罹患病態肥胖之成人其健康相關生活品質分析

Abstract

研究目的： 本論文研究之主要目的為(1)評估病態肥胖者之生活品質與健康者之差別 (2)經減重手術後隨著體重減輕、肥胖相關合併症之減輕、以及手術後所帶來的併發症之出現，經一年的臨床追蹤觀察其生活品質的動態變化(3)翻譯肥胖專屬之生活品質問卷Moorehead-Ardelt Quality of Life Questionnaire II (MA II)成中文版，並作信效度分析(4)以生活品質的觀點探討長期輪班的影響與適應之道。 研究背景： 肥胖的盛行率在過去數十年間有非常顯著的增加，在台灣，男性與女性的肥胖盛行率分別為19.2% 以及13.4%，肥胖已成為臺灣當前公共衛生之重要課題，其影響的層面甚為廣泛，尤其是與代謝症候群息息相關，而進而受到職業醫學的重視。病態肥胖會影響生活品質中的許多層面，一般而言，身體質量指數(BMI)愈高則生活品質愈差，減重手術可以有效地減低體重，降低合併症以及改善生活品質，然而目前仍缺乏研究來探討詳細的生活品質之動態變化，由肥胖相關的生活品質研究出發，可將此方法應用於職業醫學上探討長期輪班對生活品質之影響。 研究方法: 收案的對象為患有病態肥胖之患者符合亞太減重手術之共識標準而欲至本院接受手術治療者，台灣版的WHOQOL-BREF問卷將被填寫於術前一個月以及術後第一、三、六、十二個月，而同時記載身體質量指數、肥胖合併症以及手術相關併發症。健康對照組將由國健局的全國調查之資料庫中隨機選出。統計方法為使用線性迴歸控制所有可能之變因，分析肥胖會影響哪方面的生活品質面向，並與健康的對照組用trend test來比較其嚴重度之影響。再使用mixed-effect模式來分析重複測量之生活品質分數和身體質量指數以及相關的共變因子隨著時間改變之關係。另外引進目前最受重視的肥胖專用生活品質問卷Moorehead-Ardelt Quality of Life Questionnaire II (MA II)，將其中文化，並執行信效度的分析研究。最後，於健檢中心收集特定之鋼鐵廠工人執行年度健康檢查時，以WHOQOL-BREF Taiwan version測量其生活品質之影響。 結果與討論： 共收案114個接受減重手術之患者，肥胖患者在WHOQOL-BREF問卷的身體、心理、社會層面比健康對照組有較差的生活品質分數，而這些肥胖者若BMI大於32 kg/m2則生活品質之分數即開始受影響。經一年的長期追蹤研究使用Mixed-effect model將分析出生活品質在WHOQOL-BREF問卷的身體、心理、社會層面分數會受減重手術的影響而改善，而隨著時間的追蹤，生活品質之動態變化亦被呈現出來，在術後第三至第六個月病患的身體、心理層面分數會受減重手術併發症的出現而受影響，分數會下降，但隨後在第六至十二個月其生活品質的分數又會逐漸上升，接近健康對照組的平均分數。由本研究的發現將提供臨床醫師對於此類患者於術前及術後照顧上重要的資訊。而肥胖專用生活品質問卷(MA II)其有相當好之再測信度其組內相關係數為0.73-0.91。而其問卷總分與WHOQOL-BREF的四個層面以及SF-36的兩大面向皆有顯著之相關性，可見此問卷有相當好之收斂效度，本問卷之六個問題彼此間皆有很好之相關性，且迴歸分析顯示MA II的總分與BMI值有顯著的負相關性，可見MA II可能是一個單一面向的問卷。它可以提供迅速好用的臨床標準評估，並進一步可以與國際接軌作研究合作與比較。另外，於健檢中心收集特定之鋼鐵廠工人執行年度健康檢查共471名，共約35.5%是屬於輪班工作者(75.5%是四班三輪的輪班方式)，發現長期輪班工作者(大於一年以上)其睡眠與休息之影響不大，與其他不用輪班者相較，並沒較明顯之不良，反而在生理層面相關的細項以及社會層面的總分有正向的相關性。 結論: BMI值愈高生活品質愈差，本研究的結果支持了亞太減重共識會議的手術標準。病態肥胖之患者其健康相關之生活品質經減重手術後有顯著的改善效果，但在術後三至六個月會稍微下降，之後又再回升直到追蹤一年結束。經本研究成功地將MA II翻譯成中文化，並證實此問卷有良好之信效度，將來可以進行相關之臨床研究。生活品質測量在職業醫學的應用方面發現，克服了睡眠障礙以及休息，長期輪班在鋼鐵廠工人似乎會有慢性適應的特色，生活品質的測量顯示在生理層面相關的細項以及社會層面的總分有正向的相關性。

