜¦„µ¦¨—‡ªµ¤—´œÃ¨®·˜­¼ŠÃ—¥ Mertens IL ¨³‡–³6 ¡ªnµœÊ宜´„š¸É¨—¨Š ¤µ„„ªnµ®¦º°Ášnµ„´¦o°¥¨³ 5 ‹³­nŠŸ¨Ä®o‡nµ‡ªµ¤—´œÃ¨®·˜˜´ª¨nµŠ (diastolic pressure) ¨—¨ŠÁš¸¥Ášnµ „´Ÿ¼oš¸Éŗo¦´¥µ¨—‡ªµ¤—´œÃ¨®·˜ 1 œ·—
  • 124. 118 ­—ŠÄ®oÁ®Èœªnµ Á¤ºÉ°­µ¤µ¦™¨—œÊ宜´„¨Šž¦³¤µ–¦o°¥¨³ 5-10 ‹³¤¸Ÿ¨„¦³šš¸É´—Á‹œ˜n° ž{‹‹´¥Á­¸É¥Š…°ŠÃ¦‡®´ªÄ‹Â¨³®¨°—Á¨º°— „¨»n¤°µ„µ¦°oªœ¨Š¡»Š (metabolic syndrome) ¨³ Áµ®ªµœ ®¨´„“µœÁ·Šž¦³‹´„¬rÁ¡ºÉ°„µ¦ž’·´˜·„µ¦‡ª‡»¤œÊ宜´„˜´ª(Evidence for action) Scottish Intercollegiate Guidelines Network7 ŗoššªœ°Š‡r‡ªµ¤¦¼o¨³Ä®o…o°Âœ³œÎµ ®¨´„ Ĝ„µ¦žj°Š„´œ ³¨° ¨³¦´„¬µÃ¦‡°oªœÄœÁ—È„ ª´¥¦»nœ ¨³Ÿ¼oÄ®n ×¥¤¸Ážjµ®¤µ¥Ä®o»‡‡¨¤¸œÊ宜´„˜´ª š¸ÉÁ®¤µ³­¤ (healthy weight) ¨³‹´—„µ¦œÊ宜´„ (weight management) Á¤ºÉ°ž¦³­„´£µª³œÊ宜´„ Á„·œ —´Š˜´ª°¥nµŠÄœ˜µ¦µŠš¸É 3 ˜µ¦µŠš¸É 3. ®¨´„“µœÁ·Šž¦³‹´„¬rÁ¡ºÉ°„µ¦ž’·´˜·„µ¦‡ª‡»¤œÊ宜´„˜´ª Key recommendations Grade of recommendation ‡ª¦Äo—´œ¸¤ª¨„µ¥( Body mass index: BMI )Ĝ„µ¦‹ÎµÂœ„£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ ĜŸ¼oÄ®n B °µ‹Äo„µ¦ª´—Á­oœ¦°Á°ª (Waist circumferences) Á¡·É¤‹µ„„µ¦Äo—´œ¸¤ª¨„µ¥ Á¡ºÉ°„µ¦ ž¦³Á¤·œ‡ªµ¤Á­¸É¥Š…°ŠÃ¦‡š¸É¡¦nª¤„´Ã¦‡°oªœÅ—o´—Á‹œ¥·ÉŠ…¹Êœ( obesity-related co morbidities ) C Ĝ„µ¦Ä®o‡Îµž¦¹„¬µ¦µ¥»‡‡¨Äœ„µ¦‹´—„µ¦œÊ宜´„‡ª¦Âœ³œÎµÄ®o ¨—„µ¦¦´ž¦³šµœ°µ®µ¦š¸É°»—¤—oª¥¡¨´ŠŠµœ­¼ŠÃ—¥„µ¦Á¨º°„°µ®µ¦š¸É¤¸¡¨´ŠŠµœ˜É優nµ šœš¸É ¨—„µ¦¦·Ã£‡°µ®µ¦‹µœ—nªœ ¨—Á‡¦ºÉ°Š—ºÉ¤š¸É¤¸Â°¨„°±°¨r B Ĝ„µ¦Ä®o‡Îµž¦¹„¬µ¦µ¥»‡‡¨Äœ„µ¦‹´—„µ¦œÊ宜´„‡ª¦„¦³˜»oœÄ®o¤¸„µ¦Á‡¨ºÉ°œÅ®ª¦nµŠ„µ¥š¸É „¦³Œ´„¦³ÁŒŠ ¨—¡§˜·„¦¦¤œ´ÉŠÇœ°œÇ Ánœ„µ¦—¼Ãš¦š´«œr B Ĝ„µ¦Ä®o‡Îµž¦¹„¬µ„µ¦‹´—„µ¦œÊ宜´„ÄœŸ¼oÄ®n‡ª¦„¦³˜»oœÄ®o˜¦ª‹­°œÊ宜´„—oª¥˜œÁ°Š ­¤ÉεÁ­¤° B »‡¨µ„¦šµŠ„µ¦Â¡š¥r‡ª¦¡¼—‡»¥„´Ÿ¼ožiª¥™¹ŠÂ¦Š„¦³˜»oœ ¦Š‹¼ŠÄ‹š¸ÉšÎµÄ®oŸ¼ožiª¥˜o°Š„µ¦¨— œÊ宜´„ ®¨´Š‹µ„œ´Êœ¤¸„µ¦˜´ÊŠ‡nµÁžjµ®¤µ¥…°ŠœÊ宜´„š¸É˜o°Š„µ¦¨— ‹´—­¦¦ÂŸœ„µ¦ —εÁœ·œ„µ¦¨—œÊ宜´„£µ¥Ä˜o°Š‡rž¦³„°…°Š„µ¦‹´—„µ¦œÊ宜´„˜´ª Ánœ°µ®µ¦ÁŒ¡µ³ „µ¦ °°„„ε¨´Š„µ¥ ¨³/®¦º°„µ¦ž¦´„·‹„¦¦¤˜µ¤š¸ÉŸ¼ožiª¥­¤´‡¦Ä‹ Á˜È¤Ä‹ ¨³Áž}œÅžÅ—o D ¤µ˜¦„µ¦—oµœ°µ®µ¦Äœ„µ¦¨—œÊ宜´„‡ª¦‡Îµœª–Ä®o¡¨´ŠŠµœ¨—¨Š‹µ„Á—·¤ 600 ‡¨°¦¸˜n° ª´œ ަ„¦¤š¸Éčo‡ª¦‹´—Ä®oÁ®¤µ³­¤„´‡ªµ¤°°µ®µ¦…°ŠŸ¼ožiª¥Áž}œ„µ¦ÁŒ¡µ³¦µ¥ A ­™µœ¦·„µ¦š¸Éŗo¤¸„µ¦Äo°µ®µ¦š¸É¤¸¡¨´ŠŠµœ˜É夵„( very low calorie diets ) Áž}œ…o°nŠ¸ÊĜ „µ¦¨—œÊ宜´„š¸É¦ª—Á¦Èª ‡ª¦—εÁœ·œ„µ¦£µ¥Ä˜o‡ÎµÂœ³œÎµÂ¨³„µ¦—¼Â¨…°ŠÂ¡š¥r D Ÿ¼oš¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ‡ª¦­œ´­œ»œÄ®o¤¸„µ¦Á¡·É¤„µ¦Á‡¨ºÉ°œÅ®ªÁž}œ­nªœ®œ¹ÉŠÄœ ®¨µ¥°Š‡rž¦³„°…°ŠÃž¦Â„¦¤„µ¦‹´—„µ¦œÊ宜´„ A Ÿ¼oš¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœ‡ª¦„ε®œ— ž¦·¤µ–‡ªµ¤®œ´„ (intensity )…°Š„µ¦°°„ „ε¨´Š„µ¥Äœ¦³—´žµœ„¨µŠž¦³¤µ– 1,800-2,500 Kcal ˜n°­´ž—µ®r®¦º°ž¦³¤µ– 225-300 œµš¸˜n°­´ž—µ®r B ‡ª¦¤¸¤µ˜¦„µ¦—oµœ‹·˜ª·š¥µ¦µ¥»‡‡¨Â¨³¦µ¥„¨»n¤ÄœÃž¦Â„¦¤„µ¦‹´—„µ¦œÊ宜´„ A
  • 125. 119 ®¤µ¥Á®˜» : Grade of recommendation ¤¸‡ªµ¤­´¤¡´œ›r„´®¨´„“µœÁ·Šž¦³‹´„¬r—´Šœ¸Ê A – At least one meta-analysis, systematic review, or RCT rated as 1++ , and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results B - A body of evidence including studies rated as 2++ , directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C - A body of evidence including studies rated as 2+ , directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D - Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ Key recommendations Grade of recommendation „µ¦Äo¥µ Orlistat ‡ª¦¡·‹µ¦–µÁ­¦·¤‹µ„¤µ˜¦„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤Äœ„µ¦‹´—„µ¦ œÊ宜´„˜´ªŸ¼oš¸É¤¸ BMI> 28 (¨³¤¸co-morbidities ¦nª¤—oª¥) ®¦º° BMI > 30 Ž¹ÉŠ‡ª¦‹³ ¡·‹µ¦–µÁž}œ„µ¦ÁŒ¡µ³¦µ¥®¨´Š‹µ„Å—ož¦³Á¤·œ‡ªµ¤Á­¸É¥ŠÂ¨³ž¦³Ã¥œrš¸Éŗo¦´ A „µ¦Ÿnµ˜´—(Bariatric Sx )‡ª¦¡·‹µ¦–µÁž}œ„µ¦ÁŒ¡µ³¦µ¥®¨´Š‹µ„Å—ož¦³Á¤·œ‡ªµ¤Á­¸É¥ŠÂ¨³ ž¦³Ã¥œrš¸Éŗo¦´ ĜŸ¼oš¸É¤¸…o°nŠ¸Ê—´Šœ¸Ê : BMI > 35 „„/¤2 ¨³ ¤¸ severe co-morbidities š¸É¦»œÂ¦Š¤µ„„ªnµ 1…o° Ž¹ÉŠž¦³Á¤·œªnµ­µ¤µ¦™Â„oŅĮo—¸ …¹Êœ°¥nµŠ¤¸œ´¥­Îµ‡´Á¤ºÉ°œÊ宜´„˜´ª¨—¨Š C Ÿ¼oš¸É—ºÉ¤­»¦µ°¥nµŠ®œ´„(Binge-eating disorder), ¤¸ž{®µ¡§˜·„¦¦¤„µ¦¦´ž¦³šµœ ¤¸ž¦³ª´˜· „µ¦Äo­µ¦Á­¡˜·— ¤¸£µª³Ž¹¤Á«¦oµ Ťn‡ª¦œÎµ¤µ¡·‹µ¦–µÁž}œ…o°®oµ¤Äœ„µ¦¦´„¬µ—oª¥„µ¦ Ÿnµ˜´— C BMI Áž°¦rÁŽœ˜rŚ¨r‡ª¦‹³œÎµ¤µÄoĜ„µ¦ª·œ·‹Œ´¥£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœÄœÁ—È„ C „µ¦ª´—Á­oœ¦°Á°ªÅ¤n‡ª¦œÎµ¤µÄoĜ„µ¦ª·œ·‹Œ´¥£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœÄœÁ—È„ C ¤µ˜¦„µ¦Ã¦ŠÁ¦¸¥œÄœ„µ¦žj°Š„´œ£µª³œÊ宜´„Á„·œÂ¨³Ã¦‡°oªœÄœÁ—È„‡ª¦¡·‹µ¦–µÃ—¥ ˜´ªÂšœ‹µ„®¨µ¥£µ‡­nªœ „µ¦¤¸­nªœ¦nª¤…°ŠŸ¼ož„‡¦°ŠÂ¨³‡¦°‡¦´ª‹³­nŠÁ­¦·¤„µ¦ —εÁœ·œŠµœÄ®o¦µ¦ºÉœÂ¨³¥´ÉŠ¥ºœ C ަ„¦¤„µ¦¦´„¬µ®¦º°‹´—„µ¦Ã¦‡°oªœÄœÁ—È„‡ª¦°¥¼nœ¡ºÊœ“µœ…°Š‡¦°‡¦´ª ¤¸¡n°®¦º°Â¤n ®¦º°Ÿ¼oÁ¨¸Ê¥Š—¼°¥nµŠœo°¥ 1 ‡œ °¥¼nĜަ„¦¤—´Š„¨nµª¦nª¤—oª¥ª´˜™»ž¦³­Š‡rÁ¡ºÉ°ž¦´Áž¨¸É¥œ ª·™¸¸ª·˜…°Šš´ÊŠ‡¦°‡¦´ª ¤¸Ážjµ®¤µ¥š¸É°Š‡rž¦³„°­µ¤ž¦³„µ¦Å—o„n„µ¦¨—¡¨´ŠŠµœš¸Éŗo¦´ š´ÊŠ®¤—Ĝ˜n¨³ª´œ „µ¦Á¡·É¤¦³—´„µ¦°°„„ε¨´Š„µ¥ ¨³„µ¦¨—¦³¥³Áª¨µš¸É¤¸¡§˜·„¦¦¤„µ¦ Á‡¨ºÉ°œÅ®ªœo°¥¨Š B Ážjµ®¤µ¥š¸É¥°¤¦´Äœ„µ¦¦´„¬µÁ—È„°oªœ (—´œ¸¤ª¨„µ¥ > 98th Áž°¦rÁŽœ˜rŚ¨r) ‡º°„µ¦‡Š œÊ宜´„Á—·¤(weight maintenance) D „µ¦‹´—„µ¦®¦º°¨—œÊ宜´„­µ¤µ¦™ž¦³­‡ªµ¤­ÎµÁ¦È‹Å—o×¥„µ¦ž¦´¡§˜·„¦¦¤Â¨³‡Š ¡§˜·„¦¦¤Ä®o¥´ÉŠ¥ºœÁšnµœ´Êœ ˜´ª°¥nµŠÁnœ „µ¦¦´ž¦³šµœ°µ®µ¦­»…£µ¡¤µ„…¹ÊœÂ¨³¨—¡¨´ŠŠµœ¦ª¤š¸Éŗo¦´ Á¡·É¤„·‹„¦¦¤šµŠ„µ¥š¸ÉÁž}œ„·‹ª´˜¦ž¦³‹Îµª´œ (Ánœ„µ¦Á—·œÁ¦Èª) ĜÁ—È„š¸É­»…£µ¡—¸ œ³œÎµÄ®o¤¸„µ¦Á‡¨ºÉ°œÅ®ªÄœ¦³—´žµœ„¨µŠ-®œ´„œµœ°¥nµŠ œo°¥ 60 œµš¸˜n°ª´œ ¨—¦³¥³Áª¨µª·™¸¸ª·˜œ´ÉŠÇœ°œ(Ánœ—¼Ãš¦š´«œr „µ¦Á¨nœÁ„¤‡°¤¡·ªÁ˜°¦r) Ä®oŤnÁ„·œ 2´ÉªÃ¤Š˜n°ª´œ ®¦º° 14 ´ÉªÃ¤Š˜n°­´ž—µ®r D
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  • 127. 121 ˜µ¦µŠš¸É 4. …o°¡·‹µ¦–µÄœ„µ¦¦´„¬µÃ¦‡°oªœ˜µ¤—´œ¸¤ª¨„µ¥Â¨³‡ªµ¤Á­¸É¥Š —´œ¸¤ª¨„µ¥(„„./¤2 ) ‡ªµ¤Á­¸É¥Š 25-29.9 ˜Éε 30-34.9 žµœ„¨µŠ 35-39.9 ­¼Š >40 ¦»œÂ¦Š ㍜µ„µ¦ x X X X „µ¦Á‡¨ºÉ°œÅ®ª x X X X „µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ x x x X „µ¦Äo¥µ x+ * x x X „µ¦Ÿnµ˜´— ? x X + °µ‹‹³Á¦·É¤š¸É BMI >27 „„./¤.2 * °µ‹Á¦·É¤™oµ¤¸ concomitant obesity-related risk-factors or diseases ŗo„n HT, DM, dyslipidemia, CHD, sleep apnea „¨ª·›¸„µ¦—εÁœ·œ„µ¦ „µ¦‹´—„µ¦Â¨³„µ¦‡ŠÁ—·¤œÊ宜´„˜´ªÁž}œš´„¬³°¥nµŠ®œ¹ÉŠ „µ¦—εÁœ·œŠµœ‡ª¦¤¸¦³Â¨³Áž}œ …´Êœ˜°œ (Ÿœ£¼¤·š¸É 2) Ÿ¼ožiª¥‹ÎµÁž}œ˜o°Š¤¸‡ªµ¤˜¦³®œ´„ ˜´ÊŠÄ‹ ¤¸Â¦Š‹¼ŠÄ‹š¸É‹³¨—œÊ宜´„ ˜o°Š¤¸„µ¦ ˜´ÊŠÁžjµ®¤µ¥š¸É´—Á‹œ ­µ¤µ¦™ž’·´˜·Â¨³ž¦´­¼n¡§˜·„¦¦¤Ä®¤nŗo „µ¦‹—´œš¹„„·‹„¦¦¤ ¨³ž¦³Á¤·œ ˜œÁ°ŠÁž}œ¦³¥³Ç nª¥¥ÊεÁ˜º°œÄ®ož¦³­‡ªµ¤­ÎµÁ¦È‹ Á‹oµ®œoµš¸É­µ›µ¦–­»…°µ‹Äo®¨´„„µ¦ 5A’s (Ask, Advise, Assess, Assist, Arrange) ¤µ ž¦³¥»„˜rĜ„µ¦—εÁœ·œŠµœ—´Šœ¸Ê Ask ™µ¤ ®¦º°ª´—œÊ宜´„ ­nªœ­¼Š Á­oœ¦°Á°ª…°ŠŸ¼ožiª¥š»„¦µ¥š¸É¤µ¦´¦·„µ¦Äœ­™µœ¦·„µ¦ ­»…£µ¡ ¨³´œš¹„ÄœÁª¦³Á¸¥œ ‡Îµœª–‡nµ—´œ¸¤ª¨„µ¥ ‹oŠŸ¨—´œ¸¤ª¨„µ¥ ¡¦o°¤Ä®o‡ªµ¤¦¼oÁ¦ºÉ°Š —´œ¸¤ª¨„µ¥ ¨³­™µœ³‡ªµ¤Á­¸É¥Š Advise œ³œÎµ­´ÊœÇ Ä®o‡ª‡»¤œÊ宜´„Äœ¦µ¥š¸É—´œ¸¤ª¨„µ¥ž„˜· ¨³¨—œÊ宜´„Äœ¦µ¥š¸É¤¸ £µª³œÊ宜´„Á„·œÂ¨³°oªœ Assess ž¦³Á¤·œ‡ªµ¤¡¦o°¤‡ªµ¤˜´ÊŠÄ‹š¸É‹³Áž¨¸É¥œÂž¨Š ®¦º°Â¦Š‹¼ŠÄ‹š¸É‹³¨—œÊ宜´„ ™µ¤ Ÿ¼ožiª¥£µª³œÊ宜´„Á„·œÂ¨³°oªœš»„¦µ¥ ™¹Š‡ªµ¤‡·— ®¦º°‡ªµ¤¡¥µ¥µ¤š¸É‹³¨—œÊ宜´„ÄœnªŠš¸ÉŸnµœ¤µ ®¦º°£µ¥ÄœnªŠ 1 Á—º°œ ¨³‡ª¦ž¦³Á¤·œÄœž¦³Á—Èœ˜nµŠÇ Á¡ºÉ°„µ¦°°„ÂŸœ„µ¦ª·›¸„µ¦¨—œÊ宜´„ Ä®o­¤¼¦–r Á¡·É¤‡ªµ¤¤´ÉœÄ‹ Á˜¦¸¥¤„µ¦„n°œ„µ¦¦´„¬µ®¦º°‹´—„µ¦œÊ宜´„˜´ª —´Šœ¸Ê - ¦³—´‡ªµ¤¦»œÂ¦Š…°Š£µª³œÊ宜´„Á„·œÂ¨³°oªœ ‡ªµ¤Á­¸É¥Š, co morbidities Ÿ¨„¦³š š¸ÉÁ„·—…¹Êœ - „µ¦¦´¦¼o­µÁ®˜»Â¨³°´œ˜¦µ¥…°ŠÃ¦‡
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  • 132. 126 y ž{‹‹´¥£µ¥Äœ ŗo„n ¦Š‹¼ŠÄ‹ °µ¦¤–r ­£µ¡‹·˜Ä‹ „µ¦…µ—‡ªµ¤¤´ÉœÄ‹ ¨³š´«œ‡˜·˜n° „µ¦‹´—„µ¦œÊ宜´„˜´ª y Co-morbidities ®¦º°Ã¦‡šµŠ„µ¥˜nµŠÇ š¸ÉÁž}œ°¥¼n¦nª¤—oª¥ Ánœ 懮¨°—Á¨º°—®´ªÄ‹ æ‡ …o°Á­ºÉ°¤ 懇ªµ¤—´œÃ¨®·˜­¼Š 懮¨°—Á¨º°—­¤°Š y „µ¦Å—o¦´¥µµŠœ·— Ánœ ¥µ‹·˜Áª ¥µ¦´„¬µÃ¦‡Áµ®ªµœ beta-blocker, steroid, tamoxifen, highly active antiretroviral drug y ¡´œ›»„¦¦¤ ‹³Á®ÈœÅ—oªnµ œ°„‹µ„ž{‹‹´¥­nªœ»‡‡¨®¦º°ž{‹‹´¥£µ¥ÄœÂ¨oª ž{‹‹´¥šµŠ—oµœ­·ÉŠÂª—¨o°¤„ÈÁž}œ ž{‹‹´¥®œ¹ÉŠš¸É¤¸°·š›·¡¨®¦º°Áž}œ°»ž­¦¦‡˜n°„µ¦‹´—„µ¦œÊ宜´„˜´ª „µ¦Á…oµ­¼n„¦³Â­Ã¨„µ£·ª´•œr ‡nµœ·¥¤š¸É Áž¨¸É¥œÅž ¤¸ª·™¸¸ª·˜š¸É­³—ª„­µ¥Á¡·É¤…¹Êœ Á‡¨ºÉ°œÅ®ªœo°¥ ¤¸„µ¦…¥µ¥˜´ª…°Š°»˜­µ®„¦¦¤°µ®µ¦Â¨³ Á‡¦ºÉ°Š—ºÉ¤ °·š›·¡¨‹µ„„µ¦ž¦³µ­´¤¡´œ›r „µ¦˜¨µ— „µ¦Ã‰¬–µ ¨oªœÁ°ºÊ°˜n°„µ¦¦·Ã£‡°µ®µ¦š¸É¤¸ Á„¨º° œÊ嘵¨ ¨³Å…¤´œ­¼Š ¤µ„„ªnµ„µ¦Äo¡¨´ŠŠµœ Á¡·É¤‡ªµ¤Á­¸É¥Š˜n°Ã¦‡°oªœ Ĝ„µ¦‹´—„µ¦œÊ宜´„ ˜´ªŸ¼oš¸É¤¸£µª³œÊ宜´„Á„·œÂ¨³°oªœ‹¹Š˜o°Šž¦´˜´ªÄ®o­µ¤µ¦™¦¼oÁšnµš´œ ®¨¸„Á¨¸É¥Š£´¥‡»„‡µ¤­»…£µ¡ ¤¸ ‡ªµ¤˜¦³®œ´„¨³ÂœnªÂœnĜ„µ¦Á…oµ™¹Š„µ¦¦·Ã£‡°µ®µ¦­»…£µ¡ ¨³Á¡·É¤Ã°„µ­Äœ„µ¦Á‡¨ºÉ°œÅ®ª®¦º° °°„„ε¨´Š„µ¥ „µ¦Å—o¦´Â¦Š­œ´­œ»œ‹µ„Á¡ºÉ°œ ‡¦°‡¦´ª „µ¦Á…oµ¦nª¤„¨»n¤ ¤¦¤ „µ¦Á­¦·¤­¦oµŠ ­£µ¡Âª—¨o°¤š¸ÉÁ°ºÊ°˜n°­»…£µ¡Äœ­™µœš¸ÉšÎµŠµœ oµœ »¤œ ‹³nª¥Á­¦·¤¡¨´ŠÄœ„µ¦‹´—„µ¦œÊ宜´„˜´ª ŗo¤µ„…¹Êœ Á°„­µ¦°oµŠ°·Š 1. WHO. Diet, Nutrition and the prevention of chronic diseases: Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization, 2003. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. Obes Res 1998; 6 (suppl 2): 51S–209S. [Published erratum appears in Obes Res 1998; 6: 464]. 3. Blackburn G. Effect of degree of weight loss on health benefits. Obes Res 1995; 3 (Suppl 2): 211S-216S. 4. Ditschunheit HH, et al. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr 2002; 56: 264-70. 5. Wing RR, et al. Long-term effects of modest weight loss in type 2 diabetic patients. Arch Intern Med 1987; 147: 1749-53. 6. Mertens IL, VanGaal LF. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes Res 2000; 8: 270-8.
