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อ้วนและอ้วนลงพุง

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อ้วนและอ้วนลงพุง …

อ้วนและอ้วนลงพุง
พญ. วรรณี นิธิยานันท์

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

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

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

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

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

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

    DR.G. M. SINGH GENERAL MEDICAL SERVICE 3/5 WEST PATEL NAGAR NEW DELHI - 110008 INDIA 01142488406;9891635088;9990596297
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  • 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£µª³œÊε®œ´„Á„·œÂ¨³Ã¦‡°oªœ” Äœš¸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£µª³œÊε®œ´„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„oÅ…—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°¥¼nÄœªŠ‹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¸ÉÅ—oÁ¦¸¥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¥ Äœ¡¦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 Äœš»„¦³—´ ª¦¦–¸ œ·›·¥µœ´œšr ¦¦–µ›·„µ¦
  • 2. ‹»¦¸¡¦ ‡Šž¦³Á­¦·“ ¡.., ª.ª.(„»¤µ¦Áª«µ­˜¦r), °.ª.(Áª«µ­˜¦ržj°Š„´œ Â…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‡»¤œÊε®œ´„˜´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¦‡ŠœÊε®œ´„˜´ªš¸É¨—¨ŠÅ¤nÄ®oÁ¡·É¤…¹Êœ®¨´Š„µ¦¨—œÊε®œ´„ 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. °¥¼nÄœšnµ¥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„ȝŪoÄœÁŽ¨¨rÅ…¤´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¨¨rÅ…¤´œÅ¤n¤¸…¸—‹Îµ„´—´—Á‹œ ÁŽ¨¨rÅ…¤´œ‹³…¥µ¥…œµ—Ä®n …¹Êœ˜µ¤ž¦·¤µ–ئ„¨¸ÁŽ°Å¦—rš¸ÉÁ¡·É¤…¹Êœ Äœ…–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 Äœ…–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¦—rÄœÁŽ¨¨rÅ…¤´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¨¨rÅ…¤´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¨¨rÅ…¤´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¨¨rÅ…¤´œ¤¸ 2 „¨»n¤Ä®n‡º° ÁŽ¨¨rÅ…¤´œÄœ´ÊœÄ˜oŸ·ª®œ´ŠÂ¨³ÁŽ¨¨rÅ…¤´œš¸É°¥¼n­´¤¡´œ›r„´°ª´¥ª³ ˜nµŠÇ Ánœ ®´ªÄ‹ Ř ¨ÎµÅ­o ®¨°—Á¨º°— ×¥š´ÉªÅž„µ¦Á„ȝ­Îµ¦°Š¡¨´ŠŠµœÄœÁŽ¨¨rÅ…¤´œ‹³„¦³‹µ¥Åžš´Éª ¦nµŠ„µ¥ Á¤ºÉ°°oªœ¤µ„‹¹Š¤¸¦°Á°ªÄ®n…¹Êœ˜µ¤œÊε®œ´„š¸ÉÁ¡·É¤…¹Êœ (°oªœÂ¨³¨Š¡»Š) µŠ£µª³Â¨³ž{‹‹´¥ µŠ°¥nµŠ­nŠÁ­¦·¤Ä®o¤¸„µ¦­³­¤Å…¤´œÁ—nœ®¦º°¤µ„š¸ÉÁŽ¨¨rÅ…¤´œš¸É°¥¼n­´¤¡´œ›r„´°ª´¥ª³Äœn°Ššo°Š Á¤ºÉ° Áš¸¥„´„µ¦­³­¤š¸ÉÁŽ¨¨rÅ…¤´œÄœ´ÊœÄ˜oŸ·ª®œ´Š šÎµÄ®o¤¸¦°Á°ªÄ®n…¹Êœ®¦º°Ä®n¤µ„Ťn­´¤¡´œ›r„´ œÊε®œ´„š¸ÉÁ¡·É¤…¹Êœ (°oªœ¨Š¡»Š) ÁŽ¨¨rÅ…¤´œ¤¸ 2 œ·—‡º° ÁŽ¨¨rÅ…¤´œ…µª (white adipose tissue) ¨³ ÁŽ¨¨rÅ…¤´œ­¸œÊε˜µ¨ (brown adipose tissue) š´ÊŠ­°Š¤¸‡ªµ¤Â˜„˜nµŠ…°Š‡»–­¤´˜·ÄœÂŠn„µ¦ÁŸµŸ¨µ ¡¨´ŠŠµœ (thermogenic capacity)16-18 