發(fā)布時(shí)間：2018-09-03 11:32

【摘要】：背景： 肥胖是全球面臨的一個(gè)重要公共衛(wèi)生問(wèn)題，無(wú)論是在發(fā)達(dá)國(guó)家或是發(fā)展中國(guó)家，肥胖均呈快速增長(zhǎng)的趨勢(shì)。基于人群的研究顯示，中國(guó)也面臨著肥胖流行的問(wèn)題，肥胖增加代謝性疾病的患病率。在一般人群中，肥胖增加腦卒中風(fēng)險(xiǎn)和死亡風(fēng)險(xiǎn)。但是在腦卒中患病人群中，存在“肥胖悖論”的現(xiàn)象，即肥胖的腦卒中患者預(yù)后更好，肥胖者更容易存活。中國(guó)腦卒中患者的肥胖現(xiàn)況尚不清楚，缺乏腦卒中患者肥胖與代謝疾病關(guān)系的研究，尚無(wú)中國(guó)人群肥胖悖論的資料，現(xiàn)有關(guān)于“肥胖悖論”的研究結(jié)果不相一致，腦卒中肥胖悖論的研究主要集中于體重指數(shù)（BMI）與死亡關(guān)系，缺乏關(guān)于其他肥胖指標(biāo)及腦卒中其他預(yù)后的研究。 目的： 本研究旨在探討中國(guó)缺血性腦卒中患者的肥胖現(xiàn)況，肥胖與代謝疾病的關(guān)系及不同肥胖指標(biāo)對(duì)代謝疾病的預(yù)測(cè)作用，肥胖對(duì)腦卒中患者預(yù)后的影響。 方法： 以前瞻性、多中心的中國(guó)國(guó)家腦卒中登記研究（The China National StrokeRegistry，CNSR）中缺血性腦卒中患者為研究人群。CNSR同期收集在132家醫(yī)院就診患者的人口社會(huì)學(xué)特征、危險(xiǎn)因素、臨床特征和治療，并對(duì)腦卒中患者結(jié)局進(jìn)行前瞻性隨訪，結(jié)局包括全因死亡、神經(jīng)功能預(yù)后和腦卒中復(fù)發(fā)。全身性肥胖依據(jù)世界衛(wèi)生組織針對(duì)亞洲人群推薦的BMI切點(diǎn)：BMI18.5kg/m2為消瘦，18.5-22.9kg/m2為正常，23-27.4kg/m2為超重，≥27.5-32.4kg/m2為肥胖，≥32.5kg/m2為嚴(yán)重肥胖。中心性肥胖定義為腰圍（WC）≥男85cm/女80cm，腰圍身高比（WHtR）≥0.5。logistic回歸分析肥胖與代謝性疾病的關(guān)系。以受試者工作特性（ROC）曲線分析各肥胖指標(biāo)對(duì)≥1個(gè)代謝性疾病的預(yù)測(cè)價(jià)值。logistic回歸分析肥胖指標(biāo)與腦卒中預(yù)后關(guān)系。 結(jié)果： 中國(guó)國(guó)家腦卒中數(shù)據(jù)庫(kù)共在全國(guó)132家醫(yī)院同期連續(xù)性登記22216例發(fā)病14天內(nèi)急性腦血管病患者，本研究共納入10033例缺血性腦卒中患者，6210例（61.9%）男性，3823例（38.1%）女性。 按BMI的標(biāo)準(zhǔn)，403例（4.0%）為消瘦，，3126例（31.2%）為正常體重，4932例（49.2%）為超重，1572例（15.7%）為肥胖；按腰圍的標(biāo)準(zhǔn)，中心性肥胖6272例（62.5%）；按腰圍身高比的標(biāo)準(zhǔn)，中心性肥胖6147例（61.3%）。18-45歲的青年缺血性腦卒中男性患者中肥胖占21.2%，高于其他年齡組男性患者的肥胖比例（P0.001），也高于同年齡組女性患者（15.4%）（P0.001）。超重/肥胖的比例，北方高于南方（69.2%vs56.7%）；東部最高（66.9%），中部次之（63.5%），西部最低（58.9%）；高經(jīng)濟(jì)收入?yún)^(qū)高于低經(jīng)濟(jì)收入?yún)^(qū)（66.2%vs63.5%）；高家庭人均月收入者（66.1%）高于低家庭人均月收入者（62.6%）；文化程度高者超重/肥胖的比例高，初中及以上文化程度者為69.4%，小學(xué)和文盲為59.3%。 隨著BMI、腰圍及WHtR增大，高血壓、糖尿病、脂代謝紊亂的比例增高，BMI由低到高組，高血壓比例分別為49.1%、55.9%、65.2%、76.0%（P0.001），糖尿病比例分別為16.6%、20.7%、27.4%、33.1%（P0.001），脂代謝紊亂比例分別為38.2%、47.4%、52.1%、58.1%（P0.001）；腰圍由低到高組，高血壓比例分別為55.5%、61.7%、66.7%、70.7%（P0.001），糖尿病比例分別為19.4%、26.5%、27.3%、31.1%（P0.001），脂代謝紊亂比例分別為47.4%、49.5%、51.4%、56.6%（P0.001）；WHtR由低到高組，高血壓比例分別為54.8%、61.8%、65.3%、71.3%（P0.001），糖尿病比例分別為19.0%、25.9%、26.4%、31.7%（P0.001），脂代謝紊亂比例分別為46.3%、48.1%、53.1%、56.5%（P0.001）。高BMI組合并高血壓、糖尿病、脂代謝紊亂的比值比分別為2.69（95%CI2.35-3.06）、1.97（95%CI1.73-2.25）、1.45（95%CI1.29-1.63），高腰圍組分別為2.00（95%CI1.78-2.26）、1.92（95%CI1.68-2.18）、1.44（95%CI1.29-1.61），高WHtR組分別為2.03（95%CI1.81-2.28）、1.96（95%CI1.72-2.23）、1.50（95%CI1.35-1.68）。在男性中，ROC曲線分析各肥胖指標(biāo)診斷≥1個(gè)代謝疾病曲線下面積：BMI為0.604（95%CI0.591-0.616），WC為0.582（95%CI0.569-0.594），WHtR為0.583（95%CI0.570-0.595），在女性中， BMI為0.629（95%CI0.613-0.644），WC為0.609（95%CI0.593-0.624），WHtR為0.610（95%CI0.594-0.626），三者曲線下面積無(wú)差別。 