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  • 145. 139 ˜µ¦µŠš¸É 1. ¦¼žÂ„µ¦°°„„ε¨´Š„µ¥Äœ„·‹„¦¦¤ÂÂ°Ã¦·‡Â¨³„µ¦°°„„ε¨´ŠÁŒ¡µ³š¸É1,3-5 іѬюѰээ іѬюѰээ іѣѕѣѯњјѥ зњѥєщѨѷ іѣѕѣѯњјѥъѤѸкўєч яјъѨѷѳчҖ ѯѠдѝѥіѠҖѥкѠѧк (ьѥъѨ/зіѤѸк) (њѤь/ѝѤючѥўҙ) (ѝѤючѥўҙ) ѯёѧѷєдѧлдіієѲь 50-75% нѨёлі 30-45 ьѥъѨ 3 њѤь 9 ьѸѼѥўьѤдјчјк Miller Ѱјѣзцѣ 3 нѨњѧшюіѣлѼѥњѤь ѝѬкѝѫчшѥєѠѥѕѫ * ѳеєѤьѲьѯѝҖьѯјѪѠч- Hypertrnsion 40:612- ѯчѧьѯіѶњ зњѥєчѤь јчјк 618, 2002. њѧѷкэьјѬҕдј 55% нѨёлі 20-30 ьѥъѨ 3 њѤь 20 ьѸѼѥўьѤдјчјк Murphy Ѱјѣзцѣ 4 Int J (treadmil) ѝѬкѝѫчшѥєіѣээ ѳеєѤьўьҖѥъҖѠк Obesity 30:1211-1216, Karvonen ** шҖьѰеь, еѥ јчјк 2006. Curcuit Training 9 5-10 зіѤѸкшҕѠъҕѥ ёѤд 1-3 ьѥъѨ 3 њѤь 12 ьѸѼѥўьѤдјчјк Krametr Ѱјѣзцѣ 1 ъѼѥ*** іѣўњҕѥкъҕѥ ѳеєѤьѲьѯѝҖьѯјѪѠч J.Appk.Physiol јчјк 83(1):270-279, 1997. Curcuit Training 14 60-80% нѨёлі 28 ьѥъѨ ёѤд 30 3 њѤь 14 ьѸѼѥўьѤдјчјк Kersick Ѱјѣзцѣ 5 ъѼѥ*** ѝѬкѝѫчшѥєѠѥѕѫ * њѧьѥъѨ іѣўњҕѥкъҕѥ ѳеєѤьѲьѯѝҖьѯјѪѠч Nutrition & Metabolism јчјк 6(23):2009. * нѨёліѝѬкѝѫчшѥєѯдцфҙѠѥѕѫ = 220 - Ѡѥѕѫ (юҍ) ** шѥєіѣээ Karvonen = (нѨёліѝѬкѝѫчшѥєѯдцфҙѠѥѕѫ - нѨёлііѣѕѣёѤд) *** Circuit training ѯюҝьдѥіѠѠддѼѥјѤкѯмёѥѣъѨѷ ѱчѕѕдьѸѼѥўьѤдѯюҝьњкіѠэ Ѱеь-еѥ-јѼѥшѤњ ѝјѤэдѤь ѠѕҕѥкшҕѠѯьѪѷѠк š¸É 2 „ε®œ—‹µ„—´œ¸£µ¥Äœ¦nµŠ„µ¥ Ánœ čoÁž°¦rÁŽÈœ˜r…°Š°´˜¦µ¸¡‹¦­¼Š­»— (% Age predicted maximum heart rate, % HRmax) ×¥°´˜¦µ¸¡‹¦­¼Š­»— ‡Îµœª–‹µ„ 220 – °µ¥»Äœ®œnª¥ že (¦¼žš¸É 1) ¨³ž¦³Á¤·œ‹µ„‡ªµ¤¦¼o­¹„Á®œºÉ°¥ (subjective evaluation) ×¥„µ¦¡¼—„´˜´ªÁ°Š (self-talk test) ®µ„Ťn­µ¤µ¦™¡¼—˜n°ÁœºÉ°Š ˜n¡¼—Áž}œ‡ÎµÇ …µ—Ç ®µ¥Ç ­—ŠªnµÁ®œºÉ°¥¤µ„¨oª6 °´˜¦µ¸¡‹¦(‡¦´ÊŠ˜n°œµš¸) °µ¥» (že) „µ¦ f„Á¡ºÉ°¦³®´ªÄ‹Â¨³®¨°—Á¨º°— „µ¦ f„Á¡ºÉ°¨—Å…¤´œ­Îµ®¦´Ÿ¼oÁ¦·É¤˜oœ „µ¦ f„Á¡ºÉ°¨—Å…¤´œ…´Êœ„oµª®œoµ ¦¼žš¸É 1. „µ¦„ε®œ—‡ªµ¤®œ´„Äœ„µ¦°°„„ε¨´Š„µ¥­Îµ®¦´ª´˜™»ž¦³­Š‡r˜nµŠÇ ץčo°´˜¦µ ¸¡‹¦­¼Š­»—˜µ¤Á„–”r°µ¥» ‡. ‡ªµ¤™¸Én°¥Äœ„µ¦°°„„ε¨´Š„µ¥ (Frequency of exercise) ®œnª¥œ´Áž}œ‹Îµœªœ‡¦´ÊŠ ˜n°­´ž—µ®r Ĝ®œ¹ÉŠª´œ‡ª¦°°„„ε¨´Š„µ¥Ä®oŗo¦ª¤ 30 œµš¸ Ťnªnµ‹³Áž}œ„µ¦°°„„ε¨´Š„µ¥¦ª—Á—¸¥ª
  • 146. 140 ®¦º°‡n°¥Ç šÎµÂ­³­¤ Ánœ°µ‹ÂnŠ°°„„ε¨´Š„µ¥Áž}œ‡¦´ÊŠ¨³ 10 œµš¸ ¦ª¤ 3 ‡¦´ÊŠ ®¦º° 15 œµš¸ 2 ‡¦´ÊŠ (˜µ¦µŠš¸É 2) ˜µ¦µŠš¸É 2. ‹Îµœªœ‡ªµ¤™¸ÉĜ„µ¦°°„„ε¨´ŠÄœÂ˜n¨³ª´œÂ¨³„µ¦Áž¨¸É¥œÂž¨Š…°Š¦nµŠ„µ¥‹µ„„µ¦ f„7 дѥіѯюјѨѷѕьѰюјкѲь дјѫҕєѳєҕѠѠддѼѥјѤк дјѫҕєѠѠддѼѥјѤк дјѫҕєѠѠддѼѥјѤк 2 зіѤѸк дјѫҕєѠѠддѼѥјѤк 3 зіѤѸк 12 ѝѤючѥўҙ зіѤѸкѯчѨѕњьѥь 30 ьѥъѨ ьѥьзіѤѸкјѣ 15 ьѥъѨ ьѥьзіѤѸкјѣ 10 ьѥъѨ ьѸѼѥўьѤдшѤњ (дд.) ѯёѧѷє јчјк јчјкєѥд јчјкєѥдъѨѷѝѫч чѤньѨєњјдѥѕ (дд./є2 ) ѯёѧѷє јчјк јчјк јчјкєѥдъѨѷѝѫч ѳеєѤьѲшҖяѧњўьѤк (єє.) ѯёѧѷє јчјк јчјк јчјкєѥдъѨѷѝѫч ѯѝҖьіѠэѯѠњ (оє.) ѯёѧѷє јчјк јчјк јчјк зњѥєѝѥєѥіщѲьдѥіѲеҖ јчјк-зкъѨѷ ѯёѧѷє ѯёѧѷє ѯёѧѷєєѥдъѨѷѝѫч ѠѠдоѧѯль (јѧші/ьѥъѨ) Schmidt Ѱјѣзцѣ J.Am.College Nutrition 20(4):494-501, 2001. ­Îµ®¦´‡ªµ¤™¸ÉĜ˜n¨³­´ž—µ®r®µ„Áž}œ„·‹„¦¦¤š¸É®œ´„‹³Ä®o°°„„ε¨´Šš¸É 3-4 ‡¦´ÊŠ˜n°­´ž—µ®r ®µ„Áž}œ„·‹„¦¦¤Áµ°µ‹šÎµÅ—oÁ„º°š»„ª´œ (˜µ¦µŠš¸É 3) Ĝ˜n¨³­´ž—µ®r‡ª¦Ä®o¦nµŠ„µ¥Å—o¡´„oµŠÁ¡ºÉ° ŤnÄ®oÁ­ºÉ°¤Á¦Èª8 ˜µ¦µŠš¸É 3. ‹Îµœªœ‡ªµ¤™¸ÉĜ„µ¦°°„„ε¨´ŠÄœÂ˜n¨³­´ž—µ®r іѣѕѣѯњјѥ зњѥєщѨѷ ъѨѷєѥ (ьѥъѨ) (њѤьшҕѠѝѤючѥўҙ) еѨѷлѤдіѕѥьшѥєѝэѥѕ ѯшҖьіѼѥ ѯјҕьдѠјҙђ 60-90 ъѫдњѤь Dietary Guidelines for American 2005.Dept ѕѪчѯўѕѨѕч ѯчѧьнҖѥѵ (ѯэѥєѥд) Health & Human Services еѨѷлѤдіѕѥь 8 дє. ѯчѧьѯіѶњ ѯјҕьдѠјҙђ 30 5-6 Office of Disease Prevention and Health ѯјҕьѯъььѧѝзѬҕ њҕѥѕьѸѼѥ ѕдьѸѼѥўьѤд (ѯэѥ) Promotion. US Dept Health & Service 2007 еѨѷлѤдіѕѥьѯіѶњ ѯчѧьѯіѶњ њҕѥѕьѸѼѥ 30 ъѫдњѤь National Institute of Health Obes Res њѧѷкѯіѶњ (ѯэѥ) 1998:6:6-26 еѨѷлѤдіѕѥь 15 дє. ѯчѧьѯіѶњ њѧѷкѯіѶњ њҕѥѕьѸѼѥѯіѶњ 20 3-4 Office of Disease Prevention and Health ѯъььѧѝѯчѨѷѕњ ѕдьѸѼѥўьѤд (ўьѤд) Promotion. US Dept Health & Service 2007 дѧлдіієъѨѷѰьѣьѼѥ Š. ¦³¥³Áª¨µÄœ„µ¦°°„„ε¨´Š„µ¥ (Exercise duration) Ĝš¸Éœ¸Ê‹³¥„˜´ª°¥nµŠ„µ¦Á—·œ-ª·ÉŠŽ¹ÉŠ œ·¥¤Â¨³Á¨º°„šÎµ„´œ¤µ„ ¦³¥³Áª¨µÄœ„µ¦„µ¦Á—·œ-ª·ÉŠÁ¡ºÉ°¨—œÊ宜´„š¸ÉÁ®¤µ³­¤Â¨³Å—oŸ¨š¸É­»—Ĝ˜n¨³ ‡¦´ÊŠž¦³¤µ– 30 œµš¸ Ž¹ÉŠÁ…oµ­¼n­£µª³„µ¦ÄoŅ¤´œÁž}œ¡¨´ŠŠµœ (fat-burning zone) ¦³¥³Áª¨µš¸ÉŤn œ³œÎµÄœ„µ¦°°„„ε¨´Š„µ¥š¸Éœo°¥ÅžÁnœ„µ¦Á—·œoµÇ Á¡¸¥Š 15 œµš¸ ®¦º°°°„„ε¨´Š°¥nµŠ®œ´„¨³ ¦³¥³Áª¨µœµœÁ„·œÅž šÎµÄ®o¦nµŠ„µ¥‹³š¦»—Ú¦¤ žª—Á¤ºÉ°¥Â¨³˜o°ŠÄoÁª¨µ¡´„¢gœœµœ šÎµÄ®oŤn‡n°¥ ž¦³­Ÿ¨­ÎµÁ¦È‹ (¦¼žš¸É 2)
  • 147. 141 ¦¼žš¸É 2. ¦³¥³Áª¨µÄœ„µ¦°°„„ε¨´Š„µ¥Ã—¥„µ¦Á—·œoµ Á—·œÁ¦Èª ª·ÉŠ ¨³Ÿ¨˜n° „µ¦¨—œÊ宜´„9 „µ¦„ε®œ—Ážjµ®¤µ¥Á¡ºÉ°¨—œÊ宜´„ Ťn‡ª¦°°„„ε¨´Š„µ¥Â®´„¦º°šÎµÄœ‡¦µªÁ—¸¥ªŽ¹ÉŠÅ¤nÁž}œŸ¨—¸˜n°¦nµŠ„µ¥ œ³œÎµÄ®o ˜´ÊŠÁžjµ®¤µ¥š¸ÉŤn¤µ„¨³¤¸‡ªµ¤Áž}œÅžÅ—o Ánœ®µ„‹³¨—œÊ宜´„ 0.5 „·Ã¨„¦´¤ ˜o°Š°°„„ε¨´Š„µ¥Ã—¥ šÎµÄ®o¦nµŠ„µ¥ÁŸµŸ¨µ¡¨´ŠŠµœÁ¡·É¤…¹Êœ¦ª¤š´ÊŠ­·Êœ 3500 „·Ã¨Â‡¨°¦¸10 „µ¦°°„„ε¨´Š„µ¥˜É優nµœ¸Ê (2500 „·Ã¨Â‡¨°¦¸É) Áž}œÁ¡¸¥Š„µ¦‡ª‡»¤Â˜nŤnŗo¨—œÊ宜´„11 „µ¦°°„„ε¨´Š„µ¥Á¡ºÉ°¨—œÊ宜´„Ä®oŗoŸ¨ ˜o°Š„ε®œ—Ážjµ®¤µ¥—´Šœ¸Ê …´Êœš¸É 1 ˜´ÊŠÁžjµ®¤µ¥Áª¨µªnµ‹³¨—œÊ宜´„—oª¥„µ¦°°„„ε¨´Š„µ¥ ĜÁª¨µ 1 ®¦º° 2 ­´ž—µ®r ®¦º° 1 Á—º°œ …´Êœš¸É 2 ˜´ÊŠÁžjµ®¤µ¥œÊ宜´„š¸É‹³¨— Ánœ ®µ„‹³¨—œÊ宜´„ 1 „„.Ĝ 1 ­´ž—µ®r ˜o°Š°°„„ε¨´Š„µ¥®œ´„¤µ„ (ÁŸµŸ¨µ¡¨´ŠŠµœÄ®oŗo 1000 „·Ã¨Â‡¨°¦¸˜n°ª´œ) °µ‹šÎµÄ®o¦nµŠ„µ¥š¦»—Ú¦¤ ®µ„˜´ÊŠÁžjµ®¤µ¥Åªoš¸É ¨—œÊ宜´„ 0.5 „„.ĜÁª¨µ 1 ­´ž—µ®r (°°„„ε¨´Š„µ¥ÁŸµŸ¨µ¡¨´ŠŠµœ 500 „·Ã¨Â‡¨°¦¸˜n°ª´œ) œnµ‹³Áž}œÅžÅ—o¤µ„š¸É­»— °¥nµŠÅ¦„Șµ¤ „µ¦°°„„ε¨´Š„µ¥¦³—´œ¸Ê (ÁŸµŸ¨µ ¡¨´ŠŠµœ 500 „·Ã¨Â‡¨°¦¸˜n°ª´œ) ¦nª¤„´¨—°µ®µ¦‡º°„·œœo°¥¨Š 500 „·Ã¨Â‡¨°¦¸˜n°ª´œ‹³¨—œÊ宜´„ 1 „„.Ĝ 1 ­´ž—µ®rŗoÁnœ„´œ …´Êœš¸É 3 ˜´ÊŠÁžjµ„·‹„¦¦¤š¸É‹³šÎµ ­Îµ®¦´Ÿ¼oÁ¦·É¤˜oœ°°„„ε¨´Š„µ¥¨—œÊ宜´„ ‡ª¦°°„„ε¨´Š„µ¥Á¡·É¤„µ¦ÁŸµŸ¨µ¡¨´ŠŠµœª´œ¨³ JAMA 297(19):2081-2091, 2007 œÊ宜´„˜´ª(„„) 85 84 85 83 Ņ¤´œ(%) 30.7 27.5 29 28.6 Ťn°°„„ε¨´Š Ťn°°„„ε¨´Š Á—·œoµ Á—·œÁ¦Èª Á—·œÁ¦Èª¤µ„-ª·ÉŠ 83 72 „n°œ ®¨´Š „n°œ ®¨´Š „n°œ ®¨´Š „n°œ ®¨´Š 29.8 28.1 25.3 28.6 „n°œ ®¨´Š„n°œ ®¨´Š„n°œ ®¨´Š„n°œ ®¨´Š 84 83 Á—·œoµ Á—·œÁ¦Èª Á—·œÁ¦Èª¤µ„-ª·ÉŠ ª´œ¨³ 15 œµš¸ ª´œ¨³ 28 œµš¸ ª´œ¨³ 39 œµš¸
  • 148. 142 300 „·Ã¨Â‡¨°¦¸ Ĝ 2-3 ª´œÂ¦„ ×¥Á¨º°„„·‹„¦¦¤ÁµÇ (˜µ¦µŠš¸É 4) š¸ÉÁ®¤µ³­¤ Ánœ Ÿ¼oš¸É¤¸œÊ宜´„˜´ª 80 „„.‹³¨—œÊ宜´„ 1 „„.˜n°­´ž—µ®r ®µ„Á¨º°„š¸É‹³Á¨nœÃªr¨·ÉŠœµœ 1 ¤ (čo¡¨´ŠŠµœÅž 258 „·Ã¨ ‡¨°¦¸) Ž¹ÉŠ°µ‹Å¤nÁ¡¸¥Š¡° ŤnÁ®¤µ³­¤ ¨³œnµÁºÉ° ‹ÎµÁž}œ˜o°Šž¦´ Ánœ Ä®ošÎµ„·‹„¦¦¤ 2-3 °¥nµŠÄœ ˜n¨³ª´œ Á¡ºÉ°Ä®o¤¸„µ¦ÁŸµŸ¨µÂ‡¨°¦¸‹Îµœªœ¦ª¤˜µ¤š¸É˜o°Š„µ¦ ˜µ¦µŠš¸É 4. ž¦·¤µ–¡¨´ŠŠµœ („·Ã¨Â‡¨°¦¸É) š¸Éčo„´„·‹„¦¦¤Áµ žµœ„¨µŠ ¨³®œ´„ зњѥєўьѤд шѤњѠѕҕѥкдѧлдііє 60 дд. 70 дд. 80 дд. ѯэѥ ѱэњҙјѧѷк 177 211 258 еѨѷлѤдіѕѥь (16 дє.) 236 281 345 ъѼѥкѥьэҖѥьъѤѸкњѤь 266 317 388 юѥьдјѥк юқҞьлѤдіѕѥьѠѕѬҕдѤэъѨѷ (ѳєҕѐҏч) 325 387 474 ѯшҖьѰѠѱіэѧз 354 422 518 ѯшҖь Steps ѰѠѱіэѧз 413 493 404 ўьѤд ѠѠддѼѥјѤкшҕѠѯьѪѷѠкѲьѕѧє 472 563 690 юқҞьлѤдіѕѥьѠѕѬҕдѤэъѨѷ (ѐҏчєѥд) 620 739 906 юқҞьлѤдіѕѥьѰеҕкеѤь 944 1126 1380 лѼѥьњьѰзјѠіѨѷѝѼѥўіѤэяѬҖъѨѷєѨьѸѼѥўьѤд „µ¦°°„„ε¨´Š„µ¥ÂÂ°Ã¦·‡š¸Éœ³œÎµ „µ¦°°„„ε¨´ŠÂÂ°Ã¦·‡Äo®¨´„„µ¦Ä®o„¨oµ¤ÁœºÊ°¤´—Ä®nÇ ®¨µ¥Ç ¤´—Å—ošÎµŠµœ¡¦o°¤„´œ ­¨´„´œ°¥nµŠ˜n°ÁœºÉ°Š Á®˜»œ¸ÊšÎµÄ®oÁ„·—…ªœ„µ¦œÎµÅ…¤´œš¸É­³­¤˜µ¤š¸É˜nµŠÇ ¤µÄoÁž}œ¡¨´ŠŠµœ ‡Îµªnµ „µ¦°°„„ε¨´ŠÂÂ°Ã¦·‡‹¹ŠÅ¤nŗo®¤µ¥™¹Š„µ¦Á˜oœÂ°Ã¦·‡Á¡¸¥Š°¥nµŠÁ—¸¥ª ®µ„­µ¤µ¦™°°„ „ε®œ—„µ¦°°„„ε¨´Š—oª¥®¨´„„µ¦Á—¸¥ª„´œ šÎµÄ®o¦nµŠ„µ¥šÎµŠµœÂÂ°Ã¦·‡Å—oÁnœ„´œ Ánœ „µ¦°°„ „ε¨´ŠÂÂ°Ã¦·‡š¸Éoµœ (home-based aerobic) „µ¦¦nª¤Á˜oœÂ°Ã¦·‡š¸É«¼œ¥r„µ¦‡oµ Ĝ­™µœ°°„ „ε¨´Š„µ¥ (outdoor aerobic) „µ¦°°„„ε¨´ŠÂÂ°Ã¦·‡š¸Éž’·´˜·„´œ°¥¼n Áž}œ¦¼žÂš¸É„¨oµ¤ÁœºÊ°­nªœ…µ˜o°ŠšÎµŠµœŽÊ뵂 ˜n°ÁœºÉ°ŠœµœÁ„·œÅž °µ‹Å¤nÁ®¤µ³­¤ÄœŸ¼o­¼Š°µ¥»®¦º°Ÿ¼oš¸É¤¸ž{®µ…°Š…o°ÁšoµÂ¨³Á…nµ12 (˜µ¦µŠš¸É 4)