ÁºÉ°ªnµÁŽ¨¨rÅ…¤´œ­¸œÊε˜µ¨Á¡·É¤„µ¦ÁŸµŸ¨µ¡¨´ŠŠµœ ¤¸­nªœšÎµ Ä®o„µ¦­³­¤Å…¤´œ¨—¨Š ž{‹‹´¥­nŠÁ­¦·¤Ä®o„µ¦­³­¤Å…¤´œÁ—nœš¸ÉÁŽ¨¨rÅ…¤´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 ÄœŸ¼oµ¥Á¤ºÉ°œÊε®œ´„…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¤rÄœ„¦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°¨„°±°¨rÄœž¦·¤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 œÊε®œ´„¨³¦°Á°ª26.27 „µ¦—ºÉ¤Á‡¦ºÉ°Š—ºÉ¤š¸ÉŸ­¤œÊε˜µ¨ (soft drink) ¨³œÊεŸ¨Å¤ož¦³‹Îµ ª´œ¨³ 2 „oª šÎµÄ®oœÊε®œ´„…¹ÊœÂ¨³°oªœÅ—o ×¥ÁŒ¡µ³°¥nµŠ¥·ÉŠœÊε˜µ¨¢¦»p„Ø­‹µ„…oµªÃ¡— (high fructose corn syrup) Ž¹ÉŠœ·¥¤ÄoÄœ°»˜­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 Äœ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 „´œÊε®œ´„˜´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 œÊε®œ´„ ­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˜œÊε®œ´„˜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®oœÊε®œ´„¨³¦°Á°ªÁ¡·É¤…¹Êœ‹œÁ„·—£µª³ °oªœÂ¨³°oªœ¨Š¡»Š
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  • 15. 9 ª·´¥ Á°„¡¨µ„¦ °Š‡r„µ¦°œµ¤´¥Ã¨„ Å—o­—Š…o°¤¼¨‡ªµ¤»„…°Š£µª³œÊε®œ´„Á„·œÂ¨³°oªœÄœ 90 ž¦³Áš« (Global Data on Body Mass Index) ¡ªnµ‡ªµ¤»„…°Š£µª³œÊε®œ´„Á„·œ (body mass index, BMI •25 „„./¤.2 ) Äœž¦³Áš«˜nµŠÇ ¤¸˜´ÊŠÂ˜n˜É優nµ¦o°¥¨³ 5 Äœž¦³Áš«Áª¸¥—œµ¤Â¨³°·œÁ—¸¥ ‹œ„¦³š´ÉŠ­¼Š „ªnµ¦o°¥¨³ 50 Äœž¦³Áš«­®¦´“°Á¤¦·„µ Seychelles œ·ªŽ¸Â¨œ—r ¨³°°­Á˜¦Á¨¸¥ ­Îµ®¦´‡ªµ¤»„…°Š £µª³œÊε®œ´„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« ÄœnªŠÁª¨µ—´Š„¨nµª1,2 ˜µ¦µŠš¸É 1. ‡ªµ¤»„£µª³œÊε®œ´„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 Åš¥ 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 ˜nÂœªÃœo¤‡ªµ¤»„…°ŠÃ¦‡°oªœ¤¸Á¡·É¤…¹Êœ˜µ¤¨Îµ—´ ¨³‡ªµ¤»„Ťnœo°¥Åž„ªnµ º··Õè 2
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  • 21. 15 ­»…£µ¡¦³—´ž{‹Á‹„ (individual approach) Å—o„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›»„¦¦¤ Äœ¦³¥³ 2-3 š«ª¦¦¬š¸ÉŸnµœ¤µ Å—o¤¸„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‡»¤œÊε®œ´„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 ÄœšµŠ˜¦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 Äœ hypothalamus š¸É¤¸šµšÄœ„µ¦‡ª‡»¤œÊε®œ´„¤¸®¨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¦ Å—o„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‡»¤œÊε®œ´„ Å—o„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 Åž¤¸ 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 Äœ˜´ 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´ÊœœÊε®œ´„˜´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¨¨rÅ…¤´œ ™¼„­nŠŸnµœ blood brain barrier Åž¥´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 ÅžšÎµŠµœŸnµœšµŠ 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‡»¤œÊε®œ´„˜´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¤nÅ—oÁ¡·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 ¤¸œÊε˜µ¨¤µ„…¹ÊœÂ˜nÄ¥°µ®µ¦¨—¨Š ¤¸ž¦·¤µ– Å…¤´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¤¸œÊε®œ´„…¹ÊœÅ—o¤µ„ ×¥ÁŒ¡µ³Äœ‡œ°oªœ ¤¸„µ¦„·œ °µ®µ¦¤µ„…¹ÊœšÎµÄ®oÅ—o¦´¡¨´ŠŠµœ­¼Š…¹Êœ ˜n¦o°¥¨³…°ŠÅ…¤´œš¸É¦·Ã£‡Áš¸¥„´¡¨´ŠŠµœš¸É¦·Ã£‡„¨´ ¨—¨Š8 —´Šœ´ÊœÅ…¤´œÄœ¦nµŠ„µ¥Å¤nÅ—o™¼„‡ª‡»¤Ã—¥°µ®µ¦Å…¤´œ9 šÎµÄ®o°›·µ¥Å—oªnµ°µ®µ¦Å…¤´œ˜Éε ®¦º°Å¦oÅ…¤´œÂ˜n¤¸¡¨´ŠŠµœÁšnµ„´°µ®µ¦Å…¤´œÁ˜È¤­nªœÅ¤nnª¥Äœ„µ¦¨—œÊε®œ´„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 Åž‹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°¥¼nÄœÁ…˜ 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®oÅ—o¡¨´ŠŠµœ¦ª¤ ¨—¨Š ×¥š¸É°µ®µ¦š¸É¤¸¡¨´ŠŠµœ­¼Š °µ‹¤¸Å…¤´œ œÊε˜µ¨ ®¦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¤¸œÊε˜µ¨¢¦»p„Ø­­¼Š (high-fructose corn syrup: HFCS) Äœž¦·¤µ–š¸É¤µ„…¹Êœ¤µ„„ªnµ 1000% Äœ¦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¦ ¨³œÊε®œ´„˜´ª „µ¦„·œ°µ®µ¦š¸É¤¸¢¦»p„Ø­­¼Š °µ‹šÎµÄ®oÅ—o¦´¡¨´ŠŠµœ¦ª¤Á¡·É¤…¹Êœ šÎµÄ®o¤¸œÊε®œ´„˜´ª Á¡·É¤…¹ÊœÅ—o ‡œš¸É„·œÁ‡¦ºÉ°Š—ºÉ¤š¸É¤¸‡ªµ¤®ªµœ¤µ„ °µ‹šÎµÄ®oÅ—o¡¨´ŠŠµœ¦ª¤Á„·œÅž¤µ„—oª¥Ánœ„´œ ¡¨´ŠŠµœ­nªœÁ„·œ‹³™¼„­³­¤Áž}œÅ…¤´œ (triaceylglycerols) ­³­¤ÅªoÄœÁœºÊ°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®oœÊε®œ´„˜´ªÁ¡·É¤…¹Êœ 0.45 „·Ã¨„¦´¤/že ™oµÁ„·—˜n°ÁœºÉ°ŠÁž}œÁª¨µ 10 že „Ȥ¸ ‡ªµ¤­Îµ‡´šµŠ‡¨·œ·„Å—o œÊε®œ´„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¨¨rÅ…¤´œ (adipocyte) ¥´ŠšÎµ®œoµš¸ÉÄœ¨´„¬–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¨¨rÅ…¤´œ Áž}œ­´—­nªœš¸É­´¤¡´œ›r„´ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥ ¥·ÉŠ¤¸ÁŽ¨¨rÅ…¤´œ¤µ„‹³­¦oµŠ leptin Å—o¤µ„17 懰oªœ ‹¹Š­´¤¡´œ›r„´„µ¦¤¸¦³—´…°Š leptin Äœ„¦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 Å—o19 Äœ®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 ŤnÅ—o¤¸ 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¤¸œÊε®œ´„Ä„¨oÁ‡¸¥Š„´œ¤µ„„ªnµ  —Áš¸¥¤š¸É°µ¥» 20 že ¨³¡ªnµ¨¼„»›¦¦¤¤¸œÊε®œ´„š¸É­´¤¡´œ›r„´œÊε®œ´„…°Š¡n°Â¤nš¸Éšo‹¦·Š ץŤn ¤¸‡ªµ¤­´¤¡´œ›r„´œÊε®œ´„…°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…°ŠœÊε®œ´„¨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°œÊε®œ´„˜´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„ŤnÅ—oÁ„·—…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¥ Ä„¨oÁ‡¸¥Š„´œ šÎµÄ®o‡·—ªnµÃ¦‡°oªœš¸É¦³µ—°¥¼nÄœž{‹‹»´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´¥ Å—o„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¤¸œÊε®œ´„¦„‡¨°—˜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) Äœ 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 Å—o 1 ‡³Âœœ …–³š¸É 1 minor criteria Å—o 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¨—œÊε®œ´„š¸É¨—‡ªµ¤°¥µ„°µ®µ¦°µ‹Å¤nÅ—oŸ¨ „µ¦Ä®o growth hormone ÄœÁ—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 