10033例缺血性腦卒中患者中，9342例（93.1%）完成12月隨訪，691（6.9%）例失訪。存活患者中，高BMI組的神經(jīng)功能預(yù)后良好（mRS0-1）比例更高，3個(gè)月mRS0-1的比例：消瘦組51.7%，正常體重組54.9%，超重組60.0%，肥胖組59.3%，嚴(yán)重肥胖組59.5%（P0.001）。12個(gè)月mRS0-1的比例：消瘦組57.0%，正常體重組63.1%，超重組65.1%，肥胖組66.4%，嚴(yán)重肥胖組66.4%（P=0.018）。多因素logistic回歸分析顯示：超重與3個(gè)月神經(jīng)功能預(yù)后良好獨(dú)立相關(guān)（OR=1.26;95%CI,1.13-1.39），BMI與12個(gè)月神經(jīng)功能預(yù)后無(wú)相關(guān)性。全因死亡的比例較高為消瘦組和嚴(yán)重肥胖組，3個(gè)月死亡比例：消瘦組15.7%，正常體重組8.3%，超重組7.7%，肥胖組7.3%，嚴(yán)重肥胖組12.1%（P0.001）。12個(gè)月死亡比例：消瘦組25.3%，正常體重組14.2%，超重組12.3%，肥胖組11.3%，嚴(yán)重肥胖組16.7%（P 0.001）。多因素logistic回歸分析顯示：嚴(yán)重肥胖與3個(gè)月死亡獨(dú)立相關(guān)（OR2.13;95%CI1.15-3.68），與12個(gè)月死亡獨(dú)立相關(guān)（OR1.46;95%CI1.09-2.50）。多因素logistic回歸分析顯示BMI與12個(gè)月腦卒中復(fù)發(fā)無(wú)相關(guān)性。中心性肥胖與腦卒中預(yù)后無(wú)相關(guān)性。 結(jié)論： 1．中國(guó)缺血性腦卒中患者中，超重和肥胖較為普遍。18-45歲青年男性患者肥胖比例高；北方地區(qū)、經(jīng)濟(jì)收入高、文化水平高者肥胖比例更高。在缺血性腦卒中患者中，應(yīng)注重肥胖的宣教和干預(yù)，尤其應(yīng)關(guān)注上述人群和地區(qū)。 2．肥胖增加缺血性腦卒中患者高血壓、糖尿病、脂代謝紊亂的患病率，肥胖與代謝性疾病關(guān)系密切。但肥胖指標(biāo)對(duì)代謝性疾病預(yù)測(cè)價(jià)值有限，在所有缺血性腦卒中患者中應(yīng)注意危險(xiǎn)因素的檢查。 3．缺血性腦卒中患者中，盡管超重者短期神經(jīng)功能預(yù)后良好，嚴(yán)重肥胖增加死亡風(fēng)險(xiǎn)。需要更多的研究闡明肥胖與腦卒中預(yù)后關(guān)系，從而指導(dǎo)腦卒中的二級(jí)預(yù)防。
[Abstract]:Background:
Obesity is an important public health problem facing the world. Obesity is increasing rapidly in both developed and developing countries. Population-based studies show that China is also facing an obesity epidemic, with obesity increasing the prevalence of metabolic diseases. In the general population, obesity increases the risk of stroke and death. Risk. However, there is a "obesity paradox" in stroke patients, that is, obese stroke patients have a better prognosis, obese people are more likely to survive. The status of obesity in stroke patients in China is still unclear, there is no research on the relationship between obesity and metabolic diseases in stroke patients, and there is no data on the obesity paradox in Chinese population. The results of the obesity paradox are inconsistent. The obesity paradox of stroke is mainly focused on the relationship between body mass index (BMI) and death. There is no research on other obesity indicators and other prognosis of stroke.
Objective:
The purpose of this study was to investigate the prevalence of obesity in Chinese patients with ischemic stroke, the relationship between obesity and metabolic diseases, the predictive effect of different obesity indices on metabolic diseases, and the effect of obesity on the prognosis of stroke patients.
Method:
