【作者】 张雅楠；

【导师】 齐玉梅；

【作者基本信息】 天津医科大学 ， 营养与食品卫生学， 2011， 硕士

【摘要】 目的本文旨在明确初发2型糖尿病患者静息能量消耗(REE)及呼吸商(RQ)的影响因素,分析各影响因素的可能原因和影响效果,为REE和RQ检测结果更好的用于糖尿病患者的医学营养治疗提供参考依据。方法选择2010.1～2011.2期间就诊于我院门诊的初发2型糖尿病患者,共89例。所有患者均符合1999年WHO的糖尿病诊断标准且未使用过任何降糖药物和胰岛素治疗。采用横断面研究方法,运用间接能量测定系统(代谢车)测量患者的REE、RQ及蛋白质、脂肪和碳水化合物的氧化利用率。运用人体成分分析仪测量患者去脂组织质量(FFM)、脂肪组织质量(FM)、体脂百分比(PBF),并结合患者的人体测量指标、临床血清学指标和膳食调查结果,分析REE和RQ的影响因素。结果1.基本资料(1)人体成分分析男性身高、体重、FFM高于女性(P=0.000),而女性PBF、上肢瘦体组织质量与理想瘦体组织质量百分比高于男性(P=0.000)。男、女均是上肢瘦体组织质量与理想瘦体组织质量百分比高于下肢(P=0.000)。不同年龄组FFM及内脏脂肪面积(VFA)各组之间差别有统计学意义(P=0.001), FFM青年组最高,老年组最低,而VFA老年组最高,青年组最低。不同血糖水平各组间在人体成分上差别无统计学意义(P>0.05)。(2)人体测量男性的腰围(WC)、腰臀比(WHR)、上臂肌围(AMC)、握力均高于女性,差别有统计学意义(P<0.05),而不同年龄组及不同血糖水平组的各项指标差别均无统计学意义(P>0.05)。(3)血清学指标按性别、年龄、空腹血糖分组分析,各指标差别均无统计学意义(P>0.05)。(4)膳食调查确诊后饮食总能量平均减少750kcal/day,食物蛋白质供能比增加1.64%,碳水化合物供能比减少2.37%,而脂肪供能比差别无统计学意义(P>0.05)。2.静息能量消耗的影响因素(1)REE实测值与H-B公式预测值比较初发2型糖尿病患者REE实测值比H-B公式预测值平均高出15.60%(P=0.000)。(2)REE影响因素的协方差分析用独立样本t检验发现男女之间REE差别有统计学意义(P=0.000),男性多于女性。但改用协方差分析,以FFM作为协变量,则REE差别无统计学意义(P=0.437)。方差分析发现不同年龄组间REE差别无统计学意义(P=0.075),以FFM作为协变量分析后,差别有统计学意义(P=0.047),青年组REE最高,老年组REE最低。不同血糖水平REE差别无统计学意义(P=0.495),但以FFM作为协变量分析后,差别有统计学意义(P=0.000),血糖水平高于10.1 mmol/L时REE最高,血糖水平介于8.0mmol/L至10.1 mmol/L之间时最低。(3)REE影响因素的多重线性回归分析分析发现FFM、C反应蛋白(CRP)、确诊后饮食总能量为REE的影响因素(P=0.000,P=0.005,P=0.046),用包含以上三个变量的回归方程可以解释REE变异性的66.4%。3.呼吸商的影响因素(1)RQ实测值与正正常值比较RQ实测值低于进食混合性食物健康者的RQ,差别有统计学意义(P=0.000)。(2)血糖水平对RQ的影响不同血糖水平的RQ及npRQ之间差别无统计学意义(P>0.05)。不同血糖水平蛋白质的氧化利用率及24h尿氮排出量差别有统计学意义(P=0.015,P=0.032),血糖水平介于8.0mmol/L至10.1 mmol/L之间时最高。(3)膳食因素对RQ的影响确诊后的食物脂肪供能比和碳水化合物供能比与RQ有相关性(P=0.012, P=0.014),食物脂肪供能比越高RQ值越低,而食物碳水化合物供能比越高RQ值越高。食物脂肪供能比与脂肪的氧化利用率呈正相关(r=0.243,P=0.022),与碳水化合物氧化利用率呈负相关(r=-0.258,P=0.015);食物碳水化合物供能比与脂肪氧化利用率呈反比(r=-0.240, P=0.023),与碳水化合物氧化利用率呈正比(r=0.263, P=0.013)。结论1.初发2型糖尿病患者体内存在能量及蛋白质、脂肪、碳水化合物代谢紊乱。2.初发2型糖尿病患者普遍存在腹型肥胖。3.性别是初发2型糖尿病患者REE的影响因素之一,但是这种影响是由于男女之间体成分差别造成的。4.空腹血糖水平是初发2型糖尿病患者REE的影响因素之一,但其与REE并非简单的线性关系。5.FFM是初发2型糖尿病患者REE的主要影响因素,CRP和近期饮食总能量对REE也有一定的影响。6.初发2型糖尿病患者空腹血糖水平与体内蛋白质的代谢紊乱相关,高血糖刺激时机体出现自我保护机制。7.膳食中脂肪、碳水化合物供能比对RQ值有影响。更多还原