ÄœÁ—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 Äœ 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´¥ Å—o„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¤¸œÊε®œ´„¦„‡¨°—˜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) Äœ 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 Å—o 1 ‡³Âœœ …–³š¸É 1 minor criteria Å—o 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¨—œÊε®œ´„š¸É¨—‡ªµ¤°¥µ„°µ®µ¦°µ‹Å¤nÅ—oŸ¨ „µ¦Ä®o growth hormone ÄœÁ—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 ÄœÁ—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 Äœ 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 Âœ³œÎµÄ®o˜´—°°„˜´ÊŠÂ˜n…ªže ¦„ ÁšoµŸ·—¦¼ž¦nµŠÄ®oÄ­n¦°ŠÁšoµš¸ÉÁ®¤µ³­¤ ˜¦ª‹˜µÁ¡ºÉ°®µ‡ªµ¤Ÿ·—ž„˜·Â¨³Â„oÅ… 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) Äœ‡¦°‡¦´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 Äœ 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 Å—on°¥ ª·œ·‹Œ´¥ congenital leptin deficiency Å—o ×¥„µ¦˜¦ª‹Å¤n¡ leptin Äœ Á¨º°— ¦nª¤„´¡ ob gene ¨³ª·œ·‹Œ´¥ leptin receptor deficiency Å—o×¥¡¤¸°µ„µ¦Â­—ŠÁ®¤º°œ congenital leptin deficiency ˜n¤¸¦³—´ leptin Äœ„¦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®oœÊε®œ´„˜´ªÂ¨³ž¦·¤µ–Å…¤´œÄœ¦nµŠ„µ¥¨—¨Š ץčo…œµ—¥µÁ¦·É¤˜oœ 0.01 ¤„./„„.…°ŠœÊε®œ´„ „¨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¨³œÊε®œ´„˜´ª°¥nµŠ¤µ„ Äœ 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¨³œÊε®œ´„¨³ ÁºÊ°µ˜·Á—¸¥ª„´œ Äœ„¨»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¸ÉÅž¦„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 Å—o Ž¹ÉŠ‹³˜°­œ°ŠÅ—o—¸˜o°Š„µ¦Ä®o glucocorticoid replacement ˜nÄœš¸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®oœÊε®œ´„˜´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 Äœ POMC ¦ª¤š´ÊŠ mutation Äœ D ¨³ E-MSH 8. POMC mutations affecting specific melanocortin peptides 8.1 missense mutations š¸ÉÅž¤¸Ÿ¨˜n° POMC gene š¸ÉÅž encode melanocortin peptide Á„·—Áž}œ E-MSH / E-endorphin fusion protein Åž‹´„´ melanocortin 4 receptor (MC4R) ˜nÅž activate receptor Å—oŤn—¸ °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®oÅž 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 Äœ®œ¼š—¨°ŠÅ—ož¦³Ã¥œr ¨³°µ‹œÎµ¤µÄož¦³Ã¥œrÄœ‡œš¸É…µ— E-MSH Å—o 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 Äœ„¦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—oÄœ 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¤ÅªoÄœ 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 Äœ MC4R Äœ¤œ»¬¥ršÎµÄ®oÁ„·—懰oªœ„¦¦¤¡´œ›»r ×¥¤¸°»´˜·„µ¦–r…°Š„µ¦Á„·— MC4R mutation 0.5% ÄœŸ¼oÄ®n°oªœ ‹œ™¹Š 6% ÄœÁ—È„š¸É°oªœ¦»œÂ¦Š Äœ°´Š„§¬Â¨³¥»Ã¦ž¡ªnµ 1-2.5% …°Š‡œš¸É¤¸—´œ¸¤ª¨„µ¥ >30 „„./¤2 ‹³¤¸ mutation Äœ 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®ªnµŠœÊε®œ´„˜´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 