  • 149. 143 ˜µ¦µŠš¸É 4. ž¦³Á£š…°Š„µ¦°°„„ε¨´Š„µ¥ÂÂ°Ã¦·‡ ¨³‡ªµ¤Á®¤µ³­¤Äœ„µ¦Äo„´ „¨»n¤Ážjµ®¤µ¥˜nµŠÇ13 юіѣѯѓъдѥіѠѠддѼѥјѤк јѤдќцѣ еҖѠчѨ еҖѠѯѝѨѕ ѯўєѥѣѝєдѤэдјѫҕєѯюґѥўєѥѕ ѰээѰѠѱіэѧз дјѫҕєдѥіѯшҖьѰѠѱіэѧз ѯшҖьѰѠѱіэѧз ѯюҝь Low Impact ѯзјѪѷѠьѳўњнҖѥѝјѤэѯіѶњ ѕѷѼѥѠѕѬҕдѤэъѨѷ ўѥдѲнҖлѤкўњѣѯіѶњўіѪѠєѨдѥідіѣѱчч дјѫҕєяѬҖѝѬкѠѥѕѫ зьѠҖњь (Aerobic Dance) Aerobic ѝьѫд єѨѯёѪѷѠь ѯеҖѥіҕњєѳчҖѝєѷѼѥѯѝєѠ лѣъѼѥѲўҖеѥеҖѥкўьѩѷкіѤэьѸѼѥўьѤдєѥд яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ ѲьъѤьъѨъѤьѲч ѰѠѱіэѧзѲььѸѼѥ ѯюҝь Low Impact ѯзјѪѷѠьѳўњнҖѥшҖѥьўіѪѠшѥєѰікўєѫьњь ъѼѥѳчҖѲьѝіѣьѸѼѥѯъҕѥьѤѸь дјѫҕєяѬҖѝѬкѠѥѕѫ зьѠҖњь Aerobic еѠкьѸѼѥ єѨзњѥєшҖѥьъѥьъѫдъѧћъѥк ўрѧкшѤѸкзііѓҙ яѬҖъѨѷѳєҕєѨ зњѥєшҖѥьъѥьеѩѸьдѤэзњѥєѯіѶњдѥі юқрўѥъѥкдѥѕ ѯзјѪѷѠьѳўњ єѨѰікјѠѕшѤњ ѯзјѪѷѠьѳўњѳчҖкҕѥѕ ѰѠѱіэҗѠдоҙ ѯюҝь High Impact дјҖѥєѯьѪѸѠѲўрҕѵ ўјѥѕєѤчъѼѥкѥь шҖѠкѕҕѠѯеҕѥ зјҖѥѕдѥішҕѠѝѬҖ дјѫҕєўьѫҕє-ѝѥњ яѬҖѝѬкѠѥѕѫ зьѠҖњь (Aerobox) Aerobic ѳєҕєѨдѥіўєѫьшѤњ ндєњѕ яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ ѝѯшѶю ѰѠѱіэѧз ѯюҝь Very High Impact ѯзјѪѷѠьѳўњѯіѶњ діѣѱччўєѫьшѤњ њѧкѯњѨѕь-ѯѝѨѕдѥіъікшѤњ-јҖє дјѫҕєўьѫҕє-ѝѥњ (Step Aerobic) Aerobic дҖѥњеѩѸь-јк лѩкѲнҖёјѤккѥь ъѼѥѳчҖѳєҕшҕѠѯьѪѸѠк яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ єѥддњҕѥюдшѧ дјѫҕєдѨџѥъѨѷѯюҝьѰѠѱіэѧз еѨѷлѤдіѕѥь дјҖѥєѯьѪѸѠѰеь ўјѤк ўьҖѥъҖѠк дҖь ѯдѧчѰікдчѯмёѥѣъѨѷ юњчўјѤк дјѫҕєяѬҖѝѬкѠѥѕѫ зьѠҖњь ўрѧк шҖьеѥ ѳчҖъѼѥкѥьёіҖѠєѵ дѤь ьҕѠк еҖѠѯъҖѥ ѯлѶэдҖь шѤѸкзііѓҙ яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ дііѯнѨѕкэд дјҖѥєѯьѪѸѠѰеь ўјѤк ўьҖѥъҖѠк дҖь Ѡѫюдіцҙ-ѝщѥьъѨѷѯмёѥѣ дјѫҕєўьѫҕє-ѝѥњ яѬҖѝѬкѠѥѕѫ зьѠҖњь шҖьеѥ ѳчҖъѼѥкѥьёіҖѠєѵ дѤь іѥзѥѰёк яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ ѯчѧьѯіѶњ дјҖѥєѯьѪѸѠеѥъѼѥкѥьєѥд ѲнҖѯњјѥьѥь ѯєѪѷѠѕеѥ дјѫҕєяѬҖѝѬкѠѥѕѫ зьѠҖњь ўрѧк шјѠчѯњјѥ шѤѸкзііѓҙ яѬҖъѨѷѳєҕєѨюқрўѥъѥкдѥѕ ъѨѷєѥ Peter Klihjn Ѱјѣзцѣ 2007;12 „µ¦°°„„ε¨´Š„µ¥Â Circuit training š¸Éœ³œÎµ čo®¨´„„µ¦°°„„ε¨´Š„µ¥­¨´-¡´„…°Š¦nµŠ„µ¥®¨µ¥­nªœ šÎµÄ®o¦nµŠ„µ¥šÎµŠµœÄœ¦³—´ 40- 50% …°Š‡ªµ¤­µ¤µ¦™­¼Š­»— ×¥š»„­nªœÅ—ošÎµŠµœ (whole body workout)14 ­µ¤µ¦™šÎµÅ—o˜n°ÁœºÉ°Š Áž}œ¦³¥³Áª¨µœµœ ¨³¥´Š„ε®œ—Å—oªnµ°¥µ„Áœoœ¨—Äœ­nªœÄ—…°Š¦nµŠ„µ¥ ¦¼žÂš¸Éž’·´˜·‡º° - ¥º—Á®¥¸¥— + °°„„ε¨´Š­¨´Â…œ-šo°Š-…µ 12 ­™µœ¸ (šnµ) °°„„ε¨´Š„µ¥Ã—¥Ä®ošÎµ 1-2 œµš¸ ˜n°­™µœ¸ ¡´„ 30 ª·œµš¸ šÎµ‡¦š»„­™µœ¸œ´Áž}œ 1 ÁŽÈš ¡´„ 3-5 œµš¸¦³®ªnµŠÁŽÈš šÎµ¦ª¤ 3-5 ÁŽÈš15 ¤¸ Ÿ¨šÎµÄ®oŅ¤´œ¦·Áª–š¸É°°„„ε¨´Š„µ¥¨—¨Š „¨oµ¤ÁœºÊ°„¦³´Â¨³Â…Ȋ¦Š¤µ„…¹Êœ °µ‹ž¦´Ÿ­¤Ÿ­µœ¦nª¤„´„µ¦°°„„ε¨´Š„µ¥ÂÂ°Ã¦·‡Å—o®¨µ¥¨´„¬–³ —´Šœ¸Ê - ¥º—Á®¥¸¥— + °æ·‡ + °°„„ε¨´Š­¨´Â…œ-šo°Š-…µ ץŤnčo°»ž„¦–r (­Îµ®¦´„µ¦Á¦·É¤˜oœ) - ¥º—Á®¥¸¥— + ª·ÉŠ + °°„„ε¨´Š­¨´Â…œ-šo°Š-…µ —oª¥°»ž„¦–r˜»o¤œÊ宜´„ ¥µŠ¥º— (­Îµ®¦´…´Êœ „oµª®œoµ)
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  • 153. 147 дјѫҕєѯчѶдѯјѶд дѧлдіієдѥіѠѠддѼѥјѤкдѥѕъѨѷзњіъѼѥ Ѡѥѕѫ 4-6 ењэ ѯчѶдѲьњѤѕьѨѸєѨдѥіѯіѨѕьіѬҖ єѨёѤхьѥдѥіёѪѸьуѥьъѥкдѥѕ ѯнҕь ѝѤєяѤѝіѬюъікњѤшщѫ зњѥєѠҕѠьшѤњ дѥіъікшѤњ њѤѕьѨѸєѨеҖѠэдёіҕѠкчҖѥьзњѥєъьъѥьъѨѷѕѤкѳєҕѝєэѬіцҙ дѧлдіієъѨѷзњіъѼѥ ѳчҖѰдҕ дѥіњѧѷкдіѣѱччеѥѯчѨѕњ-ѝѠкеѥ њѧѷкѳјҕлѤэ діѣѱччѯнѪѠд ѯшѣјѬдэѠј дјѧѸкшѤњ єҖњьшѤњ дѥіюҍьюҐѥѕ ѯдєѝҙъѨѷѯдѨѷѕњдѤэдѥіъікшѤњ ењҖѥк-іѤэјѬдэѠј ѯюҝьшҖь ѯьҖьдѧлдіієъѨѷѝѠчзјҖѠкдѤэ зњѥєнѠэеѠкѯчѶд ѝьѫдѝьѥьшѠэѝьѠкњѤѕоѫдоь дѧлдіієъѨѷѳєҕзњіъѼѥ ѳчҖѰдҕ шҖѠкѳєҕэѤкзѤэѲўҖѯчѶдъѼѥ ѰјѣшҖѠкѯѝѨѷѕкдѤэдѧлдіієэѥкѠѕҕѥк Ѡѥъѧ дѥідіѣѱчч эьёѪѸьъѨѷѳєҕєѤѷьзк ѯёіѥѣєѨяјшҕѠѱзікѝіҖѥкеѠкѯъҖѥяѧчіѬюѳчҖ ѯнҕь Trampoline ўјѨдѯјѨѷѕкдѥіѠѠддѼѥјѤк юіѣѯѓъъьъѥьъѨѷъѼѥьѥьѯдѧьѳю дјѫҕєѯчѶдѱш дѧлдіієдѥіѠѠддѼѥјѤкдѥѕъѨѷзњіъѼѥ Ѡѥѕѫ 7-12 ењэ ѯчѶдѲьњѤѕьѨѸєѨёѤхьѥдѥіёѪѸьуѥьъѥкчҖѥьюіѣѝѥъѝѤєяѤѝдѥіѯзјѪѷѠьѳўњъѨѷзіэщҖњьѝєэѬіцҙ ъѼѥдѧлдіієъѨѷєѨ зњѥєоѤэоҖѠьѯёѧѷєєѥдеѩѸь, зњѥєѰєҕьѕѼѥ, ѐҎдъѤдќѣ дѧлдіієъѨѷзњіъѼѥ ѳчҖѰдҕ дѥіѱѕьјѬдэѠјѲўҖјкўҕњкўіѪѠшѣдіҖѥ ѯшѣјѬдэѠјѲўҖѯеҖѥюіѣшѬ еѨѷлѤдіѕѥь ѰэчєѧьшѤь ѯъььѧѝ юҌкюѠк ѕѧєьѥѝшѧд ђѫшэѠј дѧлдіієъѨѷѳєҕзњіъѼѥ ѳчҖѰдҕ дѥіѯјҕьѕдьѸѼѥўьѤдъѨѷєѥдѳю ѠѥлєѨяјъѼѥѲўҖюјѥѕдіѣчѬдѳєҕѯшѧэѱш дјѫҕєњѤѕіѫҕь дѧлдіієдѥіѠѠддѼѥјѤкдѥѕъѨѷзњіъѼѥ Ѡѥѕѫ 13-20 юҍ њѤѕіѫҕьєѨёѤхьѥдѥіъѥкдѥѕєѥд діѣчѬд-дјҖѥєѯьѪѸѠѲўрҕеѩѸьнѤчѯль ѝѥєѥіщѯеҖѥіҕњєдѧлдіієѳчҖъѫдньѧч іњєщѩк дѥіѠѠддѼѥјѤкдѥѕъѨѷѕѫҕкѕѥдоѤэоҖѠь ѰјѣдѥіѰеҕкеѤьдѨџѥ дѥішѤчѝѧьѲл дѥіѝіҖѥкзњѥєєѤѷьѲл дѧлдіієъѨѷзњіъѼѥ ѳчҖѰдҕ дѥіѠѠддѼѥјѤкдѥѕъѨѷѲнҖдјҖѥєѯьѪѸѠєѤчѲўрҕ ѯнҕь еѥ Ѱеь јѼѥшѤњ, ѠѠддѼѥјѤкъѨѷєѨдѥі јкьѸѼѥўьѤд дѥідіѣѰъд дѥіѯюјѨѷѕьъѧћъѥк дѥіњѧѷк дѥіѠѠддѼѥјѤкдѥѕѰээ Aerobic ѯёѪѷѠіѬюіҕѥкѰјѣъіњч ъік ѰјѣдѥіѕдьѸѼѥўьѤд (Weight/Resistance Training) ѯёѪѷѠѯѝіѧєѝіҖѥкзњѥєѰеѶкѰікеѠкдіѣчѬд дѧлдіієъѨѷѳєҕзњіъѼѥ зњііѣњѤкѯіѪѷѠкзњѥєюјѠчѓѤѕѲьдѧлдіієъѨѷѯѝѨѷѕк ўіѪѠдѨџѥъѨѷєѨдѥіюѣъѣ дѥіѲнҖьѸѼѥўьѤд шҖѥьъѥьєѥдѯдѧьѳю дјѫҕєњѤѕъѼѥкѥь дѧлдіієдѥіѠѠддѼѥјѤкдѥѕъѨѷзњіъѼѥ Ѡѥѕѫ 21-50 юҍ іҕѥкдѥѕъѨѷшіѥдшіѼѥѕҕѠєєѨдѥіѯѝѪѷѠєщѠѕѰјѣшҖѠкѳчҖіѤэдѥічѬѰјђҏҟьђѬѝѓѥё ўјѤклѥдѠѥѕѫ 30 юҍ ѳюѰјҖњ зњѥє ѝѥєѥіщъѥкдѥѕлѣјчјкіҖѠѕјѣ 1 шҕѠюҍ ьѤѷьзѪѠѯєѪѷѠщѩкѠѥѕѫ 60 юҍ ѯіѥлѣєѨёјѤкјчьҖѠѕјкѳю 30% лѥдъѨѷѯзѕ єѨѯєѪѷѠѠѥѕѫ 30 юҍ дѥіѠѠддѼѥјѤкдѥѕѯёѪѷѠнҕњѕнѣјѠзњѥєѯѝѪѷѠє лѩкєѨзњѥєлѼѥѯюҝь дѥіѠѠддѼѥјѤкдѥѕѓѥѕѲшҖ зњѥєлѼѥдѤчеѠкѯњјѥлѩкшҖѠкюіѤэѯюјѨѷѕьіѬюѰээѲўҖѯўєѥѣѝє дѧлдіієъѨѷзњіъѼѥ ѳчҖѰдҕ дѥіюіѤэѯёѧѷєёїшѧдіієъѥкдѥѕѲьнѤѷњѱєкъѼѥкѥьѰјѣнѨњѧшюіѣлѼѥњѤь дѥіњѧѷк дѥіѕд ьѸѼѥўьѤдѲьѱікѕѧє дѥіѯјҕьдѨџѥъѨє ѰѠѱіэѧздјѫҕє дѧлдіієъѨѷѳєҕзњіъѼѥ ѳчҖѰдҕ еҖѠѠҖѥкъѨѷњҕѥѳєҕєѨѯњјѥњҕѥк, дѥіѯјҕьѕдьѸѼѥўьѤдъѨѷєѥдѳюѠѥлєѨяјъѼѥѲўҖдјҖѥєѯьѪѸѠмѨд дјѫҕєяѬҖѝѬкѠѥѕѫ дѧлдіієдѥіѠѠддѼѥјѤкдѥѕъѨѷзњіъѼѥ єѥддњҕѥ 51 юҍ ѲьяѬҖѝѫкѠѥѕѫ іҕѥкдѥѕєѨдѥіѯѝѪѷѠєщѠѕјкнѤчѯль дѥіѠѠддѼѥјѤкдѥѕлѩкєѨзњѥєлѼѥѯюҝьєѥд оѩѷкєѨўјѥѕіѬюѰээ ѝѥєѥіщюіѤэѯюјѨѷѕьіѬюѰээдѥіѠѠддѼѥјѤкдѥѕѲўҖѯўєѥѣѝєдѤэіҕѥкдѥѕ ѯњјѥ ѰјѣѝщѥьъѨѷ ьѠдлѥдьѨѸ ѕѤкєѨдѥі ћѩдќѥњѧлѤѕёэњҕѥ ўјѤклѥдѠѥѕѫ 30 юҍ ѳюѰјҖњ зьѯіѥлѣєѨёјѤкјчјкіҖѠѕјѣ 1 ъѫдѵ юҍ оѩѷкўєѥѕзњѥєњҕѥ ѯєѪѷѠ Ѡѥѕѫщѩк 60 юҍ ѯіѥлѣєѨёјѤкјчьҖѠѕјкѳющѩкіҖѠѕјѣ 30 лѥдъѨѷѯзѕєѨѯєѪѷѠѠѥѕѫ 30 юҍ ѝѼѥўіѤэюіѣѱѕньҙъѨѷлѣѳчҖ ѠѕҕѥкѰьҕьѠьлѥддѥіѠѠддѼѥјѤкдѥѕ дѶзѪѠ ѝѥєѥіщнҕњѕнѣјѠзњѥєѯѝѪѷѠєъѨѷлѣѯдѧчшѥєыіієнѥшѧюіѣєѥц 1% ъѫдѵюҍ ўјѤклѥдѠѥѕѫ 30 юҍѳюѰјҖњ ѲўҖѯѝѪѷѠєнҖѥјкѳчҖ дѧлдіієъѨѷзњіъѼѥ ѳчҖѰдҕ дѥіњѧѷк дѥіѠѠддѼѥјѤкдѥѕѰээ Aerobic ѰјѣдѥіѕдьѸѼѥўьѤд (Weight/Resistance Training) зњіѯјѪѠдньѧчдѥіѠѠддѼѥјѤкдѥѕѱчѕѯіѧѷєъѨѷјѣѯјѶдјѣьҖѠѕ ѰјҖњзҕѠѕѵ ѯёѧѷєеѩѸьшѥєјѼѥчѤэзњѥє ѝѥєѥіщ ѯнҕь дѥіѯчѧьеѩѸьэѤьѳчѰъьдѥіѲнҖјѧђъҙўіѪѠэѤьѳчѯјѪѷѠь дѥіеѩѸьэѤьѳчеѠкяѬҖўрѧкњѤѕъѠк ѕѤкнҕњѕ ѯѝіѧєѝіҖѥкдіѣчѬдѠѨдчҖњѕ дҕѠьѰјѣўјѤкдѥіѠѠддѼѥјѤкдѥѕўіѪѠѯјҕьдѨџѥъѫдзіѤѸк зњієѨдѥіѕѪчўѕѫҕьдјҖѥєѯьѪѸѠ ѲьъҕѥёѪѸьуѥь ѰјҖњлѩкѠѠддѼѥјѤкдѥѕѠѕҕѥкнҖѥѵ ѯнҕь дѥііѼѥєњѕлѩь ѳъѯдҗд нѨдк іѼѥѳєҖёјѠк ўіѪѠѱѕзѣ дѧлдіієъѨѷзњііѣњѤк ѳчҖѰдҕ 1.зњѥєѯнѪѷѠъѨѷѳєҕщѬдшҖѠкъѨѷњҕѥяѬҖѝѬкѠѥѕѫзњілѣёѤдяҕѠьѲўҖєѥд ѯзјѪѷѠьѳўњўіѪѠѠѠддѼѥјѤкдѥѕѲўҖьҖѠѕ 2.ѳєҕзњіѠѠддѼѥјѤкдѥѕъѨѷшҖѠкѠѠдѰікѯдіѶк ѯэҕк діѣѰъдѠѕѬҕдѤэъѨѷ њѧѷкѯіѶњєѥд дѥіеѩѸьэѤьѳчўјѥѕеѤѸьѲьзіѥњ ѯчѨѕњ дѥіьѤѷкѕѠкѵ ѳєҕэіѧўѥііҕѥкдѥѕѲьъҕѥъѨѷѯюјѨѷѕьъѧћъѥкѠѕҕѥкмѤэёјѤь дѥіѯчѧьэьъѥкјѥч ъѥкјѪѷь 3.ѳєҕзњіѠѠддѼѥјѤкдѥѕѲьъѨѷъѨѷєѨѠѥдѥћіҖѠьѠэѠҖѥњ ўіѪѠѰччлҖѥ 4.ѳєҕзњіѠѠддѼѥјѤкдѥѕецѣіҕѥкдѥѕіѬҖѝѩдѠҕѠьѯёјѨѕўіѪѠѳєҕѝэѥѕ
  • 154. 148 °»ž­¦¦‡Äœ„µ¦°°„„ε¨´Š„µ¥Á¡ºÉ°¨—œÊ宜´„16 1. ˜´ÊŠÁžjµ®¤µ¥­¼Šš¸ÉÁž}œÅžÅ—o¥µ„ (Set a non-realistic goal) ˜´ÊŠÁžjµ®¤µ¥­¼Š£µ¥ÄœÁª¨µ­´Êœ 2. ˜o°Š„µ¦Á®ÈœŸ¨Äœš´œš¸ (Expecting immediate result) ¤´„Ä‹¦o°œÂ¨³°¥µ„¨—œÊ宜´„Ä®o ŗo×¥Á¦Èª 3. —ε¦Š¡§˜·„¦¦¤„µ¦„·œ°¥¼nÁ—·¤ (Keep the same behavior) °µš· œ·­´¥„µ¦„·œ¤µ„ „·œ‹»„„·œ‹· „µ¦ŽºÊ°°µ®µ¦¤µÁ„ȝ čoÁ‡¦ºÉ°Š°Îµœª¥‡ªµ¤­³—ª„ œ³œÎµÄ®o„·œoµ¨ŠÃ—¥ „µ¦Á‡¸Ê¥ª°µ®µ¦œµœ…¹Êœ (ž¦³¤µ–Á„·œ„ªnµ 15 œµš¸) ˜´„°µ®µ¦Ä®oœo°¥¨Š ªµŠo°œÂ¨³ Žo°¤š´œš¸š¸É¦¼o­¹„°·É¤ 4. ¦Š‹¼ŠÄ‹Å¤nÁ…o¤…oœ (Weak stimulus) ‹¹ŠÅ¤n¤¸¡¨´Š…´Á‡¨ºÉ°œš¸É¥µªœµœ¡° 5. ¡¹ÉŠ¡µª·›¸„µ¦°ºÉœ (Believe in other methods) „µ¦°°„„ε¨´Š„µ¥Á¡ºÉ°žj°Š„´œÅ¤nÄ®oœÊ宜´„Á¡·É¤ Ĝª´¥Ÿ¼oÄ®n¡ªnµÂ˜n¨³žeœÊ宜´„‹³…¹Êœž¦³¤µ– 0.8 „·Ã¨„¦´¤ —´Šœ´Êœ ®µ„ž¦·¤µ–°µ®µ¦š¸É„·œ ŤnÁž¨¸É¥œÂž¨Š „µ¦Á¡·É¤ÁŸµŸ¨µ¡¨´ŠŠµœª´œ¨³ 100 „·Ã¨Â‡¨°¦¸É ×¥šÎµ„·‹„¦¦¤®¦º°„µ¦°°„„ε¨´Š „µ¥‹³žj°Š„´œÅ¤nÄ®oœÊ宜´„Á¡·É¤17 …o°¤¼¨„µ¦«¹„¬µÁ„¸É¥ª„´Ãž¦Â„¦¤žj°Š„´œÅ¤nÄ®oœÊ宜´„˜´ªÁ¡·É¤…¹Êœ¤¸ ‡n°œ…oµŠ‹Îµ„´—18,19 ¨³Ÿ¨¨´¡›rž¦ž¦ªœ „µ¦‡ª‡»¤°µ®µ¦‡ª‡¼n„´„µ¦šÎµ„·‹„¦¦¤®¦º°„µ¦°°„ „ε¨´Š„µ¥­¤ÉεÁ­¤°¥´ŠÁž}œ„»Â‹­Îµ‡´­Îµ®¦´„µ¦žj°Š„´œ£µª³œÊ宜´„Á„·œÂ¨³°oªœ20 ×¥š´ÉªÅžÄo ®¨´„„µ¦Â¨³ª·›¸„µ¦ÁnœÁ—¸¥ª„´„µ¦¨—œÊ宜´„ ¦¼žÂÃž¦Â„¦¤š¸ÉÁ…o¤Šª—°µ‹Å¤nž¦³­‡ªµ¤­ÎµÁ¦È‹ „µ¦ °°„„ε¨´Š„µ¥ÂÂ°Ã¦·„¦nª¤„´ f„„¨oµ¤ÁœºÊ°š¸É¡°Á®¤µ³ ‹³nª¥Ä®o¦nµŠ„µ¥¤¸­¤¦¦™£µ¡Â¨³¡¨³„ε¨´Š š¸É—¸21 ¡ªnµ„µ¦ f„Ã¥‡³nª¥¨—°´˜¦µ„µ¦Á¡·É¤…°ŠœÊ宜´„˜´ªÅ—o22 Á°„­µ¦°oµŠ°·Š 1. Kraemer WJ, Volek JS, Clark KL, et al. Physiological adaptations to a weight-loss dietary regimen and exercise programs in women. J Appl. Physiol 1997; 83: 270-9. 2. Ballor DL, Harvey-Berino JR, Ades PA, Cryan J, Calles-Escandon J. Contrasting effects of resistance and aerobic training on body composition and metabolism after diet-induced weight loss. Metabolism 1996; 45: 179-83. 3. Miller ER, Erlinger TP, Young DR, et al. Results of the diet, exercise and weight loss intervention trials. Hypertension 2002; 40: 612-8. 4. Murphy KYT, Demons JL, Lenchick L, Nicklas BJ. Addition of aerobic exercise to diet weight loss preferentially reduces abdominal adipocyte size. Inter J Obesity 2006; 30: 1211-6. 5. Kersick C, Thomas A, Campbell B, et al. Effects of a popular exercise and weight loss program on weight loss, body composition, energy expenditure and health in obese women. Nutrition and Metabolism 2009; 6:23-40.