Objective: The aims of our study are to (1) compare the health-related quality of life (HRQOL) between patients with morbid obesity and the healthy population in Taiwan (2) evaluate the effects of bariatric surgery on the dynamic changes of HRQOL during one year follow-up (3) translate the Moorehead-Ardelt Quality of Life Questionnaire II (MA II) into Chinese and validate it (4) use QOL measurement to investigate the impact of long-term rotating shift work. Background: The prevalence of obesity has increased markedly in the past several decades, and is now a major public health issue. In Taiwan, the prevalence of obesity were 19.2% and 13.4% for man and woman, respectively. Many obesity-related co-morbidities have been documented and account for the use of considerable medical resources worldwide. In particular, obesity is closely related to metabolic syndrome, which has been emphasized by rotating shift work (RSW) in occupational medicine recently. Morbid obesity could also significantly affect quality of life. Bariatric surgery could reduce body weight and improve HRQOL effectively, but no study has shown detailed profiles of HRQOL changes along with time. The MA II is a obesity specific questionnaire and it has been applied in many studies. The impact of RSW on QOL is unclear. Material and Methods: Patients were enrolled for bariatric surgery by a modified recommendation of the Asia-Pacific consensus. WHOQOL-BREF was administered 1 month before the operation, 1, 3, 6, and 12 months after surgery. BMI, co-morbidities and operation related complications was also measured simultaneously. A healthy reference group was randomly sampled from the database of National Health Interview Survey in Taiwan. Mixed-effect model was constructed to analyze the repeated measurements and determine the relationship among the BMI, WHOQOL scores, and other covariates. MA II was translated into Taiwan version in Chinese fist. Cross-validation of MA-II with WHOQOL and SF-36 were performed. WHOQOL-BREF was applied for the steel workers in annual health check up. Multiple linear regression models were conducted for the analysis of QOL and its determinants in all steel workers. Results: A total of 114 consecutive patients with obesity coming for bariatric surgery at E-Da hospital were enrolled. Obese subjects had poorer WHOQOL-BREF scores than those of the healthy referents in physical, psychological and social domains but not in environment domain. Patients with BMI >32 kg/m2 had consistently poorer scores in various facets after adjusting for other risk factors. The mixed effect model showed that the physical, psychological and social domains improved after bariatric surgery with simultaneous reduction in weight and improvement in co-morbidities. There was a dip in scores in physical and psychological domains three to six months after surgery, significantly related to complications. All patients gradually improved between six and 12 months after surgery reaching levels similar to those of healthy subjects. Good test-retest reliability was shown by intra-class correlations ranging from 0.73 to 0.91. The total sum of MA II scores was significantly correlated with all 4 domains of the WHOQOL-BREF and 2 major components of SF-36. Totally 471 steel workers were enrolled for QOL measurement and 35.5% of them had RSW. Morbid obesity decreased the QOL scores of psychological domain. The facet of sleep and rest did not showed negative impact by long-term RSW. Conclusion: The higher the BMI level the poorer the HRQOL. Our findings seem to support the recommendations of Asia-Pacific consensus based on HRQOL considerations. HRQOL improved dramatically after bariatric surgery, dipped slightly between three and six months and improved again up to the end of the first year. The MA II Taiwan version is an obesity-specific questionnaire for QOL evaluation with satisfactory reliability and validity. The steel workers in Taiwan with long-term RSW seem to accommodate the circadian rhythm without disturbance of sleep and rest, whose sores of WHOQOL-BREF were better in various associating facets of physical and social domains.