Äœž¦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 Å…¤´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 Å…¤´œš¸É­³­¤ÄœÁŽ¨¨rÅ…¤´œ °¥¼nÄœ¦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 Äœ­£µª³ž„˜·ÁŽ¨¨rÅ…¤´œšÎµ®œoµš¸ÉÁž}œÂ®¨nŠ­³­¤¡¨´ŠŠµœ ¨³Ÿ¨·˜±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­r (cytokines) Á¡ºÉ°‡ª‡»¤­¤—»¨…°Š¡¨´ŠŠµœ ¦³—´œÊε˜µ¨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¨¨rÅ…¤´œ ¨³„µ¦Á¡·É¤…¹Êœ…°ŠŽ´¥Ã˜Å‡œ­r (cytokines) ®¨µ¥œ·—š¸É­¦oµŠ‹µ„ÁŽ¨¨r Å…¤´œŽ¹ÉŠ¤¸Ÿ¨Â˜„˜nµŠ„´œ (˜µ¦µŠš¸É 2) Å—o„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¨¨rÅ…¤´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 Äœ 5 ‡ªµ¤Ÿ·—ž„˜·š¸É¡ - °oªœ¨Š¡»Š - ¦³—´œÊε˜µ¨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 œÊε˜µ¨ ¨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„oÅ…Å—o x °µ¥» x Á¡« x ¡´œ›»„¦¦¤
  • 38. 32 ˜µ¦µŠš¸É 2. ±°¦räœÂ¨³Ž´¥Ã˜Å‡œ­r­nªœ®œ¹ÉŠš¸ÉŸ¨·˜‹µ„ÁŽ¨¨rÅ…¤´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¨¨rÅ…¤´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¨¨rÅ…¤´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 ÄœÁ¨º°—¤¸‡ªµ¤­´¤¡´œ›rŸ„Ÿ´œ„´ž¦·¤µ–Å…¤´œš¸É­³­¤Äœn°Ššo°Š ÁŽ¨¨rÅ…¤´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—´œÊε˜µ¨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 ÄœÁ¨º°—­¼Š •150 ¤„./—¨. 4. ¦³—´ HDL-C ÄœÁ¨º°—˜Éε <40 ¤„./—¨.ÄœŸ¼oµ¥ ®¦º° <50 ¤„./—¨.ÄœŸ¼o®·Š 5. ¦³—´œÊε˜µ¨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—´œÊε˜µ¨ ÄœÁ¨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—´œÊε˜µ¨ÄœÁ¨º°—Ÿ·—ž„˜· Ÿ¼oš¸É¤¸Å…¤´œ­³­¤Äœ¦nµŠ„µ¥ž¦·¤µ–¤µ„ ‹³¡Å…¤´œ­³­¤ÄœÁŽ¨¨rœ·—°ºÉœš¸ÉŤnčnÁŽ¨¨rÅ…¤´œ ‡º° „¨oµ¤ÁœºÊ°¨µ¥ ˜´ ¨³°ª´¥ª³°ºÉœ Á¦¸¥„ªnµÅ…¤´œ­³­¤Ÿ·—š¸É (ectopic fat) Å…¤´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) Äœ„¦³Â­Á¨º°—­¼Š Áž}œ˜oœ„εÁœ·—…°Š £µª³—ºÊ°°·œŽ¼¨·œ „¦—Å…¤´œ°·­¦³Å—o‹µ„„µ¦­¨µ¥ triacylglycerol š¸É­³­¤ÄœÁŽ¨¨rÅ…¤´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 Äœ…–³š¸É„¦³ªœ„µ¦°È°„Ž·Á—´Éœ (oxidaton) ÄœÁŽ¨¨r„¡¦n°Š Ťn­µ¤µ¦™Á˜·¤„¦—Å…¤´œ°·­¦³Ä®o diacylglycerol Áž¨¸É¥œÁž}œ triacylglycerol Å—o 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—´œÊε˜µ¨ÄœÁ¨º°—­¼Š…¹Êœ °µ‹ „¨nµªÅ—oªnµÁ„·—£µª³Å…¤´œÁž}œ¡·¬ (lipotoxicity)12 Äœ¦³¥³˜oœ ¸˜oµÁŽ¨¨r…°Š˜´°n°œ‹³Ÿ¨·˜°·œŽ¼¨·œ Á¡·É¤…¹ÊœÁ¡ºÉ°Â„oÅ…£µª³—ºÊ°°·œŽ¼¨·œ ž¦³„°„´ÁŽ¨¨rÅ…¤´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¨¨rÅ…¤´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¦—rÄœÁ¨º°—­¼ŠÂ¨³¦³—´Á°—¸Â°¨‡°Á¨­Á˜°¦°¨˜Éε Äœ£µª³ž„˜·„µ¦­¨µ¥Å…¤´œÁž}œ„¦—Å…¤´œ°·­¦³°µ«´¥Á°ÈœÅŽ¤rŨÁž­ÄœÁŽ¨¨rÅ…¤´œ (adipocyte lipase) ×¥„¦³ªœ„µ¦ hydrolysis13 °·œŽ¼¨·œšÎµ®œoµš¸É¥´¥´ÊŠÁŽ¨¨rÅ…¤´œÅ¤nÄ®o­¨µ¥Å…¤´œÁž}œ„¦— Å…¤´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¦—rÄœ 