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  • 166. 160 4. Realistic ­°—‡¨o°Š„´‡ªµ¤Áž}œ‹¦·Š 5. Timely ª´—Å—o˜µ¤nªŠÁª¨µš¸É„ε®œ— ­¦»žÅ—oªnµ „µ¦—εÁœ·œ„·‹„¦¦¤®¦º°Ã‡¦Š„µ¦Ä—Ç ®¨´„­Îµ‡´¥·ÉŠš¸ÉŸ¼o—εÁœ·œ„µ¦˜o°ŠÄo‡º° PDCA ¨³„ε®œ—˜´ª¸Êª´—…°Š„·‹„¦¦¤Åªo°¥nµŠ´—Á‹œ ­µ¤µ¦™ª´—ž¦³Á¤·œÅ—o ¨³˜´ª¸Êª´—®¨´„¤¸‹ÎµœªœÅ¤n¤µ„ ˜´ª¸Êª´—Ÿ¨­´¤§š›·Í˜o°Šª´—š¸ÉŸ¨Ÿ¨·˜ Ÿ¨¨´¡›r ¨³Ÿ¨„¦³šš¸ÉÁ„·—…¹Êœ Ánœ ǦŠ„µ¦ž¦´Áž¨¸É¥œ ¡§˜·„¦¦¤­»…£µ¡‹³Äo˜´ª¸Êª´—Ÿ¨­´¤§š›·Í Ÿ¨Ÿ¨·˜Áž}œ¦o°¥¨³…°Š‹ÎµœªœŸ¼oÁ…oµ¦nª¤Ã‡¦Š„µ¦ ­nªœ ˜´ª¸Êª´—Ÿ¨¨´¡›rª´—‹µ„¦o°¥¨³…°Š‹ÎµœªœŸ¼oÁ…oµ¦nª¤Ã‡¦Š„µ¦š¸É¤¸Ÿ¨„µ¦Áž¨¸É¥œÂž¨Š…°Š¡§˜·„¦¦¤ ­»…£µ¡—¸…¹Êœ Ÿ¨„µ¦Áž¨¸É¥œÂž¨ŠšµŠ¦nµŠ„µ¥ ¨³Ÿ¨„µ¦˜¦ª‹Á¨º°—Áž}œÅžÄœšµŠš¸É—¸…¹Êœ „µ¦¤°ŠÃ¨„Šn—¸ (Optimism: O) Ĝ­£µª³ž{‹‹»´œš¸É„µ¦—εÁœ·œ¸ª·˜˜o°ŠÁŸ·„´£µª³‡ªµ¤‡´…o°Š®¤nœ®¤°Š ­´­œ ª»nœªµ¥ ¨³µŠ°¥nµŠ¦„ªœ‹·˜Ä‹ ‹œ­nŠŸ¨°¥nµŠ¥·ÉŠ˜n°„ε¨´ŠÄ‹Äœ„µ¦˜n°­¼o®¦º°‡ªµ¤„¨oµ˜n°„µ¦ÁŸ·Á¡ºÉ°¢{œ iµ °»ž­¦¦‡œµœ´ž„µ¦Ä®o¨—œo°¥¨Š Ÿ¼oš¸ÉŤn­µ¤µ¦™Ÿnµœ¡oœÅžÅ—o˜o°Š‹¤°¥¼n„´‡ªµ¤‡·—š¸ÉÁž}œš»„…r Ťn ­µ¤µ¦™„oµª…oµ¤ž{®µš¸ÉŸnµœÁ…oµ¤µÅ—o ‹œÁ„·—Ÿ¨Á­¸¥˜n°„µ¦—εÁœ·œ¸ª·˜Ã—¥Å¤n­µ¤µ¦™˜¸‡nµÁž}œÁŠ·œ˜¦µ ŗo —´Šœ´Êœ ‹¹Š˜o°Š¤¸„µ¦¡´•œµ‡ªµ¤‡·—Ä®oÁž}œ‡ªµ¤‡·—ª„¤µ„…¹Êœ Á¡¦µ³Áž}œª·›¸„µ¦‡·—š¸É¤¸‡ªµ¤­Îµ‡´ ¨³¥´ŠÁž}œÂœªšµŠž’·´˜·š¸Énª¥Â„ož{®µ˜nµŠÇ ŗo Ÿ¼oš¸É­µ¤µ¦™ž¦´Áž¨¸É¥œ¤»¤¤°Š…°Š‡ªµ¤‡·—Ä®o ˜„˜nµŠÅž‹µ„Á—·¤ ‹³¡Äœ­·ÉŠ—¸Ç š¸ÉÁ„·—…¹ÊœÅ—o°¥nµŠœnµ°´«‹¦¦¥r Á¡¦µ³„µ¦‡·—Á·Šª„Áž}œ‡ªµ¤‡·—š¸É nª¥šÎµÄ®o¸ª·˜¤¸‡ªµ¤­¤—»¨ ¤¸‡ªµ¤­»…¤µ„…¹Êœ Ÿ¼oš¸É«¹„¬µÁ„¸É¥ª„´„µ¦‡·—Á·Šª„čo‡Îµš¸É˜„˜nµŠ„´œÂ˜n¤¸‡ªµ¤®¤µ¥Ä„¨oÁ‡¸¥Š„´œ µŠšnµœ Á¦¸¥„žœÅž—oª¥„´œ ŗo„n „µ¦‡·—Á·Šª„Áž}œ„¦³ªœ„µ¦šµŠ‡ªµ¤‡·—…°Š»‡‡¨š¸ÉÁ„·—‹µ„¦¼žÂ „µ¦¦´¦¼o¨³„µ¦¦¼o‡·— (perception and cognitive style) ŞĜš·«šµŠš¸É—¸ ¤°ŠÂ¨³¦´¦¼o­·ÉŠ˜nµŠÇ ˜µ¤ ‡ªµ¤Áž}œ‹¦·Š Áž}œÁ®˜»Áž}œŸ¨—oª¥°µ¦¤–rš¸ÉŸn°ŠÄ­ ‹¹ŠšÎµÄ®o¤¸¡§˜·„¦¦¤„µ¦Â­—Š°°„š¸ÉÁ®¤µ³­¤14 ®¦º°„µ¦‡·—Á·Šª„Áž}œ„µ¦Ãœo¤œoµª‹·˜Ä˜o­Îµœ¹„ÄœšµŠš¸É—¸ Áž}œ„µ¦­¦oµŠÁ‹˜‡˜·š¸É—¸˜n°˜œÁ°Š˜n°Ÿ¼o°ºÉœ ¨³˜n°ª´˜™»®¦º°­£µ¡„µ¦–r Á‹˜‡˜·š¸ÉÁž}œª„‹³Áž}œÁ‡¦ºÉ°Š¤º°­Îµ‡´Äœ„µ¦—ε¦Š°¥¼nĜ脚¸É­´­œ ª»nœªµ¥œ¸Êŗo°¥nµŠž¦³­‡ªµ¤­ÎµÁ¦È‹Â¨³¤¸‡ªµ¤­»…15 ®¦º°„µ¦‡·—Á·Šª„Áž}œ«·¨ž³­Îµ‡´…°Š„µ¦ —ε¦Š¸ª·˜Ä®o¤¸‡ªµ¤­»… Áž}œ°»µ¥„¨n°¤Ä‹Ä®o¥°¤¦´­£µ¡ž{®µš¸É„ε¨´Šž¦µ„’ Á¡ºÉ°Ä®o¤¸„ε¨´ŠÄ‹Â¨³ ‡ªµ¤Á…o¤Â…ÈŠÄœ„µ¦˜n°­¼o„´¸ª·˜˜n°Åž16 ­¦»žÅ—oªnµ „µ¦‡·—Á·Šª„ Áž}œ„¦³ªœ„µ¦šµŠ‡ªµ¤‡·—…°Š»‡‡¨š¸ÉÁ„·—‹µ„„µ¦¤¸¦¼žÂ„µ¦ ¦´¦¼o „µ¦‡·—ŞĜšµŠš¸É—¸ Áž}œ„µ¦­¦oµŠÁ‹˜‡˜·Â¨³ÂœªÃœo¤‹·˜Ä˜o­Îµœ¹„š¸É—¸˜n°˜œÁ°Š ˜n°Ÿ¼o°ºÉœ ¨³˜n° ª´˜™»®¦º°­™µœ„µ¦–r˜nµŠÇ Ž¹ÉŠÁž}œÁ‡¦ºÉ°Š¤º° Áž}œª·›¸„µ¦š¸ÉšÎµÄ®o¥°¤¦´­£µ¡ž{®µš¸ÉÁ„·—…¹Êœ°¥nµŠ Á…o¤Â…ÈŠ ­µ¤µ¦™—ε¦Š¸ª·˜°¥nµŠž¦³­‡ªµ¤­ÎµÁ¦È‹Â¨³¤¸‡ªµ¤­»… ‡ªµ¤®¤µ¥…°Š„µ¦‡·—Á·Šª„Áž}œÄœ¨´„¬–³š·«šµŠÁ—¸¥ª„´Âœª‡·—„µ¦¤°ŠÃ¨„ĜŠn—¸ ˜µ¤ œª‡·—˜³ª´œ˜„ „µ¦¤°ŠÃ¨„ĜŠn—¸ (optimism) Áž}œ°Š‡rž¦³„°®œ¹ÉŠ…°Šž¦¸µÁ·Š°µ¦¤–r (Emotional Intelligence, EQ) Ĩ¤œ17 ŗo„ε®œ—ªnµ„µ¦¤°ŠÃ¨„ĜŠn—¸Áž}œ­nªœ®œ¹ÉŠš¸É­Îµ‡´Äœ„µ¦
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  • 177. 171 „µ¦„ε„´˜œÁ°Š (Self-regulation) „µ¦„ε„´˜œÁ°Š®¤µ¥™¹Š „¦³ªœ„µ¦š¸É»‡‡¨ž’·´˜·Â¨³­œ´­œ»œ˜n°¡§˜·„¦¦¤ ‡ªµ¤¦¼o‡ªµ¤ Á…oµÄ‹ ¨³°µ¦¤–r‡ªµ¤¦¼o­¹„š¸É¤»nŠÅž­¼nÁžjµ®¤µ¥š¸É˜´ÊŠÅªo—oª¥˜œÁ°Š°¥nµŠÁž}œ¦³33 Áž}œ„µ¦ ˜´ÊŠÁžjµ®¤µ¥ „µ¦ªµŠÂŸœ „µ¦—εÁœ·œ„µ¦˜·—˜µ¤Ÿ¨ š´ÊŠÄœ—oµœ¡§˜·„¦¦¤ —oµœ‡ªµ¤¦¼o ‡ªµ¤Á…oµÄ‹ ¨³ —oµœÂ¦Š‹¼ŠÄ‹…°Š˜œÁ°Š Á¡ºÉ°Ä®o¦¦¨»™¹Š­·ÉŠš¸É¤»nŠ®ª´ŠÅ—o—oª¥˜œÁ°Š »Š‡r ¨³ Ž·¤Á¤°¦r¤œ34 „¨nµª™¹Š „¨»n¤š¸ÉÁºÉ°ªnµ„µ¦„ε„´˜œÁ°ŠÅ—o¦´°·š›·¡¨¤µ‹µ„­´Š‡¤ ŗo¦´Âœª‡·—‹µ„š§¬‘¸˜nµŠÇ —´Šœ¸Ê 1. š§¬‘¸Á·Šž{µ­´Š‡¤ (Social cognitive theory) 2. š§¬‘¸ª´•œ›¦¦¤Á·Š­´Š‡¤ (Sociocultural theory) 3. š§¬‘¸„µ¦˜´—­·œÄ‹—oª¥˜œÁ°Š (Self – determination theory) Ÿ¼oÁ…¸¥œÄ®o‡ªµ¤­œÄ‹Âœª‡·—„µ¦„ε„´˜œÁ°Š‹µ„š§¬‘¸Á·Šž{µ­´Š‡¤ (Social cognitive theory) …°ŠÂœ—¼¦nµ3,30 Ž¹ÉŠÁºÉ°ªnµ¡§˜·„¦¦¤…°Š¤œ»¬¥rŤnŗoÁž}œŸ¨¤µ‹µ„„µ¦Á­¦·¤Â¦Š ¨³„µ¦¨ŠÃš¬‹µ„£µ¥œ°„˜nÁ¡¸¥Š°¥nµŠÁ—¸¥ª ˜n¤œ»¬¥r­µ¤µ¦™„¦³šÎµµŠ­·ÉŠµŠ°¥nµŠÁ¡ºÉ°‡ª‡»¤ ‡ªµ¤‡·— ‡ªµ¤¦¼o­¹„ ¨³„µ¦„¦³šÎµ…°Š˜œÁ°Š „¦³ªœ„µ¦—´Š„¨nµªœ¸Ê‡º°„µ¦„ε„´˜œÁ°Š (self- regulation) Ĝ„µ¦„ε„´˜œÁ°Šž¦³„°—oª¥ 3 „¦³ªœ„µ¦¥n°¥34 (¦¼žš¸É 3) 1. „µ¦­´ŠÁ„˜˜œÁ°Š (Self-observation) 2. „µ¦˜´—­·œ˜œÁ°Š (Self-judgment) 3. „µ¦Â­—Šž’·„·¦·¥µ˜n°˜œÁ°Š (Self-reaction) „µ¦­´ŠÁ„˜˜œÁ°Š (Self-observation) ®¤µ¥™¹Š ‡ªµ¤­œÄ‹˜n°¨´„¬–³š¸É‹ÎµÁ¡µ³Äœ ¡§˜·„¦¦¤…°Š»‡‡¨°¥nµŠ¡·œ·‹¡·Á‡¦µ³®r35 ¤¸°Š‡rž¦³„° 2 ž¦³„µ¦ ‡º° „µ¦˜´ÊŠÁžjµ®¤µ¥ ¨³„µ¦ Á˜º°œ˜œÁ°Š „µ¦˜´ÊŠÁžjµ®¤µ¥ (Goal setting) ®¤µ¥™¹Š „µ¦„ε®œ—¡§˜·„¦¦¤Ážjµ®¤µ¥®¦º°„ε®œ—Á„–”r Ĝ„µ¦Â­—Š¡§˜·„¦¦¤Ä—¡§˜·„¦¦¤®œ¹ÉŠš¸É˜o°Š„µ¦Áž¨¸É¥œÂž¨Š Ĝ¦³¥³Â¦„…°Š„µ¦„ε„´˜œÁ°Š »‡‡¨‹³˜o°Š˜´ÊŠÁžjµ®¤µ¥ Ž¹ÉŠÁž}œ„¦³ªœ„µ¦­Îµ‡´š¸É‹³nª¥Ä®o»‡‡¨Å—o¦¼o™¹Š¡§˜·„¦¦¤š¸É˜o°Š„µ¦ „¦³šÎµ°¥nµŠ´—Á‹œ ¨³¥´ŠÄoÁž}œÁ„–”rĜ„µ¦ž¦³Á¤·œÁ¡ºÉ°Áž¦¸¥Áš¸¥„´¡§˜·„¦¦¤š¸É»‡‡¨„¦³šÎµ „´¡§˜·„¦¦¤Ážjµ®¤µ¥š¸É„ε®œ—Ūo „µ¦˜´ÊŠÁžjµ®¤µ¥˜o°ŠÁ®¤µ³­¤„´¦³—´‡ªµ¤­µ¤µ¦™…°Š»‡‡¨ œ´Êœ ‹¹Š‹³¤¸Ã°„µ­¦¦¨»Ážjµ®¤µ¥Å—o ‡»–­¤´˜·…°ŠÁžjµ®¤µ¥‡ª¦¤¸¨´„¬–³—´Šœ¸Ê36 1) ‡ªµ¤ÁŒ¡µ³Á‹µ³‹Š Áž}œ„µ¦¦³»¡§˜·„¦¦¤š¸É´—Á‹œ Ánœ Ÿ¼oš¸É¨—œÊ宜´„‹³„ε®œ— Ážjµ®¤µ¥ÁŒ¡µ³Á‹µ³‹Šªnµ°µ®µ¦¤ºÊ°Á¥Èœ˜o°Š„·œÅ¤nÁ„·œ 500 „·Ã¨Â‡¨°¦¸É Ážjµ®¤µ¥š¸ÉÁŒ¡µ³Á‹µ³‹Š‹³ nª¥Á¡·É¤Â¦Š‹¼ŠÄ‹ ­nŠÁ­¦·¤„µ¦Á¦¸¥œ¦¼o ¨³Šnµ¥˜n°„µ¦ª´—¡§˜·„¦¦¤ 2) ‡ªµ¤Ä„¨oÁ‡¸¥Š Áž}œÁžjµ®¤µ¥š¸Éčo¦³¥³Áª¨µ­´ÊœÇ Ĝ„µ¦„¦³šÎµ¡§˜·„¦¦¤ Ážjµ®¤µ¥š¸É¤¸ ‡ªµ¤Ä„¨oÁ‡¸¥Š‹³­nŠÁ­¦·¤‡ªµ¤­µ¤µ¦™Â¨³Â¦Š‹¼ŠÄ‹…°Š˜œÁ°ŠÂ¨³Šnµ¥˜n°„µ¦ª´—¡§˜·„¦¦¤ ‡ªµ¤ Ą¨oÁ‡¸¥Š‹³¤¸°·š›·¡¨˜n°„µ¦šÎµ¡§˜·„¦¦¤ ×¥ÁŒ¡µ³„´Á—È„Á¨È„š¸É­œÄ‹ŠµœÄœnªŠ¦³¥³Áª¨µ­´ÊœÇ 3) ‡ªµ¤¥µ„ „µ¦˜´ÊŠÁžjµ®¤µ¥š¸É¥µ„ šÎµÄ®o»‡‡¨Äo‡ªµ¤¡¥µ¥µ¤­¼ŠÁ¡ºÉ°„¦³šÎµ¡§˜·„¦¦¤Ä®o ¦¦¨»Ážjµ®¤µ¥ Á¤ºÉ°ž¦³­Ÿ¨­ÎµÁ¦È‹‹³Á„·—‡ªµ¤¡¹Š¡°Ä‹Â¨³¦´¦¼oªnµ˜œÁ°Š¤¸‡ªµ¤­µ¤µ¦™
  • 178. 172 „µ¦˜´ÊŠÁžjµ®¤µ¥š¸É¤¸‡ªµ¤ÁŒ¡µ³Á‹µ³‹Š ‡ªµ¤Ä„¨oÁ‡¸¥Š ¨³‡ªµ¤¥µ„—oª¥˜œÁ°Š šÎµÄ®o»‡‡¨ ‡µ—®ª´Šš¸É‹³Â­—Š¡§˜·„¦¦¤Ä®o¦¦¨»Ážjµ®¤µ¥œ´Êœ ™oµž¦³­‡ªµ¤­ÎµÁ¦È‹‹³¦¼o­¹„ªnµ˜œÁ°Š¤¸ ‡ªµ¤­µ¤µ¦™Â¨³Á¦¸¥œ¦¼oŗo—¸š¸É­»— „µ¦˜´ÊŠÁžjµ®¤µ¥ ¤¸ 2 ª·›¸‡º° 1) „µ¦˜´ÊŠÁžjµ®¤µ¥—oª¥˜œÁ°Š ‡º° »‡‡¨œ´Êœ„ε®œ—¡§˜·„¦¦¤Ážjµ®¤µ¥š¸É˜o°Š„µ¦„¦³šÎµ —oª¥˜œÁ°Š Ž¹ÉŠ„µ¦˜´ÊŠÁžjµ®¤µ¥—oª¥˜œÁ°Š‹³¤¸…o°—¸‡º°‹³šÎµÄ®o»‡‡¨¦¼o­¹„ªnµÁ…µÁž}œŸ¼o„¦³šÎµÂ¨³Áž}œŸ¼o ˜´—­·œÄ‹—oª¥˜œÁ°Š šÎµÄ®oÁ„·—‡ªµ¤¦¼o­¹„­µ¥Ä‹Â¨³¡¥µ¥µ¤„¦³šÎµ¡§˜·„¦¦¤Ä®o¦¦¨»Ážjµ®¤µ¥š¸É˜œ „ε®œ—Ūo 2) „µ¦˜´ÊŠÁžjµ®¤µ¥Ã—¥»‡‡¨°ºÉœ ‡º° »‡‡¨°ºÉœÁž}œŸ¼o„ε®œ—¡§˜·„¦¦¤Ážjµ®¤µ¥š¸É˜o°Š„µ¦ Áž¨¸É¥œÂž¨ŠÄ®o Ž¹ÉŠ„µ¦˜´ÊŠÁžjµ®¤µ¥—oª¥»‡‡¨°ºÉœ‹³¤¸…o°—¸˜¦Šš¸Énª¥Ä®o»‡‡¨š¸ÉŤn­µ¤µ¦™˜´ÊŠÁžjµ®¤µ¥ —oª¥˜œÁ°ŠÅ—o°¥nµŠÁ®¤µ³­¤ Ä®o­µ¤µ¦™˜´ÊŠÁžjµ®¤µ¥Å—o°¥nµŠÁ®¤µ³­¤„´‡ªµ¤­µ¤µ¦™˜œÁ°Š¥·ÉŠ…¹Êœ35 £µ¡ž¦³„° 4 „µ¦„ε„´˜œÁ°Š33 [54] ¦¼žš¸É 3. „¦³ªœ„µ¦„ε„´˜œÁ°Š „µ¦Á˜º°œ˜œÁ°Š (Self-monitoring) ®¤µ¥™¹Š „¦³ªœ„µ¦š¸É»‡‡¨­´ŠÁ„˜Â¨³´œš¹„ ¡§˜·„¦¦¤Ážjµ®¤µ¥š¸ÉÁ„·—…¹Êœ—oª¥˜œÁ°Š Á¡ºÉ°Áž}œ…o°¤¼¨Á„¸É¥ª„´¡§˜·„¦¦¤š¸É˜œÁ°Š„¦³šÎµ ‹³šÎµÄ®o »‡‡¨¦¼oªnµ˜œÁ°Š„¦³šÎµ¡§˜·„¦¦¤Äœ¨´„¬–³Ä—‹³œÎµÅž­¼n„µ¦Áž¨¸É¥œÂž¨Š¡§˜·„¦¦¤…°Š»‡‡¨Å—o ÁœºÉ°Š‹µ„»‡‡¨Å—oÁ®Èœ…o°¤¼¨¥o°œ„¨´Â¨oªšÎµÄ®o¦¼oªnµ‡ª¦šÎµÁnœÅ¦˜n°ÅžÁ¡ºÉ°Åž­¼n¡§˜·„¦¦¤Ážjµ®¤µ¥š¸É ˜o°Š„µ¦ …´Êœ˜°œÄœ„µ¦Á˜º°œ˜œÁ°Šš¸É¤¸ž¦³­·š›·£µ¡37 1) ‹ÎµÂœ„Ážjµ®¤µ¥Ä®o´—Á‹œªnµ‹³˜o°Š­´ŠÁ„˜ ¡§˜·„¦¦¤°³Å¦ 2) „ε®œ—Áª¨µš¸É‹³­´ŠÁ„˜Â¨³´œš¹„¡§˜·„¦¦¤ 3) „ε®œ—ª·›¸„µ¦´œš¹„¨³Á‡¦ºÉ°Š¤º°š¸Éčo Ĝ„µ¦´œš¹„¡§˜·„¦¦¤ 4) ­´ŠÁ„˜Â¨³´œš¹„¡§˜·„¦¦¤˜œÁ°Š 5) ­—ŠŸ¨„µ¦´œš¹„¡§˜·„¦¦¤˜œÁ°ŠÁž}œ „µ¦­´ŠÁ„˜˜œÁ°Š (Self-observation) - „µ¦˜´ÊŠÁžjµ®¤µ¥ (Goal setting) - „µ¦Á˜º°œ˜œÁ°Š (Self-monitoring) „µ¦˜´—­·œ˜œÁ°Š (Self-Judgment) - œ·—…°Š¤µ˜¦“µœ (Type of standards) - °Š‡rž¦³„°…°ŠÁžjµ®¤µ¥ (Goal properties) - ‡ªµ¤­Îµ‡´…°Š„µ¦¦¦¨»Ážjµ®¤µ¥ (Importance of goal attainment) „µ¦Â­—Šž’·„·¦·¥µ˜n°˜œÁ°Š (Self-Reaction) - „µ¦ž¦³Á¤·œ¡§˜·„¦¦¤ (Evaluative) - ‡ªµ¤Áž}œÅžÅ—oš¸É‹³ž¦³­‡ªµ¤­ÎµÁ¦È‹(Tangible) Ážjµ®¤µ¥ „µ¦¦´¦¼o‡ªµ¤­µ¤µ¦™˜œÁ°Š (Self-efficacy) „µ¦°œ»¤µœ­µÁ®˜» (Attributions)