【Abstract】 ObjectiveThe purpose of this study was to determine influencing factors of resting energy expenditure and respiratory quotient in patients with new diagnosed type 2 diabetes mellitus, and to explore causes and effect of them. So we can make better use of the result of REE and RQ test on nutritional therapy.MethodsA total of 89 outpatients with new diagnosed type 2 diabetes mellitus, who met diagnostic criteria of WHO in 1999 and had never taken any medicine or insulin for lowering blood sugar, were collected from January,2010 to February,2011. REE, RQ, protein, fat and carbohydrate oxidation were tested by indirect calorimetry. And FMM, FM and PBF were measured by using body composition analyzer. We also take anthropometric measurements, serological test and dietary survey. All the results were analyzed by cross-sectional study to investigate influencing factors of resting energy expenditure and respiratory quotient.Results1. Basic data(1) Body composition analysisThe value of height, body weight and fat free mass in male is higher than that in female (P=0.000), while percent body fat and arm lean/ideal lean in female are higher than those in male (P=0.000). Arm lean/ideal lean is higher than leg lean/ideal lean in both male and female. The differences on FFM and VFA between each age group are statistically significant (P=0.001). There is no significant difference between body composition of each group that is divided by the level of plasma glucose (P>0.05).(2) Anthropometric measurementsThe value of waist circumference, waist-hip ratio, arm muscle circumference and grip strength is higher than that of female, and the differences are statistically significant (P＜0.05), while no significant difference can be observed between each group that is divided by the level of age or plasma glucose (P>0.05).(3) The serum markers There are no significant differences on serum markers between each group divided by gender, age or level of fasting plasma glucose.(4) Dietary surveyMean of total diet calories decreased by 750 kcal/day, protein of total diet calories increased by 1.64%, carbohydrate of total diet calories decreased by 2.37%, and the differences are statistically significant (P<0.05),but the difference on fat of total diet calories is no statistically significant (P>0.05).2. Influencing factors of resting energy expenditure(1) Comparison of measured REE and predicted value calculated via H-B equationmeasured REE is 15.60% more than predicted value on average.(2) Co variance analysis of influencing factorsSignificant difference was observed on REE between male and female when analyzing via two independent sample t-test (P=0.000). And the value in male is higher than that in female. But there is no significant difference when analyzing via covariance analysis with fat free mass as covariant (P=0.437). No significant difference can be observed on REE among each group divided by age when analyzing via ANOVA (P=0.075), while statistical difference can be observed when analyzing via covariance analysis with fat free mass as covariant (P=0.047), and young group is higher. There is no significant difference on REE among each group divided by plasma glucose via ANOVA. But statistical difference can be observed when analyzing via covariance analysis with fat free mass as covariant (P=0.000).(3) Multiple linear regression of influencing factorsIt shows that the free fat mass, C-reactive protein and total diet calories after final diagnosis are influencing factors for REE (P=0.000, P=0.005, P=0.046).3. Influencing factors of respiratory quotient(1) Comparison of tested RQ and normal valueMeasured RQ is lower than RQ of normal people who take mixed food, and the difference is statistically significant (P=0.000).(2) The effect of level of blood sugar on RQNo significant differences on RQ and npRQ can be observed among each group with different level of plasma glucose. But the difference on protein oxidation and urinary nitrogen in 24 hours are significant (P=0.015, P=0.032). And a maximum value is obtained when plasma glucose is between 8mmol/L and 10.1mmol/L.(3) The effect of diet on RQFat and carbohydrate of total diet calories after final diagnosis are associated with RQ (P=0.012, P=0.014). The higher fat of total diet calories is, the lower RQ is observed. On contrary, the higher carbohydrate of total diet calories is, the higher RQ is observed. A positive correlation is found between fat of total diet calories and fat oxidation (r=0.243, P=0.022), while a negative correlation is found between fat of total diet calories and carbohydrate oxidation (r=-0.258,P=0.015); A negative correlation is found between carbohydrate of total diet calories and fat oxidation (r=-0.240, P=0.023), while a positive correlation is found between carbohydrate of total diet calories and carbohydrate oxidation (r=0.263, P=0.013).Conclusion1. Metabolic disorder of calorie, protein, fat and carbohydrate exists in patients with newly diagnosed type 2 diabetes mellitus.2. Abdominal obesity exists in patients with newly diagnosed type 2 diabetes mellitus.3. Gender is one of influencing factors for REE of patients with newly diagnosed type 2 diabetes mellitus. And this influence results from the difference on body composition between male and female.4. Level of fasting plasma glucose is one of influencing factors for REE of patients with newly diagnosed type 2 diabetes mellitus.5. Fat free mass is one of influencing factors for REE of patients with newly diagnosed type 2 diabetes mellitus. C-reactive protein and recent total diet calories also influence REE.6. Level of fasting plasma glucose in patients with new diagnosed type 2 diabetes mellitus is associated with metabolic disorder of protein.7. Fat and carbohydrate of total diet calories have an effect on RQ.更多还原