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 Äœ„¦³Â­Á¨º°— Á°ÈœÅŽ¤rŨÁž­ (lipoprotein lipase) ‹µ„ÁŽ¨¨rŸœ´Š®¨°—Á¨º°——Š °¥ (Á°Èœ ×›¸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 Äœ°–¼ Á°—¸Â°¨ (HDL, high density lipoprotein) „´ ئ„¨¸ÁŽ° Ŧ—rÄœ°–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˜°¦°¨ ÄœÁ¨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¦—rÄœÁ¨º°—­¼Š ¨³Á°—¸Â°¨ ‡°Á¨­Á˜°¦°¨ ÄœÁ¨º°—˜Éε ×¥š¸É¦³—´ °¨—¸Â°¨ ‡°Á¨­Á˜°¦°¨ °µ‹ž„˜·®¦º°­¼Š ‹¹Š™º°Áž}œ£µª³ Å…¤´œÄœÁ¨º°—Ÿ·—ž„˜·š¸ÉÁ­¸É¥Š˜n°„µ¦Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— „µ¦Á„·—‡ªµ¤—´œÃ¨®·˜Ÿ·—ž„˜· Äœ‡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) ÄœÁŽ¨¨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¥¤¨—˜Éε¨Š16 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¨¨rÅ…¤´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¨¨rÅ…¤´œ­¦oµŠ…¹Êœ°¥¼n¨oª ‹¹Š¤¸„µ¦„¦³˜»oœ„¦³ªœ„µ¦°´„Á­ (inflammation) ÄœÁœºÊ°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—´œÊε˜µ¨ÄœÁ¨º°—­¼Š®¦º°Áµ®ªµœ ¨³‡ªµ¤—´œ è®·˜­¼Š šÎµÄ®oÁ„·—®¨°—Á¨º°——Š˜¸Â…Ȋ¨³°»—˜´œ Äœš¸É­»—Á„·—懮´ªÄ‹Â¨³®¨°—Á¨º°— Å—o„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¡ Å—o„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¦‡ Äœ¦³¥³˜oœ‡º° ˜´°´„Á­ (non-alcoholic steatohepatitis, NASH) ˜n°¤µÁ„·—¡´ŠŸº— (fibrosis) Äœ˜´¤µ„…¹Êœ „¨µ¥Áž}œÃ¦‡˜´Â…ÈŠ (cirrhosis) Ž¹ÉŠ Äœš¸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 Å…¤´œ—o°¥­¤¦¦™£µ¡ Å…¤´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¨¨rÅ…¤´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¸ÊÅ—oÁ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¨¨rÅ…¤´œ ¨³Ž´¥Ã˜Å‡œ­rš¸É ÁŽ¨¨rÅ…¤´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 Å…¤´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¨¨rÅ…¤´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°¥¼nÄœÁœºÊ°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°¤œÊεœ¤ (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 Äœ…–³š¸É°³—·ÃžÁœÈ‡˜·œŽ¹ÉŠ­nŠŸ¨˜¦Š …oµ¤„¨´¨—¨Š Ž´¥Ã˜Å‡œ­rš¸É­¦oµŠ‹µ„ÁŽ¨¨rÅ…¤´œšÎµÄ®oÁ„·—„¦³ªœ„µ¦°´„Á­ œ°„‹µ„œ¸Ê ¡ªnµÁ¨Èž ˜·œ¤¸‡»–­¤´˜·„¦³˜»oœÁŽ¨¨r˜n°¤œÊεœ¤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—oÄœÁŽ¨¨rÅ…¤´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¨¨rÅ…¤´œ¦´„¦—Å…¤´œ°·­¦³—¸…¹Êœ ¨³¤¸ adipocyte differentiation ˜n„µ¦Áž¨¸É¥œÂž¨Š…°ŠŽ´¥ ØŇœ­r¤¸‡ªµ¤Âž¦ž¦ªœ Ánœ plasminogen activator inhibitor-1 °µ‹¨—¨Š®¦º°Á¡·É¤…¹Êœ ¡ PPAR- J ÄœÁŽ¨¨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 Å—o 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 Å—o„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 Äœ‡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¸ÉœÎµœÊε˜µ¨¢¦»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¨¨rÅ…¤´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 