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  • 186. 180 ˜µ¦µŠš¸É 2. …´Êœ˜°œ„µ¦Áž¨¸É¥œ¡§˜·„¦¦¤ š´«œ‡˜·Â¨³¨´„¬–³…°ŠŸ¼ožiª¥ …´Êœ˜°œ „µ¦Áž¨¸É¥œ š´«œ‡˜·˜n° „µ¦ž¦´Áž¨¸É¥œ ¨´„¬–³…°Š‡œÄœÂ˜n¨³…´Êœ˜°œ 1. Precontemplation “Never” ŤnÁ‡¥˜´ÊŠÄ‹š¸É‹³Áž¨¸É¥œÄœ °œµ‡˜Ä„¨oÇ (¤µ„„ªnµ 6 Á—º°œ…¹ÊœÅž) -Ťn¦¼o¤µ„n°œªnµ¤¸ž{®µ­»…£µ¡Â¨³˜n°˜oµœ„´‡ªµ¤¡¥µ¥µ¤ š¸É‹³ž¦´Áž¨¸É¥œ -°µ‹Å¤n¦¼oªnµ„µ¦Áž¨¸É¥œÂž¨Š‹³¤¸Ÿ¨°¥nµŠÅ¦ -ž’·Á­›Å¤n¥°¤¦´ªnµ¡§˜·„¦¦¤š¸ÉÁž}œ°¥¼nŤn™¼„˜o°Š -°µ‹Á‡¥¨o¤Á®¨ª˜n°‡ªµ¤¡¥µ¥µ¤š¸É‹³ž¦´Áž¨¸É¥œ¤µ„n°œ ¨³¦¼o­¹„®¤—„ε¨´ŠÄ‹ -ŤnÁ®Èœªnµ„µ¦Áž¨¸É¥œ‹³Ä®ož¦³Ã¥œr°¥nµŠÅ¦ -¤°Šªnµ„µ¦ž¦´Áž¨¸É¥œšÎµÄ®oÁ­¸¥‡nµÄo‹nµ¥®¦º°Á­¸¥Áª¨µÄœ „µ¦šÎµŠµœ®¦º°„µ¦šÎµ›»¦„·‹ 2.Contemplation “Might” Á¦·É¤¤¸‡ªµ¤‡·—š¸É‹³ Áž¨¸É¥œ -¦¼oªnµÁž¨¸É¥œÂ¨oª‹³—¸„ε¨´Š˜´—­·œÄ‹ -°µ‹‹³¥´Š…µ—‡ªµ¤ÁºÉ°¤´Éœ -„ε¨´Š®µ…o°¤¼¨Â¨³Ÿ¼onª¥Äœ„µ¦Áž¨¸É¥œ 3. Preparation “Soon” „ε¨´ŠªµŠÂŸœš¸É‹³ Áž¨¸É¥œ¡§˜·„¦¦¤Ä®oŗo˜µ¤ Ážjµ®¤µ¥Äœ°œµ‡˜°´œÄ„¨o (Ánœ Ĝ 30 ª´œ…oµŠ®œoµ) -Á¦·É¤ž¦´Áž¨¸É¥œš¸¨³œo°¥ÅžoµŠÂ¨oª -¤°ŠÁ®Èœž¦³Ã¥œrĜ„µ¦Áž¨¸É¥œ -Á˜¦¸¥¤¡¦o°¤š¸É‹³Á—·œ­¼nÁžjµ®¤µ¥ -¤¸‡ªµ¤¤´ÉœÄ‹ªnµ‹³Áž¨¸É¥œÅ—o (Á„·—Self- efficacy ‡º°¤¸„µ¦¦´¦¼o‡ªµ¤­µ¤µ¦™Äœ˜œÁ°Š) 4.Action “Now” ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤Å—o ˜µ¤š¸É˜´ÊŠÄ‹£µ¥Äœ 6 Á—º°œ š¸ÉŸnµœ¤µ -„ε¨´Šž¦´Áž¨¸É¥œ¡§˜·„¦¦¤°¥nµŠÁ®ÈœÅ—o´— -¡§˜·„¦¦¤Ä®¤nÇ š¸ÉšÎµ¥´ŠÅ¤n­¤ÉεÁ­¤° -¤¸­·ÉŠ¥´Éª¥ªœš¸É‹³´„œÎµÄ®o„¨´Åž­¼n¡§˜·„¦¦¤Á—·¤Ç -¤¸‡ªµ¤Á­¸É¥Š­¼Šš¸É‹³„¨´Åž­¼n¡§˜·„¦¦¤„n°œ®œoµœ¸Ê 5. Maintenance “Forever” ž¦´¡§˜·„¦¦¤ ŗo°¥nµŠ˜n°ÁœºÉ°Š™¹Š 6 Á—º°œ Áž}œ°¥nµŠœo°¥ -¡¥µ¥µ¤°¥nµŠÁ˜È¤š¸É š¸É‹³Å¤n„¨´Åž­¼n¡§˜·„¦¦¤Á—·¤Ç -¤´ÉœÄ‹š¸É‹³Áž¨¸É¥œÅ—o˜¨°—Åž -°µ‹¤¸‡ªµ¤Á­¸É¥Šš¸É‹³¡¨´ÊŠÁŸ¨°Ã—¥ÁŒ¡µ³Áª¨µš¸É¤¸ ‡ªµ¤Á‡¦¸¥— 6. Relapse °µ‹„¨´Åž¤¸ž{®µŽÊεŗo ™oµ°¥¼nĜ­™µœ„µ¦–r¥´Éª¥» -™°¥„¨´Åž¤¸¡§˜·„¦¦¤Á—·¤Á¡¦µ³ °µ¦¤–r ‹·˜Ä‹Áž¦µ³µŠ Ťn…Ȋ„¦nŠ¡° -ž„˜·¦o°¥¨³ 80 ‹³Å¤n„¨´Åž­¼n…´Êœ„n°œ®œoµœ¸Êŗo ‹¹Š ‡ª¦‹´— ަ„¦¤˜o°ŠÁ­¦·¤‡ªµ¤Â…Ȋ„¦nŠšµŠ‹·˜ (‡ª¦­¦oµŠÄ®oÁž}œÂ„œœÎµ ®¦º°¤¸Á‡¦º°…nµ¥) ˜´ª°¥nµŠ „µ¦Ä®o‡Îµž¦¹„¬µŸ¼ožiª¥Áµ®ªµœ47 „¨»n¤Ÿ¼ožiª¥‹³¤¸¨´„¬–³˜nµŠÇ (˜µ¦µŠš¸É 2) ­Îµ®¦´ ‡¦´ÊŠÂ¦„„´‡œ„¨»n¤ precontemplation ¨³ contemplation œ´Êœ‡ª¦Áœoœ™¹Š‡ªµ¤Á­¸É¥Šš¸É‹³Á„·—…¹Êœ„´ ¡§˜·„¦¦¤ž{‹‹»´œ ¡¼—™¹Š„µ¦ž¦´Áž¨¸É¥œš¸ÉŠnµ¥Ç ĜšµŠª„š¸É‡œ„¨»n¤œ¸Ê‹³šÎµÅ—oÁ¡ºÉ°¨—‡ªµ¤Á­¸É¥Š…°Š æ‡ Ÿ¼oš¸É°¥¼nĜ¦³¥³ precontemplation °µ‹¡¼—™¹ŠŸ¨—¸Â¨³„µ¦Â„oŅ°»ž­¦¦‡ š¸É‹³nª¥Ä®o‡»¤¦³—´œÊ嘵¨ ĜÁ¨º°—Å—o—¸…¹Êœ Ÿ¼oÁ¸É¥ªµ—oµœ„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤¸ÊÄ®oÁ®Èœ‡ªµ¤ÁºÉ° 2 ž¦³„µ¦š¸É‹³Ãœo¤œoµªÄ®o
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  • 190. 184 ‡¦´ÊŠš¸Éª.—.ž. ¨´„¬–³„·‹„¦¦¤ Áš‡œ·‡/ª·›¸„µ¦ ‹Îµœªœ ˜´ª¸Êª´—Ÿ¨Ÿ¨·˜/Ÿ¨¨´¡›r 5 4 -Á­¦·¤Â¦ŠÃ—¥„µ¦ f„‹·˜ ¡´•œµ°µ¦¤–r -ž¦³Á¤·œŸ¨„µ¦ ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤² -„µ¦ f„‹·˜Á¡·É¤¡¨´Š¸ª·˜—oª¥¡¨´Š¦´„ -šÎµÂš—­° ž¦³Á¤·œ¡§˜·„¦¦¤ ¨³™nµ¥¦¼ž®¨´ŠÁ…oµ¦nª¤„·‹„¦¦¤‡¦ -¨„Áž¨¸É¥œÁ¦¸¥œ¦¼o¦nª¤„´œÄœ„µ¦—¼Â¨ ˜œÁ°Š¡¦o°¤nª¥„´œ˜°ž{®µ ­»…£µ¡Ž¹ÉŠ„´œÂ¨³„´œÄœ„¨»n¤ -ž¦³Á¤·œž{®µ°»ž­¦¦‡Á¡ºÉ° ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤š¸ÉŗoŸ¨Â¨³ ¥´ÉŠ¥ºœ -Ä®o„ε¨´ŠÄ‹„´š»„‡œ -ºÉœ¤ ­—Š‡ªµ¤¥·œ—¸Â¨³ ¤°Ä ž¦³„µ«Á„¸¥¦˜·‡»–˜oœÂ ‡ªµ¤­ÎµÁ¦È‹ 50 ‡œ - 70 % Ÿ¼oÁ…oµ¦nª¤ „·‹„¦¦¤¤¸„µ¦ Áž¨¸É¥œÂž¨ŠÅž ĜšµŠš¸É—¸…¹Êœ ×¥ª´— ‹µ„ BMI , BP ¦° Á°ª - 70 % …°ŠŸ¼oÁ…oµ¦nª¤ „·‹„¦¦¤ ¤¸‡ªµ¤¡¹Š ¡°Ä‹ºÉ°Ã‡¦Š„µ¦ - 70 % …°ŠŸ¼oÁ…oµ¦nª¤ „·‹„¦¦¤¤¸¡§˜·„¦¦¤ 3 Self —¸…¹Êœ„ªnµ„n°œ Á…oµ¦nª¤Ã‡¦Š„µ¦ Á°„­µ¦°oµŠ°·Š 1. °Îµ¡¨ ‹·œ—µª´•œ³ (2551). ž’·ª´˜·¤»¤¤°Š­»…£µ¡­¼n­£µª³­´Š‡¤š¸É—¸„ªnµ. ‡–³„¦¦¤„µ¦­»…£µ¡ ®nŠµ˜· (­.) ­º‡oœ‹µ„ http://www.naewna.com/news.asp?ID =86119 Á¤ºÉ°10 ›´œªµ‡¤ 2551. 2. °´Š«·œ´œšr °·œš¦„ε®Š, °¦¡·œš¦r ¼¤, ª¦­¦–r Áœ˜¦š·¡¥r, ¡´¦¸ —ªŠ‹´œš¦r. „µ¦¦·®µ¦‹´—„µ¦ ¨³ž¦³Á¤·œÃ‡¦Š„µ¦Á¡ºÉ°„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤­»…£µ¡…°Š®œnª¥ŠµœÄœÁ…˜„¦»ŠÁš¡¤®µœ‡¦ ªµ¦­µ¦¡§˜·„¦¦¤«µ­˜¦r 15 (1), 28-38. 3. ­¤Ã£œr Á°¸É¥¤­»£µ¬·˜. š§¬‘¸Â¨³Áš‡œ·‡„µ¦ž¦´¡§˜·„¦¦¤ (Theories and Techniques in Behavior modification) ¡·¤¡r‡¦´ÊŠš¸É 6. „¦»ŠÁš¡¤®µœ‡¦ ­Îµœ´„¡·¤¡r‹»¯µ¨Š„¦–r¤®µª·š¥µ¨´¥ 2549. 4. Mikulas W. Behavior Modification. New York: Harper & Row 1978. 5. ´¥¡¦ ª·µª»›, ›¸¦³¡¦ °»ª¦¦–Ö. ‡ªµ¤¦¼o‡¼n‡»–›¦¦¤. „¦»ŠÁš¡¤®µœ‡¦ 抡·¤¡r‹»¯µ¨Š„¦–r ¤®µª·š¥µ¨´¥ 2534. 6. Wolpe J. The Practice of Behavior Therapy. Elmsford, NY: Pergamom 1969. 7. O’Leary KD, Wilson GT. Behavior Therapy, 2nd Ed. Englewood Cliff, NJ: Prentice-Hall 1987. 8. ž¦³š¸ž ‹·œŠ¸É. „µ¦ª·Á‡¦µ³®r¡§˜·„¦¦¤Â¨³„µ¦ž¦´¡§˜·„¦¦¤. Á°„­µ¦ž¦³„°„µ¦­°œ. „¦»ŠÁš¡¤®µœ‡¦ ­™µ´œª·‹´¥¡§˜·„¦¦¤«µ­˜¦r ¤®µª·š¥µ¨´¥«¦¸œ‡¦·œš¦ª·Ã¦• 2540. 9. Prochaska JO, DiClemente C. Stages and processes of self change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology 1983; 51: 390- 5. 10. —µ¦œ¸ ­º‹µ„—¸ (2551). Stage of change-…´Êœ˜°œ…°Š„µ¦Áž¨¸É¥œÂž¨Š. š‡ªµ¤°°œÅ¨œr ­º‡oœ ‹µ„ http://203.155.220.217/doh/deptd/Article/article_07.doc. Á¤ºÉ° 9 ¤„¦µ‡¤ 2551
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  • 193. 187 39. Suwannee Chearsawad. The effectiveness of Self Control Skill Development on Avoidance of Unhealthy Snack Consumption among Grade five Students in Tak Province. Thesis in Health Education and Behavioral Science. Bangkok: Faculty of Graduate Studies, Mahidol University 2002. 40. Á„«Â„oª ­°œ—¸. Ÿ¨…°ŠÃž¦Â„¦¤­»…«¹„¬µÃ—¥ž¦³¥»„˜rœª‡·—„µ¦‡ª‡»¤˜œÁ°ŠÄœ„µ¦ž¦´Áž¨¸É¥œ ¡§˜·„¦¦¤„µ¦¦·Ã£‡°µ®µ¦Â¨³„µ¦°°„„ε¨´Š„µ¥Á¡ºÉ°„µ¦¨—œÊ宜´„ …°Šœ´„Á¦¸¥œš¸É¤¸œÊ宜´„Á„·œ ¤µ˜¦“µœ °ÎµÁ£°Á¤º°Š ‹´Š®ª´—­¦³»¦¸. ž¦·µœ·¡œ›r ªš.¤. (­»…«¹„¬µ). „¦»ŠÁš¡²: ´–”·˜ª·š¥µ¨´¥ ¤®µª·š¥µ¨´¥«¦¸œ‡¦·œš¦ª·Ã¦• 2548. 41. Orem DE. Nursing Concepts of Practice. 3rd Ed. New York: McGraw Hill Book 1985. 42. Gantz SB. Self-care: Perspectives from six disciplines. Holistic Nursing Practice 1990; 4: 1-12 43. Pender NJ. Health Promotion in Nursing Practice. 2nd Ed. California: Appleton and Lange 1987. 44. °¦­µ ¡´œ›r£´„—¸. „¦³ªœ„µ¦„µ¦—¼Â¨˜œÁ°Š…°ŠŸ¼ožiª¥‡ªµ¤—´œÃ¨®·˜­¼Šœ·—Ťnš¦µ­µÁ®˜». ª·š¥µœ·¡œ›r ¡¥µµ¨«µ­˜¦r—»¬‘¸´–”·˜. „¦»ŠÁš¡¤®µœ‡¦ ´–”·˜ª·š¥µ¨´¥ ¤®µª·š¥µ¨´¥¤®·—¨ 2542. 45. £µª·œ¸ ㇭·œ‹Îµ¦¼. ‡ªµ¤­´¤¡´œ›r¦³®ªnµŠ‡ªµ¤ÁºÉ°—oµœ­»…£µ¡„´¡§˜·„¦¦¤„µ¦—¼Â¨˜œÁ°Š…°Š ®·Š˜´ÊŠ‡¦¦£rµªÅš¥¤»­¨·¤š¸É¤¸£µª³‡ªµ¤—´œÃ¨®·˜­¼Š ÁœºÉ°Š‹µ„„µ¦˜´ÊŠ‡¦¦£r. Á°„­µ¦ž¦³„°„µ¦ œÎµÁ­œ°Äœ„µ¦ž¦³»¤ª·µ„µ¦„¦¤°œµ¤´¥ž¦³‹ÎµžeŠž¦³¤µ– 2540 46. °¤µª­¸ °´¤¡´œ«·¦·¦´˜œr. ‡ªµ¤­µ¤µ¦™Äœ„µ¦—¼Â¨˜œÁ°Š„´£µª³­»…£µ¡…°ŠŸ¼o­¼Š°µ¥»Á…˜œš °ÎµÁ£°¡¨ ‹´Š®ª´—…°œÂ„nœ. ž¦·µœ·¡œ›r ¡¥.¤. („µ¦¡¥µµ¨»¤œ). …°œÂ„nœ: ´–”·˜ ª·š¥µ¨´¥ ¤®µª·š¥µ¨´¥…°œÂ„nœ 2539. 47. ­»œš¦µ£¦–r ¡·¡´š›„»«¨„»¨, °´Š«·œ´œšr °·œš¦„ε®Š ¦µ¥Šµœ¦¼žÂ˜´ª°¥nµŠ„µ¦‹´—„·‹„¦¦¤ ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤­»…£µ¡…°ŠŸ¼ožiª¥Áµ®ªµœ˜µ¤Âœª‡·— 3 Self ¨³ PROMISE Model. 2553 ­Îµœ´„Šµœ®¨´„ž¦³„´œ­»…£µ¡Â®nŠµ˜·Á…˜ 13 „¦»ŠÁš¡¤®µœ‡¦ ¦nª¤„´ ­™µ´œª·‹´¥ ¡§˜·„¦¦¤«µ­˜¦r 48. ­¤¡¦ ċ­¤»š¦, °´Š«·œ´œšr °·œš¦„ε®Š. ¦¼žÂ˜´ª°¥nµŠ„µ¦‹´—„·‹„¦¦¤Ã‡¦Š„µ¦‹´—¦·„µ¦ ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤­»…£µ¡…°Š„¨»n¤Ÿ¼o¤¸œÊ宜´„Á„·œ¤µ˜¦“µœ˜µ¤Âœª‡·— 3 Self ¨³ PROMISE Model. ­Îµœ´„Šµœ®¨´„ž¦³„´œ­»…£µ¡Â®nŠµ˜·Á…˜ 13 „¦»ŠÁš¡¤®µœ‡¦ ¦nª¤„´ ­™µ´œª·‹´¥ ¡§˜·„¦¦¤«µ­˜¦r 2553
  • 194. 188 ´¥µ —¸Ã¦‹œªŠ«r ®¨´„„µ¦Äœ„µ¦Äo¥µ¨—œÊ宜´„ 1. „µ¦Äo¥µ¨—œÊ宜´„˜o°ŠÄo¦nª¤„´„µ¦‡ª‡»¤°µ®µ¦Â¨³„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤Á­¤° 2. ¥µ¨—œÊ宜´„Ťn­µ¤µ¦™šÎµÄ®o®µ¥‹µ„懰oªœ Á¤ºÉ°®¥»—¥µœÊ宜´„‹³„¨´…¹ÊœÅ—o°¸„ 3. ¥µ¨—œÊ宜´„‡ª¦Äo£µ¥Ä˜o„µ¦—¼Â¨…°ŠÂ¡š¥r°¥nµŠÄ„¨o·— 4. ‡ª¦¡·‹µ¦–µ¦³®ªnµŠŸ¨Á­¸¥š¸É°µ‹‹³Á„·—‹µ„Ÿ¨…oµŠÁ‡¸¥Š…°Š¥µš¸Éŗo „´Ÿ¨—¸‹µ„„µ¦¨— œÊ宜´„ 5. „n°œš¸É‹³Á¦·É¤Äo¥µ¨—œÊ宜´„ ‡ª¦‹³Ä®o„µ¦¦´„¬µ—oª¥„µ¦‡ª‡»¤°µ®µ¦ „µ¦°°„„ε¨´Š„µ¥ ¨³„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ Áž}œÁª¨µ°¥nµŠœo°¥ 3 Á—º°œ Ĝ„¦–¸š¸É®¨´ŠÄ®o„µ¦¦´„¬µ—´Š„¨nµªÂ¨oª œÊ宜´„¨—Á„·œ¦o°¥¨³ 10 „µ¦Äo¥µ¨—œÊ宜´„°µ‹‹³Å¤n¤¸‡ªµ¤‹ÎµÁž}œÄœŸ¼ožiª¥„¨»n¤œ¸Ê1 6. ®¨´Š‹µ„čo¥µ¨—œÊ宜´„Áž}œ¦³¥³Áª¨µ 3 Á—º°œ ™oµœÊ宜´„¨—¨Šœo°¥„ªnµ¦o°¥¨³ 5 …°Š œÊ宜´„˜´ª„n°œÁ¦·É¤Äo¥µ ‡ª¦¡·‹µ¦–µÁ¨·„čo¥µ—´Š„¨nµªÁœºÉ°Š‹µ„¤¸„µ¦«¹„¬µ¡ªnµ™oµÄo¥µ˜n°Åž‹³Å¤n ŗoŸ¨Â¨³°µ‹Á­¸É¥Š˜n°Ÿ¨…oµŠÁ‡¸¥Š…°Š¥µÅ—o1 …o°¡·‹µ¦–µÄœ„µ¦Äo¥µ¨—œÊ宜´„2 1. —´œ¸¤ª¨„µ¥¤µ„„ªnµ®¦º°Ášnµ„´ 27 „„./¤.2 ®¨´ŠÄ®o„µ¦¦´„¬µ—oª¥„µ¦‡ª‡»¤°µ®µ¦ „µ¦°°„„ε¨´Š„µ¥ ¨³„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ 2. —´œ¸¤ª¨„µ¥¤µ„„ªnµ®¦º°Ášnµ„´ 25 „„./¤2 ®¨´ŠÄ®o„µ¦¦´„¬µ—oª¥„µ¦‡ª‡»¤°µ®µ¦ „µ¦ °°„„ε¨´Š„µ¥Â¨³„µ¦Áž¨¸É¥œÂž¨Š¡§˜·„¦¦¤ ĜŸ¼oš¸É¤¸ž{‹‹´¥Á­¸É¥ŠÁnœ Áµ®ªµœ ‡ªµ¤—´œÃ¨®·˜­¼Š ®¦º° Ņ¤´œÄœÁ¨º°—Ÿ·—ž„˜· ¥µ¨—œÊ宜´„Ťn‡ª¦ÄoĜ„¦–¸˜n°Åžœ¸Ê 1. Á—È„Äœª´¥Á‹¦·Á˜·Ã˜ÁœºÉ°Š‹µ„ž{‹‹»´œ¥´ŠÅ¤n¤¸…o°¤¼¨Á¡¸¥Š¡° 2. ­˜¦¸˜´ÊŠ‡¦¦£r 3. Ťnŗo°¥¼n£µ¥Ä˜o„µ¦—¼Â¨…°ŠÂ¡š¥r ž¦³Á£š…°Š¥µ¨—œÊ宜´„3-7 ¥µ¨—œÊ宜´„°µ‹ÂnŠÅ—oÁž}œ 2 ž¦³Á£šÄ®nÇ ˜µ¤˜ÎµÂ®œnŠ„µ¦°°„§š›·Í…°Š¥µ ŗo„n¥µ„¨»n¤ š¸É°°„§š›·Íš¸É­¤°ŠÃ—¥¤¸Ÿ¨˜n°«¼œ¥r‡ª‡»¤„µ¦„·œ®¦º°‡ªµ¤°¥µ„°µ®µ¦ ¨³¥µš¸É°°„§š›·Í­nªœ œ°„­¤°ŠÅ—o„n¥µš¸É°°„§š›·Íš¸É¨ÎµÅ­o¥´¥´ÊŠ„µ¦—¼—Ž¹¤…°Š­µ¦°µ®µ¦ (˜µ¦µŠš¸É 1) º··Õè 13
  • 195. 189 ˜µ¦µŠš¸É 1. ­—Šœ·—…°Š¥µ¨—œÊ宜´„š¸É¤¸ÄoĜž{‹‹»´œÂ¨³„¨Å„„µ¦°°„§š›·Í Principal mode of action Drug name Centrally acting Noradrenergic, dopamine Combined serotonergic and noradrenergic Phentermine Sibutramine* Peripherally acting Lipase inhibitor Orlistat * ¥„Á¨·„„µ¦‹Îµ®œnµ¥Â¨oª Phentermine (‹´—Áž}œª´˜™»°°„§š›·Í˜n°‹·˜ž¦³­µšž¦³Á£šš¸É 2 „µ¦ŽºÊ°˜o°ŠŽºÊ°‹µ„„°Š ‡ª‡»¤ª´˜™»Á­¡˜·—­Îµœ´„Šµœ‡–³„¦¦¤„µ¦°µ®µ¦Â¨³¥µÁšnµœ´Êœ ®oµ¤¤¸‹Îµ®œnµ¥Äœ¦oµœ¥µ) Phentermine Áž}œ¥µš¸É°°„§š›·Í˜n°¦³ž¦³­µš­nªœ„¨µŠ ×¥Á¡·É¤„µ¦®¨´ÉŠ­µ¦­ºÉ°ž¦³­µš dopamine (DA) ¨³ norepinephrine (NE) ¨³¥´Š¤¸§š›·Í¥´¥´ÊŠ„µ¦Á„ȝ„¨´ dopamine ¨³ norepinephrine °¸„—oª¥ ¥µœ¸Ê‹¹Š¤¸Ÿ¨Á¡·É¤ DA ¨³ NE š¸Éž¨µ¥ž¦³­µš°¥nµŠ¤µ„ ¨³­nŠŸ¨Ä®o¨—‡ªµ¤ °¥µ„°µ®µ¦Â¨³Å¤n®·ª ˜nÁœºÉ°Š‹µ„¥µœ¸Ê¤¸§š›·Íš´ÊŠÅ¨nš¸É¨³¥´¥´ÊŠ„µ¦Á„ȝ„¨´…°Š­µ¦­ºÉ°ž¦³­µš —´Šœ´Êœ „µ¦Äo¥µ˜·—˜n°„´œÁž}œÁª¨µœµœ °µ‹šÎµÄ®oÁŽ¨¨rž¦³­µš­¦oµŠ­µ¦­ºÉ°š´ÊŠ­°ŠÅ¤nš´œ ‹¹Š¤¸Ã°„µ­š¸É‹³šÎµ Ä®o„µ¦Äo¥µÅ¤nŗoŸ¨ ¦ª¤š´ÊŠ°µ‹šÎµÄ®oÁ„·—°µ„µ¦Ž¹¤Á«¦oµÂ¨³ rebound hyperphagia …¹ÊœÅ—o ×¥š´ÉªÅž ‹³Âœ³œÎµÄ®očo¥µœ¸Ê˜·—˜n°„´œÅ¤nÁ„·œ 3 Á—º°œ Á¡ºÉ°¨—°µ„µ¦…oµŠÁ‡¸¥Š—´Š„¨nµª „µ¦Äo¥µœ¸Ê‡ª¦Âœ³œÎµŸ¼ožiª¥Ä®o¦´ž¦³šµœ„n°œ°µ®µ¦Áoµ ®¦º° 1-2 ´ÉªÃ¤Š®¨´Š°µ®µ¦Áoµ ˜n Ťn‡ª¦Á„·œ 9.00 œ. ÁœºÉ°Š‹µ„¥µ°µ‹šÎµÄ®oŸ¼ožiª¥œ°œÅ¤n®¨´Å—o …œµ—¥µš¸ÉÁ¦·É¤Äo ‡ª¦Á¦·É¤‹µ„…œµ— ˜É뵂 Ánœ 7.5 ¤·¨¨·„¦´¤/ª´œ ¨oª‡n°¥Ç Á¡·É¤…œµ—¥µ…¹Êœ˜µ¤„µ¦šœ¥µ…°ŠŸ¼ožiª¥ …œµ—¥µ­¼Š­»—˜n°ª´œ Ťn‡ª¦Á„·œ 15-30 ¤·¨¨·„¦´¤ °µ„µ¦…oµŠÁ‡¸¥Šš¸É°µ‹Á„·—…¹Êœ¤´„Áž}œ°µ„µ¦…oµŠÁ‡¸¥Šš¸ÉÁ„·—‹µ„„µ¦Á¡·É¤…¹Êœ…°Š DA ¨³ NE —´Šœ¸Ê °µ„µ¦…oµŠÁ‡¸¥Š˜n°¦³ž¦³­µš­nªœ„¨µŠ Ánœ ®Š»—®Š·— Œ»œÁŒ¸¥ª œ°œÅ¤n®¨´ ĜŸ¼ožiª¥š¸ÉŪ˜n° ¥µ¤µ„Ç °µ‹¤¸°µ„µ¦®ªµ—¦³ÂªŠ ®¼Âªnª °µ„µ¦…oµŠÁ‡¸¥Š˜n°¦³®´ªÄ‹Â¨³®¨°—Á¨º°— Ánœ ċ­´Éœ ‡ªµ¤—´œÃ¨®·˜­¼Š °µ„µ¦…oµŠÁ‡¸¥Š˜n°šµŠÁ—·œ°µ®µ¦ Ánœ šo°ŠŸ¼„ (‡ª¦Âœ³œÎµÄ®oŸ¼ožiª¥¦´ž¦³šµœ °µ®µ¦š¸É¤¸„µ„¨³Ä®o¤¸ liquid intake š¸ÉÁ¡¸¥Š¡°) ¥µœ¸Ê¤¸…o°®oµ¤Äo ĜŸ¼ožiª¥š¸É¤¸ž¦³ª´˜·Áž}œÃ¦‡‹·˜ æ‡ Ž¹¤Á«¦oµ 懮´ªÄ‹Á˜oœŸ·—‹´Š®ª³ 懇ªµ¤—´œÃ¨®·˜­¼Šš¸É‡ª‡»¤Å—oŤn—¸ Sibutramine8-11 ¥µ sibutramine Áž}œ¥µš¸É°°„§š›·Íš¸Éž¦³­µš­nªœ„¨µŠÁnœÁ—¸¥ª„´ phentermine ˜n—oª¥ „¨Å„š¸É˜„˜nµŠ„´œ‡º° sibutramine °°„§š›·Í¥´¥´ÊŠ„µ¦Á„ȝ„¨´…°Š serotonin ¨³ norepinephrine š¸Éž¨µ¥ž¦³­µš Ťn¤¸§š›·ÍŨnš¸É­µ¦­ºÉ°Á®¨nµœ¸Ê¨³¥µœ¸Ê¤¸Ÿ¨Á¡·É¤¦³—´ dopamine Á¡¸¥ŠÁ¨È„œo°¥‹¹ŠÅ¤n¤¸ Ÿ¨šÎµÄ®oÁ„·—°µ„µ¦ž¦³­µš®¨°œÂ¨³®ªµ—¦³ÂªŠ šÎµÄ®oŤn™¼„‹´—Áž}œª´˜™»°°„§š›·Í˜n°‹·˜ž¦³­µš
  • 196. 190 ÁnœÁ—¸¥ª„´ phentermine ¥µ sibutramine …œµ—10-15 ¤„.˜n°ª´œ ­µ¤µ¦™¨—œÊ宜´„˜´ªÅ—oŸ¨—¸„ªnµ „µ¦Äo¥µ®¨°„ ®¨´Š®¥»—Ä®o„µ¦¦´„¬µ¡ªnµ œÊ宜´„„¨´Á¡·É¤…¹ÊœÅ—oÁnœÁ—¸¥ª„´¥µ¨—œÊ宜´„˜´ª°ºÉœ Ç °µ„µ¦…oµŠÁ‡¸¥Š…°Š sibutramine ŗo„n žª—«¸¦¬³ žµ„®oŠ œ°œÅ¤n®¨´ ¨³šo°ŠŸ¼„ œ°„‹µ„œ¸Ê ‡ªµ¤—´œÃ¨®·˜ ¨³°´˜¦µ„µ¦Á˜oœ…°Š®´ªÄ‹¡ªnµÁ¡·É¤…¹Êœ „µ¦«¹„¬µ¥µœ¸ÊĜŸ¼ožiª¥Ã¦‡°oªœš¸É¤¸Ã¦‡®´ªÄ‹ …µ—Á¨º°—®¦º°¤¸‡ªµ¤Á­¸É¥Š­¼ŠÄœ„µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— ¡ªnµ¤¸°´˜¦µ„µ¦Á­¸¥¸ª·˜¤µ„„ªnµ ¥µ®¨°„ —´Šœ´Êœž{‹‹»´œœ¸Ê¥µ sibutramine ‹¹Š™¼„¥„Á¨·„„µ¦‹Îµ®œnµ¥Â¨oª Orlistat12-15 ¥µ orlistat Áž}œ derivative …°Š lipstatin Ž¹ÉŠ­¦oµŠÃ—¥ Streptomyces toxytricini „¨Å„„µ¦ °°„§š›·Í×¥¥´Ê¥´ÊŠÁ°œÅŽ¤r lipase Ĝ¦³šµŠÁ—·œ°µ®µ¦ …œµ—¥µ 120 ¤„. ¦´ž¦³šµœ¡¦o°¤ °µ®µ¦ 3 Áª¨µ­µ¤µ¦™¥´¥´ÊŠ„µ¦—¼—Ž¹¤…°Š°µ®µ¦Å…¤´œÅ—o¤µ„™¹Š¦o°¥¨³ 30 orlistat ™¼„—¼—Ž¹¤Å—oœo°¥ ¤µ„Äœ¨ÎµÅ­oÁž}œŸ¨Ä®oŤn­µ¤µ¦™˜¦ª‹¡¦³—´¥µÄœ plasma ŗo „µ¦«¹„¬µŸ¨…°Š orlistat Áž¦¸¥Áš¸¥„´¥µ®¨°„Äœ„µ¦¦´„¬µŸ¼ožiª¥Ã¦‡°oªœš¸ÉŤn¤¸Ã¦‡Âš¦„ Žo°œÁž}œÁª¨µ 2 že ¡ªnµÅ—oŸ¨—¸„ªnµ¥µ®¨°„×¥š¸ÉœÊ宜´„˜´ª‹³¨—¨ŠÄœnªŠ 6 Á—º°œÂ¦„®¨´Š‹µ„œ´Êœ œÊ宜´„˜´ª‹³‡Šš¸É ®¦º°Á¡·É¤…¹ÊœÁ¨È„œo°¥Åž˜¨°— 2 žeš¸ÉšÎµ„µ¦«¹„¬µ °µ„µ¦…oµŠÁ‡¸¥Š…°Š orlistat š¸É¡Å—on°¥ ‡º° oily defecation, oily spotting, flatus with discharge µŠ¦µ¥°µ‹¡ fecal incontinence ¨³ increased defecation Ž¹ÉŠ°µ„µ¦—´Š„¨nµª¤¸ ‡ªµ¤­´¤¡´œ›r„´ž¦·¤µ–Å…¤´œÄœ°µ®µ¦š¸É¦´ž¦³šµœ „µ¦«¹„¬µ¦³—´…°Šª·˜µ¤·œš¸É¨³¨µ¥ÄœÅ…¤´œÄœ ¡¨µ­¤µ®¨´Š„µ¦¦´„¬µ—oª¥ orlistat ¡ªnµ ¦³—´ª·˜µ¤·œ—¸ °¸ ¨³Á˜µ‡µÃ¦š¸œ ¤¸‡nµ¨—¨Š°¥nµŠ¤¸ œ´¥­Îµ‡´šµŠ­™·˜·®¨´Š„µ¦¦´„¬µ —´Šœ´Êœ„µ¦Äo orlistat œµœÁ„·œ 1 že ‡ª¦‹³Å—o¦´„µ¦Á­¦·¤ª·˜µ¤·œ —´Š„¨nµª¦nª¤—oª¥ Ÿ¨„µ¦«¹„¬µšµŠ‡¨·œ·„Äœ„µ¦Äo¥µ¦³¥³¥µª 4 že ¡ªnµ orlistat ¨—œÊ宜´„Å—o ¤µ„„ªnµ„¨»n¤‡ª‡»¤ÁŒ¨¸É¥ž¦³¤µ– 2.8 „·Ã¨„¦´¤Â¨³¤¸Ÿ¨¨—„µ¦Á„·—æ‡Áµ®ªµœœ·—š¸É 2 ŗo¦o°¥¨³ 37 „µ¦ž¦³Á¤·œž¦³­·š›·£µ¡…°Š¥µ¨—œÊ宜´„ ×¥š´ÉªÅž¥µ¨—œÊ宜´„‡ª¦šÎµÄ®oœÊ宜´„¨—¨Š°¥nµŠœo°¥ 2 „·Ã¨„¦´¤ÄœÁ—º°œÂ¦„š¸ÉÁ¦·É¤Äo¥µ ¨³¨—¨Š¤µ„„ªnµ 5% …°ŠœÊ宜´„˜´ªÁ¦·É¤˜oœÁ¤ºÉ°Äo¥µÅžÂ¨oª 6 Á—º°œ œÊ宜´„š¸É¨—¨ŠÁ¡¸¥Š¦o°¥¨³ 5- 10 …°ŠœÊ宜´„˜´ªÁ¦·É¤˜oœ‹³­nŠŸ¨—¸˜n°­»…£µ¡Äœ£µ¡¦ª¤ Ánœ ¨—‡ªµ¤—´œÃ¨®·˜, Á¡·É¤ž¦³­·š›·£µ¡ „µ¦šÎµŠµœ…°Š insulin, ¨— LDL-C, triglycerides ¨³Á¡·É¤ HDL …o°¡¹Š¦³ª´ŠÄœ„µ¦Äo¥µ¨—œÊ宜´„ ×¥š´ÉªÅž¥µ¨—œÊ宜´„‹³šÎµÄ®oœÊ宜´„¨—¨ŠÅ—o…–³¦´ž¦³šµœ¥µÂ˜n‹³­¼Š„¨´…¹ÊœÁšnµÁ—·¤ Á¤ºÉ° ®¥»—¥µ œ°„‹µ„œ´Êœ ¥´Š°µ‹¤¸Ÿ¨…oµŠÁ‡¸¥Šš¸É¡n°¥Â¨³µŠ‡¦´ÊŠ¦»œÂ¦Š ‹¹Š‡ª¦®¨¸„Á¨¸É¥Š„µ¦Äo¥µÁ®¨nµœ¸Ê ™oµÅ¤n¤¸…o°nŠ¸Ê°¥nµŠ´—Á‹œ
  • 197. 191 „µ¦Ÿnµ˜´—¦´„¬µÃ¦‡°oªœ16-21 „µ¦Ÿnµ˜´—¦´„¬µÃ¦‡°oªœœ´Êœ °µ‹¡·‹µ¦–µœÎµ¤µÄoĜ£µª³ morbid obesity (BMI >40 „„./¤.2 ) ®¦º°¤¸ BMI >35 „„./¤.2 ¦nª¤„´Ã¦‡Âš¦„Žo°œ…°ŠÃ¦‡°oªœ Ž¹ÉŠÅ¤nŗoŸ¨‹µ„„µ¦¦´„¬µ—oª¥ª·›¸—´Š„¨nµª …oµŠ˜oœÂ¨oª œ°„‹µ„œ¸ÊŸ¼ožiª¥˜o°Š¤¸ž¦³ª´˜·°oªœ¤µœµœÃ—¥š¸É懰oªœÅ¤nŗoÁ„·—‹µ„懘n°¤Å¦ošn°šÎµŠµœ Ÿ·—ž„˜· ¨³Ÿ¼ožiª¥˜o°Š¤¸­»…£µ¡‹·˜š¸É—¸Â¨³­µ¤µ¦™Ä®o‡ªµ¤¦nª¤¤º°Äœ„µ¦¦´„¬µÅ—o ª·›¸„µ¦Ÿnµ˜´—š¸É¤¸Äo Ĝž{‹‹»´œ19 ‡º° 1. Roux-en-Y gastric-bypass 2. adjustable gastric banding 3. vertical sleeve gastrectomy 4. biliopancreatic diversion with duodenal switch Roux-en-Y gastric-bypass ¨³ adjustable gastric banding Áž}œ„µ¦Ÿnµ˜´—š¸Éœ·¥¤¤µ„š¸É­»— ¦¼žš¸É 1. ­—Š„µ¦Ÿnµ˜´— „. Roux-en-Y gastric by-pass ¨³ …. adjustable gastric banding19 „µ¦Ÿnµ˜´— Roux-en-Y gastric bypass ŗoŸ¨Äœ„µ¦¨—œÊ宜´„Å—o—¸„ªnµ gastric banding ¨³ ž{‹‹»´œ™º°Áž}œ¤µ˜¦µ“µœ…°Šª·›¸„µ¦Ÿnµ˜´—¨—œÊ宜´„ Ÿ¨…oµŠÁ‡¸¥ŠÄœ„µ¦Ÿnµ˜´— gastric by-pass ‡º° dumping syndrome ¤¸°µ„µ¦šo°ŠÁ—·œ °µÁ‹¸¥œÂ¨³…µ—°µ®µ¦ ª·˜µ¤·œ ›µ˜»Á®¨È„ ‡¨ÁŽ¸¥¤ ž{‹‹»´œ¤¸ „µ¦«¹„¬µ¦³¥³¥µª…°Š„µ¦Ÿnµ˜´— gastric bypass Á¡ºÉ°¦´„¬µÃ¦‡°oªœÄœŸ¼ožiª¥š¸É°oªœ¤µ„ (morbid obesity) ¡ªnµ­µ¤µ¦™¨—°´˜¦µ˜µ¥Å—o°¥nµŠ¤¸œ´¥­Îµ‡´šµŠ­™·˜·20,21 „ …
  • 198. 192 „µ¦Ÿnµ˜´—ª·›¸°ºÉœ‡º° biliopancreatic diversion with duodenal switch ŗoŸ¨Äœ„µ¦¨—œÊ宜´„—¸ ¤µ„ ­µ¤µ¦™¨—œÊ宜´„š¸ÉÁ„·œÅ—o™¹Š¦o°¥¨³ 80 ˜n„µ¦Ÿnµ˜´—ª·›¸œ¸Ê¤¸Ã¦‡Âš¦„Žo°œ¤µ„ Ánœ …µ—°µ®µ¦ ‹µ„ malabsorption 懘´ (acute fatty liver) ‹¹Š°µ‹¡·‹µ¦–µÄo¦´„¬µÁŒ¡µ³Ÿ¼ožiª¥š¸É°oªœ¤µ„Ç ¤¸ BMI >60 „„./¤.2 Ášnµœ´Êœ „µ¦Ÿnµ˜´——¼—Å…¤´œ (liposuction ®¦º° fat aspiration) Ťn™º°ªnµÁž}œª·›¸„µ¦¦´„¬µÃ¦‡°oªœÂ˜nÁž}œ Á¡¸¥Šª·›¸Ÿnµ˜´—Á¡ºÉ°ž¦´¦¼ž¦nµŠ (body contouring) ÁœºÉ°Š‹µ„Ťn¤¸Ÿ¨¨—£µª³Âš¦„Žo°œ…°ŠÃ¦‡°oªœ22 Á°„­µ¦°oµŠ°·Š 1. The Royal College of Physicians of London. Clinical management of overweight and obese patients. Wiltshire: Sarum Printed Limited, 1998. 2. WHO Expert Consultation. Appropriate body mass index for Asian populations and its implicatons for policy and intervention stratetegies. Lancet 2004; 363: 157-63. 3. Zhaoping L, Maglione M, Tu W, et al. Meta-analysis: Pharmacologic treatment of obesity. Ann Intern Med 2005; 142: 532-46. 4. Moyers SB. Medications as adjunct therapy for weight loss: approved and off-label agents in use. J Am Diet Assoc 2005; 105: 948-59. 5. Weigle D. Pharmacological therapy of obesity: past, present and future. J Clin Endocrinol Metab 2003; 88: 2642-9. 6. Padwal R, Li SK Lau DCW. Long-term pharmacotherapy for overweight and obesity: a systematic review and meta-analysis of randomized controlled trial. Int J Obesity 2003; 27: 1437-46. 7. Pawal R, Majumdar S. Drug treatments for obesity: orlistat, sibutramine, and rimonabant. Lancet 2007; 369: 71-7. 8. McNeely W and Goa K. Sibutramine: a review of its contribution to the management of obesity. Drugs 1998; 56: 1093-124. 9. Arterburn DE, Crane PK, Veenstra DL. The efficacy and safety of sibutramine for weight loss: a systemic review. Arch Int Med 2004; 164: 994-1003. 10. Waddden T, Berkowitz RI, Womble LG, Sarwer DB, Phelan S, Kato RK, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Eng J Med 2005; 353: 2111-20. 11. James WPT, Caterson ID, Coutinho W, et al. Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects. N Engl J Med 2010; 363; 905-17 12. Davidson MH, Hauptman J, DiGirolamo M, et al. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat. JAMA 1999; 281: 235-42.