ÄœŸ¼o®·Š¡ž{®µÅ—o®¨µ¥°¥nµŠ37,38 Å—o„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 ÄœÁ—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®oœÊε®œ´„ 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– Å…¤´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 Äœ°ª´¥ª³š¸ÉÁ„¸É¥ª…o°Š ¨³ž{‹‹´¥šµŠ¡´œ›»„¦¦¤ Äœ¦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 Å—o„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£µª³œÊε®œ´„Á„·œÂ¨³°oªœ…°Š„¨»n¤ž¦³Áš«š¸É¤¸¦µ¥Å—ožµœ„¨µŠÂ¨³ ˜Éε (middle– and low–income countries) Äœ£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„ £µª³œÊε®œ´„Á„·œÂ¨³Ã¦‡°oªœ °¥¼nÄœ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„£µª³œÊε®œ´„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) Äœž¦³Áš«š¸É¡´•œµÂ¨oª¡ªnµÁ„·—‹µ„ »®¦¸É °¨„°±°¨r ‡ªµ¤—´œÃ¨®·˜­¼Š Å…¤´œ‡°Á¨­Á˜°¦°¨ÄœÁ¨º°—­¼Š ¨³£µª³œÊε®œ´„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 Å—o„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¨³œÊε®œ´„Á„·œ ‡ªµ¤—´œÃ¨®·˜­¼Š Å…¤´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) Äœže ¡.«. 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¤¸œÊε®œ´„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¨³œÊε®œ´„
  • 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« Å—o„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¨³œÊε®œ´„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 Äœže ‡.«. 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¥ Äœ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°¥¼nÄœ­™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 Å—o„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 œÊε®œ´„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) Å—ož¦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 Äœ¦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£µª³œÊε®œ´„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¦rÄœže ‡.«. 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) Å—o„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 Äœže ‡.«. 2005 ‡nµÄo‹nµ¥Ã—¥˜¦Š…°ŠŸ¼oš¸ÉœÊε®œ´„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 Äœ 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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  • 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¤¸ œÊε®œ´„š¸É°¥¼nÄœÁ„–”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{®µœÊε®œ´„Á„·œ®¦º° °oªœ­µ¤µ¦™¨—œÊε®œ´„×¥¤¸ BMI ÄœÁ„–”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°¨—œÊε®œ´„‹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¨—œÊε®œ´„¤¸¤¼¨‡nµ œo°¥„ªnµ„¨»n¤š¸ÉœÊε®œ´„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¨³œÊε®œ´„Á„·œ‹³Áž}œ„µ¦¨Šš»œš¸ÉÄ®oŸ¨Äœ„µ¦ ¨—‡nµÄo‹nµ¥˜nµŠÇ Äœ¦³¥³¥µª19 „µ¦¨Šš»œ‡ª¦‡¦°‡¨»¤š»„—oµœÂ¼¦–„µ¦ (¦¼žš¸É 8) ¦¼žš¸É 8. Ÿ¨š¸ÉÅ—o‹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 Åž™¹Š¦o°¥¨³ 15 Äœže 1990 …°ŠŠž¦³¤µ–¦ª¤š´ÊŠ®¤— ¨³¤¸„µ¦‡µ—ž¦³¤µ–Ūoªnµ‹³ ¤¸Á¡·É¤¤µ„Á„·œ¦o°¥¨³ 25 Äœže 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¸ÉčoÄœ¦³¦·„µ¦­»…£µ¡…°Šž¦³Áš«­®¦´“°Á¤¦·„µ Äœ…–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oÄœ„µ¦¦´„¬µÄœž¦³Áš«­®¦´“°Á¤¦·„µ Ž¹ÉŠÁ¡·É¤‹Îµœªœ …¹Êœ°¥nµŠ´—Á‹œ ‡nµÄo‹nµ¥­nªœÁ„·œÄœ„¨»n¤š¸É¤¸£µª³œÊε®œ´„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¤¸œÊε®œ´„Á„·œÄœ­®¦´“°Á¤¦·„µ Äœž¦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 Äœže 2546 ‡nµ¦´„¬µ Ÿ¼ožiª¥Ã¦‡Áµ®ªµœ Äœ¨´„¬–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 Å—o„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„oÅ…ž{®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£µª³œÊε®œ´„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„oÅ…°¥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{®µœÊε®œ´„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„. Äœ: 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” Äœž¦³Áš«°´Š„§¬ ަ„¦¤ “Crete” Äœž¦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) Å—oŸ¨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 Å—oŸ¨‡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 ŤnÂœnœ°œªnµ¤¸ž¦³­·š›·Ÿ¨Äœ„µ¦‡ª‡»¤Ã¦‡°oªœÄœÁ—È„6 œÃ¥µ¥šµŠÁ¨º°„ (policy options) Äœ£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 Äœ„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 Äœ„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 Å—oÁ­œ°˜´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¦ Å—o„n sponsors, collaborators, coalition partners, funding officials, administrators, managers, and staff x „¨»n¤š¸ÉÅ—o¦´Ÿ¨„¦³š‹µ„ǦŠ„µ¦ Å—o„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 Å—oš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) ˜nÄœ‹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¤nÅ—o¦³» 2. Ážjµ®¤µ¥—oµœÃ£œµ„µ¦ ¤¸ 9 ž¦³Áš«š¸É„ε®œ—Ážjµ®¤µ¥—oµœÃ£œµ„µ¦ Å—o„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¸ÉÅ—o‹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˜· Äœ°—¸˜ £µª³Ã£œµ„µ¦Á„·œÂ¨³Ã¦‡°oªœÅ¤nÅ—o¦´„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 Äœš«ª¦¦¬®œoµ” ¨³ ”¨—£µª³š»¡Ã£œµ„µ¦¦³®ªnµŠ°µ¥» 0-4 že Äœ¦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) Å—o„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—oÄœ 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 ÂœªšµŠ„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¦¼oÄœ¦³¥³ 5 že Äœ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 ¤¸£µª³œÊε®œ´„Á„·œÂ¨³°oªœÅ¤nÁ„·œ¦o°¥¨³ 10 ¨³¥´Š‡ŠÁžjµ®¤µ¥
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