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  • 200. 194 °£´­œ¸ »µª¦„»¨ „µ¦¨—œÊ宜´„nª¥¨—‡ªµ¤Á­¸É¥ŠÄœ„µ¦Á„·—懘nµŠÇ ®¨µ¥ž¦³Áš«¤¸‡ÎµÂœ³œÎµÂ¨³„¦³˜»oœÄ®o ž¦³µ„¦¨—œÊ宜´„ ץœ³œÎµÄ®o¨—œÊ宜´„¨Š¦o°¥¨³ 10 …°ŠœÊ宜´„Á¦·É¤˜oœ1 „µ¦¨—œÊ宜´„Ťnªnµ‹³ ×¥ª·›¸‡»¤°µ®µ¦ °°„„ε¨´Š„µ¥ ž¦´¡§˜·„¦¦¤ ®¦º°¦´ž¦³šµœ¥µ ¡ªnµœÊ宜´„‹³¨—¨ŠÄœnªŠ 6 Á—º°œÂ¦„ ®¨´Š‹µ„œ´ÊœœÊ宜´„‹³Á¦·É¤‡Šš¸É ĜnªŠš¸ÉœÊ宜´„‡Šš¸É‹´—Áž}œnªŠ„µ¦¦´„¬µ®¦º°‡ŠœÊ宜´„˜´ªÅªo (maintenance phase) „µ¦«¹„¬µ­nªœÄ®n‹³ÁœoœÁ¦ºÉ°Š„µ¦¨—œÊ宜´„ ¤¸„µ¦«¹„¬µœo°¥Á„¸É¥ª„´„µ¦‡Š œÊ宜´„˜´ª (weight maintenance) ®¨´Š‹µ„š¸É¨—œÊ宜´„¨Š œ°„‹µ„œ¸ÊÁž}œš¸Éš¦µ—¸ªnµ„µ¦¨—œÊ宜´„Šnµ¥ „ªnµ„µ¦¦´„¬µœÊ宜´„˜´ªÄ®o‡Šš¸É®¨´Š‹µ„š¸ÉœÊ宜´„¨—¨ŠÂ¨oª —´Šœ´ÊœÄœž{‹‹»´œ˜o°Š„µ¦Šµœª·‹´¥š¸É‹³®µª·›¸ ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨oªÄ®o‡Šš¸É ‡Îµ‹Îµ„´—‡ªµ¤…°Š„µ¦‡ŠœÊ宜´„˜´ªÅ¤nÄ®oÁ¡·É¤®¨´Š„µ¦¨—œÊ宜´„ (Weight maintenance) Ĝže ‡.«.1993 Atkinson ŗoÄ®o‡Îµ‹Îµ„´—‡ªµ¤Á„¸É¥ª„´‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦¦´„¬µÃ¦‡°oªœ ×¥Áœoœ „µ¦—¸…¹Êœ…°Š£µª³Âš¦„Žo°œš¸ÉÁ„·—‹µ„懰oªœ ¨³‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦¦´„¬µÃ¦‡°oªœ‡º°„µ¦¨—œÊ宜´„ ¨Š¦o°¥¨³ 5-10 ‹µ„Á¦·É¤˜oœ1-5 ­Îµ®¦´‡Îµ‹Îµ„´—‡ªµ¤…°Š weight maintenance š´ÉªÃ¨„¥´ŠÅ¤n¤¸„µ¦˜„¨Š´—Á‹œ ˜nµŠ‹µ„Á¦ºÉ°Š …°Š„µ¦¨—œÊ宜´„ Ĝ„µ¦«¹„¬µ˜nµŠÇ ‹³¤¸‹Îµ„´—‡ªµ¤š¸É˜nµŠ„´œ—´ŠÂ­—ŠÄœ˜µ¦µŠš¸É 1 ‡Îµ‹Îµ„´—‡ªµ¤ …°Š weight maintenance ˜µ¤ the Institute of Medicine ¦³»ªnµ weight loss maintenance ®¤µ¥™¹Š„µ¦¨—œÊ宜´„°¥nµŠœo°¥¦o°¥¨³ 5 …°ŠœÊ宜´„Á¦·É¤˜oœ ®¦º° ¨——´œ¸¤ª¨„µ¥°¥nµŠœo°¥ 1 ¥¼œ·˜ ¨³‡ŠœÊ宜´„œ´Êœ°¥nµŠœo°¥ 1 že6 Šµœª·‹´¥š¸É˜°‡Îµ™µ¤Á„¸É¥ª„´ weight maintenance ¨³¤¸„µ¦ œÎµ¤µ°oµŠ°·Š¤µ„ ŗo„n the National Weight Control Registry (NWCR) Ĝže ‡.«. 1994 Ä®o…o°¤¼¨ Á„¸É¥ª„´ successful weight loss maintenance Ĝž¦³Áš«­®¦´“°Á¤¦·„µ ×¥šÎµÄ®oš¦µ™¹ŠÁ¦ºÉ°Š weight maintenance ´—Á‹œ…¹Êœ ‡Îµ‹Îµ„´—‡ªµ¤…°Š weight maintenance ˜µ¤ NWCR ®¤µ¥™¹Š „µ¦ ¤¸œÊ宜´„˜´ª¨—¨Š¦o°¥¨³ 10 …°ŠœÊ宜´„Á¦·É¤˜oœ ¨³‡ŠœÊ宜´„Å—o°¥nµŠœo°¥ 1 že7 Ĝž¦³Áš«Åš¥Å¤n¤¸ …o°¤¼¨…°ŠÁ¦ºÉ°Š„µ¦¦´„¬µœÊ宜´„˜´ªÄ®o‡Šš¸É®¨´Š‹µ„¨—œÊ宜´„ °´˜¦µ‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦‡ŠœÊ宜´„˜´ªÅ¤nÄ®oÁ¡·É¤®¨´Š„µ¦¨—œÊ宜´„ °´˜¦µ…°ŠŸ¼oš¸É­µ¤µ¦™¦´„¬µœÊ宜´„˜´ªÅªoŗo®¨´Š‹µ„¨—œÊ宜´„ ¡ªnµÂ˜„˜nµŠ„´œÄœÂ˜n¨³ „µ¦«¹„¬µ …o°¤¼¨‹µ„ NWCR Ž¹ÉŠÁž}œ„µ¦«¹„¬µ…œµ—Ä®nÁ„¸É¥ª„´„µ¦¨—œÊ宜´„¨³„µ¦‡ŠœÊ宜´„˜´ª š¸É¨—¨ŠÅ¤nÄ®oÁ¡·É¤…¹Êœ ¡ªnµ¤¸Á¡¸¥Š¦o°¥¨³ 21 š¸É¤¸œÊ宜´„˜´ª¨—¨Š¦o°¥¨³ 10 …°ŠœÊ宜´„Á¦·É¤˜oœ ¨³‡Š œÊ宜´„Å—o°¥nµŠœo°¥ 1 že Á„–”r…°ŠŸ¼oš¸ÉÁ…oµ¦nª¤Äœ„µ¦«¹„¬µ‡º° Ÿ¼oš¸É­µ¤µ¦™¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š º··Õè 14
  • 201. 195 ˜µ¦µŠš¸É 1. ‡Îµ‹Îµ„´—‡ªµ¤…°Š Weight maintenance š¸ÉčoĜ„µ¦«¹„¬µÁ„¸É¥ª„´„µ¦¦´„¬µœÊ宜´„˜´ª ®¨´Š‹µ„¨—œÊ宜´„ Ÿ¼oœ·¡œ›rºÉ° ¦„ (že) „µ¦«¹„¬µ Study cohort ‡Îµœ·¥µ¤…°Š Weight loss (¦³¥³Áª¨µ) ‡Îµœ·¥µ¤…°Š weight maintenance (¦³¥³Áª¨µ) ‹»—š¸ÉčoĜ„µ¦ °oµŠ°·ŠœÊ宜´„ š¸É¨—¨Š Justification for definition Crawford (2000)8 Community- based study „µ¦Áž¨¸É¥œÂž¨Š …°Š BMI >5% (1 že) ¦´„¬µœÊ宜´„˜´ªÄ®¤n®¦º°¨— œÊ宜´„¨Š„ªnµÁ—·¤Å—o°¥nµŠ œo°¥ 2 že ®¨´Š„µ¦¨— œÊ宜´„ Not stated Field (2001)9 Nurses health study II ¨—Ťn¤µ„: 5.0-9.9% (3 že) ¨—¤µ„: >10.0% ‡Îµœ·¥µ¤ 2  (1) œÊ宜´„Á¡·É¤ <5 ž°œ—r ‹µ„œÊ宜´„Ä®¤n (4 že) (2) œÊ宜´„Á¡·É¤ <5% ®¨´Š„µ¦¨— œÊ宜´„ Not stated Lowe (2001)10 Participants in a commercial weight loss program (weight watchers) ¨—¨Š°¥nµŠœo°¥ 5 ž°œ—r ¨³Å—o¦´ „µ¦­œ´­œ»œÄ®o BMI °¥¼nĜnªŠ 20- 25 „„./¤2 ‡Îµœ·¥µ¤ 3  (1) ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š >5% (2) ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š >10% (3) œÊ宜´„¥´Š‡Š°¥¼nĜ 5 ž°œ—r…°ŠœÊ宜´„Ážjµ®¤µ¥ œÊ宜´„Á¦·É¤˜oœ œÊ宜´„š¸É®¨´Š „µ¦¨—œÊ宜´„ Not stated McQuire (1999)11 Random digit dialing survey ¨—¨Š >10% of …°ŠœÊ宜´„š¸É¤µ„ ­»— ‡Îµœ·¥µ¤ 2  œÊ宜´„¨—¨Š¤µ„„ªn¦o°¥¨³10 …°ŠœÊ宜´„­¼Š­»— (2) ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š ¤µ„„ªnµ¦o°¥¨³ 10 ¦³¥³Áª¨µ ¤µ„„ªnµ 1 že œÊ宜´„Á¦·É¤˜oœ Not stated McGuire (1999)12 National weight loss registry °¥nµŠœo°¥ 10% …°ŠœÊ宜´„˜´ª (30 ž°œ—r) ¦³¥³Â¦„¦´„¬µœÊ宜´„˜´ªš¸É ¨—¨Š >10% ¦³¥³Áª¨µ >1 že œÊ宜´„š¸É¨—¨Š ¨³š¸É 1 že…°Š „µ¦‡ŠœÊ宜´„ ˜´ª Also used 5% and 10% similar results Moore (2000)13 Framingham study >1 ž°œ—r/že (8 že) + 1 ž°œ—r/že (8 že) œÊ宜´„š¸É¨—¨Š Not stated Mogul (2003)14 Retrospective analysis of syndrome W patients œÊ宜´„¨—>10% ®¦º° BMI ž„˜· œÊ宜´„Á¡·É¤…¹Êœ < 3 „·Ã¨„¦´¤ (2že) œÊ宜´„š¸É¨—¨Š NHLBI guidelines (1998)2 Sarlio- Lahteenkor va (2000)15 Finnish twin cohort œÊ宜´„¨— > 5% ¦³®ªnµŠže 1975 - 1984 ‡ŠœÊ宜´„Å—o˜É優nµœÊ宜´„ Á—·¤°¥nµŠœo°¥ 5%Ĝže 1990 œÊ宜´„Á¦·É¤˜oœ WHO (1998)17 Wadden (1999)16 25 obese women who lost wt & maintained for 1 year œÊ宜´„¨— 5-10% ®¦º°œÊ宜´„¨— > 10% ‡Îµœ·¥µ¤ 2  (1) ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š 5-10%(100 ­´ž—µ®r) (2) ¦´„¬µœÊ宜´„˜´ªš¸É¨—¨Š> 10% reduction (100 ­´ž—µ®r) œÊ宜´„Á¦·É¤˜oœ IOM guidelines (1995)6 Wing (2001)17 National weight control registry œÊ宜´„¨— > 10% (30 ž°œ—r) ¦´„¬µœÊ宜´„˜´ª > 10% …°ŠœÊ宜´„š¸É¨—¨Š > 1 že œÊ宜´„Á¦·É¤˜oœ IOM guidelines 6 and NHLBI guidelines1
  • 202. 196 °¥nµŠœo°¥ 30 ž°œ—r (13.6 „·Ã¨„¦´¤) ĜÁª¨µ°¥nµŠœo°¥ 1 že ¨³Ÿ¼ožiª¥˜o°Š¥·œ¥°¤Á…oµ¦nª¤Šµœª·‹´¥ ¤¸ „µ¦­nŠÂ­°™µ¤ÅžÄ®o®¨µ¥‡¦´ÊŠ ×¥Á„ȝ…o°¤¼¨Á„¸É¥ª„´œÊ宜´„˜´ªš¸É¨—¨Š ¡§˜·„¦¦¤Äœ„µ¦¦´„¬µ œÊ宜´„˜´ªÄ®o‡Šš¸É ž¦³ª´˜·Á¦ºÉ°ŠœÊ宜´„ ‡»–£µ¡¸ª·˜ ¨³…o°¤¼¨¡ºÊœ“µœ ¤¸„µ¦Á„ȝ…o°¤¼¨š»„ 1 že Ÿ¼oÁ…oµ¦nª¤¤µ„„ªnµ 3,000 ¦µ¥ °µ¥»ÁŒ¨¸É¥ 45 že ¦o°¥¨³ 80 Áž}œÁ¡«®·Š ¦o°¥¨³ 97 Áž}œ‡œŸ·ª…µª ¦o°¥ ¨³ 67 ˜nŠŠµœ œÊ宜´„ÁŒ¨¸É¥š¸É¨—¨Š 30 „·Ã¨„¦´¤ ¦³¥³Áª¨µš¸ÉœÊ宜´„˜´ª‡Šš¸ÉÁŒ¨¸É¥ 5.5 že Ÿ¼o¦nª¤ª·‹´¥ ­nªœ¤µ„ ¤¸—´œ¸¤ª¨„µ¥¨—¨Š 10 „„./¤2 Á¤ºÉ°Áš¸¥„´˜°œÁ¦·É¤˜oœ (‹µ„ 35 „„./¤2 Á®¨º° 25 „„./¤2 ) ¦o°¥¨³ 46 °oªœ˜´ÊŠÂ˜nÁ—È„ ¦o°¥¨³ 46 ¤¸·—µ®¦º°¤µ¦—µ°oªœ ¦o°¥¨³ 27 ¤¸·—µÂ¨³¤µ¦—µ°oªœ Ÿ¼oÁ…oµ¦nª¤ ǦŠ„µ¦¦o°¥¨³ 90 Á‡¥¡¥µ¥µ¤¨—œÊ宜´„˜nŤnž¦³­¡‡ªµ¤­ÎµÁ¦È‹ Ĝ„µ¦«¹„¬µ‡¦´ÊŠœ¸Ê ¦o°¥¨³ 89 ¤¸ „µ¦ž¦´Áž¨¸É¥œ°µ®µ¦Â¨³„µ¦°°„„ε¨´Š„µ¥Á¡ºÉ°Ä®oœÊ宜´„¨—¨Š˜µ¤Ážjµ®¤µ¥ ×¥‹Îµ„´—¡¨´ŠŠµœÂ¨³ œ·—…°Š°µ®µ¦ …o°¤¼¨‹µ„ systematic review …°Š 12 „µ¦«¹„¬µ18 Á„¸É¥ª„´‡ªµ¤­´¤¡´œ›r¦³®ªnµŠœÊ宜´„š¸É ¨—¨ŠÄœnªŠš¸É¤¸„µ¦‡»¤°µ®µ¦ °°„„ε¨´Š„µ¥ ¨³œÊ宜´„š¸É‡Šš¸É®¨´Š‹µ„¦³¥³¨—œÊ宜´„Áž}œÁª¨µ 1 že ×¥„µ¦«¹„¬µš¸ÉœÎµ¤µÄœ„µ¦šÎµ systematic review ¤¸Á„–”rĜ„µ¦œÎµÁ…oµ—´Šœ¸Ê Ÿ¼oš¸É¦nª¤„µ¦«¹„¬µ¤¸—´œ¸ ¤ª¨„µ¥ ŤnÁ„·œ 40 „„./¤2 ­nªœÄ®nÁž}œ‡œŸ·ª…µª „µ¦¨—œÊ宜´„˜o°Š¤¸°¥nµŠœo°¥®œ¹ÉŠ„¨»n¤š¸Éŗo¦´ „µ¦‡»¤°µ®µ¦Â¨³°°„„ε¨´Š„µ¥ ¦³¥³Áª¨µ˜´ÊŠÂ˜n 1 Á—º°œ…¹ÊœÅž ¤¸œÊ宜´„¨—¨Š°¥nµŠœo°¥¦o°¥¨³ 2 ¨³˜·—˜µ¤„µ¦«¹„¬µÄoÁª¨µœµœ°¥nµŠœo°¥ 1 že ¤¸Ÿ¼oÁ…oµ¦nª¤˜´ÊŠÂ˜n 20 ¦µ¥˜n°„µ¦Ä®o intervention œ·— ˜nµŠÇ Á„–”r˜´—°°„ ŗo„n „µ¦«¹„¬µš¸É¤¸ÁŒ¡µ³Ÿ¼ožiª¥Áµ®ªµœ Ÿ¼ožiª¥š¸É¤¸„µ¦ÄoœÊ嘵¨„¡¦n°Š ¤¸Ã¦‡ ¦oµ¥Â¦Š ŗo¥µ¨—œÊ宜´„ ®¦º°Ÿnµ˜´— ¡ªnµ¦o°¥¨³ 55 …°ŠŸ¼oš¸É¨—œÊ宜´„Å—o¦o°¥¨³ 5-10 (13 ¦µ¥) ­µ¤µ¦™¦´„¬µœÊ宜´„˜´ªÄ®o‡Šš¸É ¨³¦o°¥¨³ 49 …°ŠŸ¼oš¸É¨—œÊ宜´„Å—o¤µ„„ªnµ¦o°¥¨³ 10 (8 ¦µ¥) ­µ¤µ¦™¦´„¬µœÊ宜´„˜´ªÄ®o‡Šš¸É Ťn¡‡ªµ¤­´¤¡´œ›r¦³®ªnµŠœÊ宜´„š¸É¨—¨ŠÅ—o˜µ¤Ážjµ®¤µ¥ÄœnªŠš¸É šÎµ„µ¦ž¦´Áž¨¸É¥œ¡§˜·„¦¦¤ „´œÊ宜´„š¸É¦´„¬µÄ®o‡Šš¸ÉĜnªŠ˜·—˜µ¤„µ¦¦´„¬µ —´Šœ´Êœ„µ¦®µª·›¸„µ¦ ¦´„¬µš¸É—¸Äœ„µ¦žj°Š„´œœÊ宜´„Á¡·É¤‹¹ŠÁž}œ­·ÉŠ­Îµ‡´ „µ¦Áž¨¸É¥œÂž¨ŠšµŠÁ¤Âš°¨·‡ÄœŸ¼oš¸É¨—œÊ宜´„ ‡ªµ¤¥µ„…°Š„µ¦‡ŠœÊ宜´„˜´ª®¨´Š‹µ„š¸É¨—œÊ宜´„¨Š ­nªœ®œ¹ÉŠ°›·µ¥‹µ„Á¤ºÉ°œÊ宜´„¨—¨Š ‹³¤¸„µ¦¨—¨Š…°Š resting metabolic rate (RMR) ¨³‡ªµ¤­µ¤µ¦™Äœ„µ¦ oxidize fat ¨—¨Š šÎµÄ®o¤¸ „µ¦­³­¤Å…¤´œÁ¡·É¤…¹Êœ ¤¸„µ¦Á¡·É¤…¹Êœ…°Š insulin sensitivity ¨³„µ¦¨—¨Š…°Š¦³—´ leptin7 ¦ª¤š´ÊŠ „µ¦Á¡·É¤…¹Êœ…°Š ghrelin19 „µ¦Áž¨¸É¥œÂž¨Š…°Šš´ÊŠ leptin ¨³ ghrelin „¦³˜»oœšÎµÄ®o°¥µ„°µ®µ¦ ¡§˜·„¦¦¤š¸ÉšÎµÄ®ož¦³­¡‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦‡ŠœÊ宜´„˜´ª®¨´Š„µ¦¨—œÊ宜´„ ‹µ„„µ¦«¹„¬µ NWCR ¡ªnµ¡§˜·„¦¦¤š¸ÉšÎµœµ¥‡ªµ¤­ÎµÁ¦È‹…°Š„µ¦¦´„¬µœÊ宜´„˜´ª ŗo„n „µ¦¦´ž¦³šµœ°µ®µ¦Å…¤´œ˜Éε „µ¦Ä®o‡ªµ¤­œÄ‹˜·—˜µ¤—oª¥˜œÁ°ŠÁ¦ºÉ°Š„µ¦´ÉŠœÊ宜´„˜´ª Á¦ºÉ°Š°µ®µ¦ ¨³„µ¦°°„„ε¨´Š„µ¥7
  • 203. 197 ŸœÄœ„µ¦‡ŠœÊ宜´„˜´ª®¨´Š„µ¦¨—œÊ宜´„ Šµœª·‹´¥Äœž¦³Áš«Â‡œµ—µ …o°¤¼¨ÄœŸ¼o®·Š 200 ¦µ¥ °µ¥» 25-70 že ¨³­µ¤µ¦™¨—œÊ宜´„¨Š ŗo¦o°¥¨³ 5 ™¼„nŠÁž}œ 2 „¨»n¤ ŗo intensive program (¤¸Ÿ¼oÁ¸É¥ªµ—oµœ°µ®µ¦ ¨³°°„„ε¨´Š„µ¥) „´Å—o¦´‡ÎµÂœ³œÎµ‹µ„¡¥µµ¨ Ĝ˜n¨³„¨»n¤Å—o¡¨´ŠŠµœÅ¤n˜nµŠ„´œ nŠ­´—­nªœ°µ®µ¦Áž}œ 2 œ·— ‡µ¦rÝűÁ—¦˜­¼Š ¨³œ·—Å…¤´œ­¼Š Ĝ„¨»n¤š¸Éŗo°µ®µ¦‡µ¦rÝűÁ—¦˜­¼Š (¡¨´ŠŠµœ‹µ„‡µ¦rÝűÁ—¦˜ ¦o°¥¨³ 55 œ³œÎµÄ®o°µ®µ¦š¸É¤¸—´œ¸œÊ嘵¨˜Éε Þ¦˜¸œ¦o°¥¨³ 15-20 Ņ¤´œ¦o°¥¨³ 25-30) Ĝ„¨»n¤ °µ®µ¦Å…¤´œ­¼Š (Þ¦˜¸œ¦o°¥¨³ 25 Ņ¤´œ¦o°¥¨³ 35 ×¥¦o°¥¨³ 21 ¤µ‹µ„ monounsaturated fat, MUFA ¨³ ‡µ¦rÝűÁ—¦˜¦o°¥¨³ 40) š´ÊŠ 2 „¨»n¤Å—oÄ¥°µ®µ¦ 30 „¦´¤˜n°ª´œ Ņ¤´œ°·É¤˜´ª¦o°¥¨³ 8 Ņ¤´œÅ¤n°·É¤˜´ª®¨µ¥˜ÎµÂ®œnŠ¦o°¥¨³ 6 ˜·—˜µ¤œµœ 2 že ¡ªnµœÊ宜´„…°ŠŸ¼ožiª¥š»„„¨»n¤Å¤n˜„˜nµŠ „´œ20 ‹µ„Ÿ¨„µ¦«¹„¬µÂ­—ŠÄ®oÁ®Èœªnµ¡¨´ŠŠµœš¸Éŗo¦´¤¸‡ªµ¤­Îµ‡´Äœ„µ¦¨—œÊ宜´„ ¤µ„„ªnµ­´—­nªœ …°Š°µ®µ¦ …o°¤¼¨…°Š NWCR ¡ªnµ‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦¨—œÊ宜´„ ž¦³„°—oª¥ „·œ°µ®µ¦Å…¤´œ˜Éε ´ÉŠ œÊ宜´„˜´ªÁž}œž¦³‹Îµ ¨³°°„„ε¨´Š„µ¥­¤ÉεÁ­¤° „µ¦Áž¦¸¥Áš¸¥„¨»n¤š¸É¦´„¬µœÊ宜´„˜´ªÅ—o‡Šš¸É„´ „¨»n¤š¸É¤¸„µ¦Á¡·É¤…°ŠœÊ宜´„˜´ª ¡ªnµ„¨»n¤š¸É¦´„¬µœÊ宜´„˜´ªÅ—o‡Šš¸É‹³®¨¸„Á¨¸É¥Š°µ®µ¦š°— ¨³Á¨º°„ °µ®µ¦Å…¤´œ˜Éεšœ°µ®µ¦Å…¤´œ­¼Š Ĝ„µ¦«¹„¬µ°ºÉœÇ ¡ªnµ „µ¦¨—¡¨´ŠŠµœ ¨—­nªœ…°Š°µ®µ¦ ¨— „µ¦„·œ…°ŠªnµŠ ¨—°µ®µ¦Å…¤´œ ¨—…°Š®ªµœ ÁœºÊ°­´˜ªr ­´¤¡´œ›r„´„µ¦¦´„¬µœÊ宜´„˜´ª ¡ªnµŸ¼oš¸É„·œ ¸­ Áœ¥ °µ®µ¦ªnµŠÅ…¤´œ­¼Š °µ®µ¦š°— …œ¤®ªµœœo°¥„ªnµ­´ž—µ®r¨³‡¦´ÊŠ ‹³ž¦³­¡‡ªµ¤­ÎµÁ¦È‹Äœ „µ¦‡ŠœÊ宜´„˜´ª¤µ„„ªnµ7 „µ¦«¹„¬µ…°Š Vogel ¨³‡–³¡ªnµ ž{‹‹´¥š¸ÉšÎµœµ¥‡ªµ¤­ÎµÁ¦È‹Äœ„µ¦‡ŠœÊ宜´„˜´ªÅ—o„n „µ¦„·œ°µ®µ¦Å¤n¤µ„ „µ¦¤¸ baseline resting metabolic rate ­¼Š ¨³¤¸¤ª¨Å…¤´œ˜°œÁ¦·É¤˜oœ­¼Š‹³ nª¥Ä®o fat-free mass Ťn®µ¥Åž¤µ„21 …o°¤¼¨‹µ„ the National Health and Nutrition Examination Survey (NHANES) ¡ªnµŸ¼oš¸É ­µ¤µ¦™¨—œÊ宜´„˜´ªÅ—o¦o°¥¨³ 10 ¨³‡ŠœÊ宜´„˜´ªÅ—o¤¸¦o°¥¨³ 17.3 ¨³ ¡¤µ„ÄœŸ¼o­¼Š°µ¥» 75-84 že (Áš¸¥„´°µ¥» 20-34 že odd ratio 1.5, 95%CI 1.2-1.8) Á¡«®·Š (Áš¸¥„´Á¡«µ¥ odd ratio 1.2, 95%CI 1.1-1.3) ÁºÊ°µ˜· non-Hispanic (Áš¸¥„´ Hispanic odd ratio 1.6, 95%CI 1.3-2) Ÿ¼oš¸ÉÁ¦¸¥œ ¦³—´˜É優nµ¤´›¥¤«¹„¬µ (Áš¸¥„´¦³—´­¼Š„ªnµ¤´›¥¤«¹„¬µ odd ratio 1.3, 95%CI 1.1-1.5) ĜŸ¼oš¸ÉŤn ˜nŠŠµœÁ¤ºÉ°Áš¸¥„´‡¼n˜nŠŠµœ ‡œ®¤oµ¥ ®¦º°‡œš¸ÉÂ¥„„´œ°¥¼n ĜŸ¼oš¸É¤¸—´œ¸¤ª¨„µ¥ (BMI) œo°¥„ªnµ 25 „„./¤2 ®¦º° 25-30 „„./¤2 Áš¸¥„´ BMI ˜´ÊŠÂ˜n 40 „„./¤2 (odd ratio 9.4, 2.0 ˜µ¤¨Îµ—´) ‹Îµœªœžeš¸ÉœÊ宜´„Á¡·É¤‹œ™¹Š œÊ宜´„¤µ„­»—™oµ¤µ„„ªnµ 10 žeÁš¸¥„´ 2 že œ°„‹µ„œ¸ÊŸ¼ožiª¥Áµ®ªµœ ­µ¤µ¦™¦´„¬µœÊ宜´„˜´ªÅ—o¤µ„„ªnµŸ¼oš¸ÉŤnÁž}œÁµ®ªµœ (¦o°¥¨³ 25 Áš¸¥„´¦o°¥¨³ 16.5) Ÿ¼oš¸É‡·—ªnµ¤¸ ž{®µ­»…£µ¡‹³¨—œÊ宜´„Å—o—¸„ªnµŸ¼oš¸É‡·—ªnµÅ¤n¤¸ž{®µ­»…£µ¡22
  • 204. 198 ®¨´„„µ¦…°Š„µ¦¦´„¬µœÊ宜´„˜´ª®¨´Š„µ¦¨—œÊ宜´„ …o°¤¼¨‹µ„„µ¦«¹„¬µ˜nµŠÇ ¡°­¦»žÅ—oªnµŸ¼oš¸É­µ¤µ¦™‡ŠœÊ宜´„˜´ªÅ—o ®¨´Š‹µ„„µ¦¨—œÊ宜´„ ˜o°Š¤¸‡ªµ¤­œÄ‹Äœ„µ¦—¼Â¨Á¦ºÉ°Š °µ®µ¦ ×¥Áœoœ°µ®µ¦š¸ÉÄ®o¡¨´ŠŠµœœo°¥ °°„„ε¨´Š„µ¥­¤ÉεÁ­¤° ¨³­œÄ‹„µ¦Áž¨¸É¥œÂž¨Š…°ŠœÊ宜´„˜´ª ×¥´ÉŠœÊ宜´„˜´ª­¤ÉεÁ­¤°7 ¤¸…o°Âœ³œÎµÁ¡ºÉ°ž’·´˜·—´Šœ¸Ê 1. °µ®µ¦ …o°¤¼¨¤µ‹µ„ Food frequency questionnaire ×¥Ÿ¼oÁ…oµ¦nª¤ª·‹´¥­nªœ¤µ„„·œÅ—o¦´ °µ®µ¦ —´Šœ¸Ê x ¡¨´ŠŠµœÁŒ¨¸É¥ 1,381 „·Ã¨Â‡¨°¦¸˜n°ª´œ x ­nªœž¦³„° ¦´ž¦³šµœ°µ®µ¦Å…¤´œ˜Éε ¦o°¥¨³ 24 …°Š¡¨´ŠŠµœ¤µ‹µ„Å…¤´œ ¦o°¥¨³ 19 ¤µ‹µ„Þ¦˜¸œ ¨³¦o°¥¨³ 56 ¤µ‹µ„‡µ¦rÝűÁ—¦˜ x ®¨¸„Á¨¸É¥Š°µ®µ¦š°— ¨—°µ®µ¦ªnµŠ …°Š…Á‡¸Ê¥ª ¨—…°Š®ªµœ x „·œ°µ®µ¦Áoµš»„ª´œ x „·œ°µ®µ¦Ä„¨oÁ‡¸¥Š„´œš´ÊŠª´œ›¦¦¤—µÂ¨³ª´œ®¥»— x ŗo­µ¦°µ®µ¦š¸É¤¸Â‡¨ÁŽ¸¥¤ ª·˜µ¤·œŽ¸ Á° °¸ ‡¦˜µ¤‡ªµ¤˜o°Š„µ¦ 2. ´ÉŠœÊ宜´„˜´ªÁž}œž¦³‹Îµ ×¥´ÉŠš»„ª´œ®¦º°°¥nµŠœo°¥­´ž—µ®r¨³‡¦´ÊŠ 3. °°„„ε¨´Š„µ¥­¤ÉεÁ­¤° ×¥Áž}œ„µ¦°°„„ε¨´Š„µ¥®œ´„žµœ„¨µŠ (moderate intensity) °¥nµŠœo°¥ 60 œµš¸˜n°ª´œ Ánœ„µ¦Á—·œÁ¦Èª ®¦º° vigorous intensity 36 œµš¸˜n°ª´œ ץœ³œÎµÄ®o¤¸ moderate intensity physical activity 200-300 œµš¸˜n°­´ž—µ®r Á¡ºÉ°žj°Š„´œœÊ宜´„˜´ªÁ¡·É¤…¹Êœ ž{‹‹´¥š¸É­´¤¡´œ›r„´œÊ宜´„˜´ªš¸ÉÁ¡·É¤…¹Êœ 1. ¦³¥³Áª¨µš¸ÉœÊ宜´„˜´ª¨—¨Š (œo°¥„ªnµ 2 že Áš¸¥¤µ„„ªnµ 2 že) 2. œÊ宜´„¨—¨Š¤µ„ (>30% …°ŠœÊ宜´„˜´ª¤µ„­»— Áš¸¥„´ <30%) 3. ¤¸£µª³Ž¹¤Á«¦oµ¤µ„ 4. Ťn°°„„ε¨´Š„µ¥ °»ž­¦¦‡…°Š„µ¦¨—œÊ宜´„¨³„µ¦¦´„¬µœÊ宜´„˜´ª 1. Ážjµ®¤µ¥…°ŠœÊ宜´„ Ĝ‡œ°oªœš¸É‡µ—®ª´ŠœÊ宜´„¨—¨Š°¥nµŠ¤µ„ dream weight ‹³Áž}œ ž{®µÄœ„µ¦¨—œÊ宜´„ ÁœºÉ°Š‹µ„Ťn­µ¤µ¦™šÎµÅ—o ‹³Á„·—‡ªµ¤šo°Âšo 2. …µ—„µ¦­œ´­œ»œ‹µ„‡¦°‡¦´ª Á¡ºÉ°œ¦nª¤Šµœ°¥nµŠ‹¦·Š‹´Š 3. ž{®µ„µ¦…µ—»‡¨µ„¦ š¸É‹³Ä®o…o°¤¼¨…°Š„µ¦‡ª‡»¤œÊ宜´„˜´ªÂ„nŸ¼ožiª¥ ¨³Ä®oŸ¼ožiª¥ ˜¦³®œ´„™¹Š…o°—¸…°Š„µ¦¦´„¬µœÊ宜´„˜´ªÄ®o‡Šš¸É 4. œÃ¥µ¥…°Š„¦³š¦ªŠ­µ›µ¦–­»…¨³ž¦³Áš«Å¤nŗo„ε®œ—‡ªµ¤­Îµ‡´
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  • 207. 201 ª¦¦–¸ œ·›·¥µœ´œšr žµ‹¦¸¥r °´—»¨¨µ„µŽ·¤ ‹µ„­™µœ„µ¦–r…°Š£µª³°oªœÂ¨³°oªœ¨Š¡»Š…°Šž¦³Áš«Åš¥š¸Éž¦µ„’ ­—ŠÄ®oÁ®Èœªnµž¦³Áš« Ś¥„ε¨´ŠÁŸ·„´ž{®µ°oªœÂ¨³°oªœ¨Š¡»ŠŽ¹ÉŠÁ¡·É¤¤µ„…¹ÊœÁž}œ¨Îµ—´ ‹Îµœªœž¦³µ„¦°oªœÂ¨³°oªœ¨Š ¡»Š¤¸ÂœªÃœo¤‹³­¼Š…¹ÊœÅ¤n®¥»—¥´ÊŠ ®µ„ž¨n°¥ž¨³¨³Á¨¥ …µ—‡ªµ¤˜¦³®œ´„™¹Šž{®µ …µ—¤µ˜¦„µ¦ ‡ª‡»¤Â¨³„µ¦Á jµ¦³ª´Šš¸É—¸ ¤¸„µ¦Áž¨¸É¥œÂž¨Š¡§˜·„¦¦¤„µ¦¦·Ã£‡Â¨³­·ÉŠÂª—¨o°¤˜nµŠÇ Ĝž{‹‹»´œš¸É ˜nµŠÅž‹µ„Äœ°—¸˜ Ánœ ‡ªµ¤Áž}œ­´Š‡¤Á¤º°Š „µ¦Á¨¸¥œÂª´•œ›¦¦¤˜³ª´œ˜„ °·š›·¡¨‹µ„„µ¦ ɬ–µ „µ¦‡oµ¦³®ªnµŠž¦³Áš« —´Šœ´Êœ „µ¦Â„oŅž{®µ „µ¦‡ª‡»¤ ¨³žj°Š„´œ„µ¦Á„·—£µª³°oªœÂ¨³ °oªœ¨Š¡»Š‹³˜o°Š¡·‹µ¦–µ°¥nµŠ¦°—oµœ (¦¼žš¸É 1) ¦¼žš¸É 1. ‡ªµ¤­´¤¡´œ›r¨³š¸É¤µ…°Šž¦³Á—Èœ˜nµŠÇ ­¼nœªšµŠ„µ¦„ε®œ—œÃ¥µ¥¦³—´ž¦³Áš« Ĝ„µ¦‡ª‡»¤Â¨³žj°Š„´œ£µª³°oªœÂ¨³°oªœ¨Š¡»Š „µ¦‹´—¨Îµ—´‡ªµ¤­Îµ‡´…°Šž{®µÄœÁ·ŠœÃ¥µ¥ ‹ÎµÁž}œ˜o°Š¡·‹µ¦–µ¦nª¤„´…œµ—…°Š ž{®µš´ÊŠÄœ¤·˜·…°Š°´˜¦µ„µ¦žiª¥Â¨³°´˜¦µ„µ¦˜µ¥ ®¨´„„µ¦š¸É­Îµ‡´ž¦³„°—oª¥ Obesity and NCD ѝѧѷкѰњчјҖѠєѯёѪѷѠ дѥіѠѠддѼѥјѤкдѥѕ ѯзіѪѠеҕѥѕзњѥєіҕњєєѪѠ ёїшѧдіієдѥіэіѧѱѓз дѥізњэзѫєюіѧєѥц ѰјѣзѫцѓѥёѠѥўѥі мјѥдѰјѣеҖѠєѬј ѱѓньѥдѥі ѝщѥьъѨѷѠѠддѼѥјѤкдѥѕ дѥіѯјѨѸѕкчѬѯчѶд њѧщѨнѨњѧшзьѯєѪѠк дѥіѯеҖѥщѩкѠѥўѥі дѥідѧьѯюҝьњѧщѨнѨњѧш ѰікдіѣшѫҖьэіѧѱѓз ѓѥќѨ дѥіѱйќцѥ яѬҖѯдѨѷѕњеҖѠк іѣчѤэєѥшідѥіѝѪѷѠѰјѣнҕѠкъѥк ѝѪѷѠѝѥі дѥіэѤкзѤэѲнҖ ьѱѕэѥѕеьѝҕкѝѥыѥіцѣ ёѪѸьъѨѷѝѥыѥіцѣ ѯъзѱьѱјѕѨ чѬѱъіъѤћьҙѯјҕьѯдєѝҙ юіѣѯѓъѠѥўѥі іѥзѥѠѥўѥі дѥішјѥч дѥіѠѫчўьѫь дѥізҖѥѯѝіѨ ѠѥўѥіѝчѰјѣ ьѱѕэѥѕѯдќші ѰјѣѠѥўѥі юіѣѯчѶьдѥіеѤэѯзјѪѷѠь єѫєєѠкъѨѷѰшдшҕѥк дсўєѥѕ ѝѤкзє ёіэ.Ѡѥўѥі º··Õè 15
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