A prospective, multicenter, China National Stroke Registry (CNSR) study of ischemic stroke patients was conducted. CNSR collected demographic and sociological characteristics, risk factors, clinical characteristics, and treatment of patients in 132 hospitals at the same time. Prospective follow-up was conducted to determine the outcome of stroke patients. Systemic obesity was defined as waist circumference (WC) > male 85. The relationship between obesity and metabolic diseases was analyzed by logistic regression. The predictive value of obesity indices for more than 1 metabolic disease was analyzed by ROC curve. The relationship between obesity indices and stroke prognosis was analyzed by logistic regression.
Result:
A total of 22216 patients with acute cerebrovascular disease (ACVD) within 14 days were registered in 132 hospitals nationwide. This study included 1 033 patients with ischemic stroke, 6 210 (61.9%) were males and 3 833 (38.1%) were females.
According to BMI criteria, 403 (4.0%) were emaciated, 3126 (31.2%) were normal weight, 4932 (49.2%) were overweight, and 1572 (15.7%) were obese; according to waist circumference criteria, 6 272 (62.5%) were central obesity; according to waist circumference height ratio criteria, 6 147 (61.3%) were central obesity in young men aged 18-45 with ischemic stroke, 21.2% were obese, higher than that in young men aged 18-45. The proportion of obesity in male patients of other age groups (P 0.001) was also higher than that in female patients of the same age group (P 0.001). The proportion of overweight/obesity in the North was higher than that in the South (69.2% vs 56.7%), the highest in the East (66.9%), the second highest in the middle (63.5%) and the lowest in the West (58.9%); the highest in the high-income area was higher than that in the low-income area (66.2% vs 63.5%); and the average monthly per capita of high-income families. Income (66.1%) was higher than average monthly income (62.6%) in low-income families; overweight/obesity was higher in high-educated people, 69.4% in junior high school and above, and 59.3% in primary school and illiteracy.
With the increase of BMI, waist circumference and WHtR, the proportion of hypertension, diabetes mellitus and lipid metabolism disorder increased. BMI from low to high group was 49.1%, 55.9%, 65.2%, 76.0% (P 0.001), the proportion of diabetes mellitus was 16.6%, 20.7%, 27.4%, 33.1% (P 0.001), the proportion of lipid metabolism disorder was 38.2%, 47.4%, 52.1%, 58.1% (P 0.001). The proportion of hypertension was 55.5%, 61.7%, 66.7% and 70.7% (P 0.001), the proportion of diabetes mellitus was 19.4%, 26.5%, 27.3%, 31.1% (P 0.001), the proportion of lipid metabolism disorder was 47.4%, 49.5%, 51.4%, 56.6% (P 0.001), the proportion of hypertension was 54.8%, 61.8%, 65.3%, 71.3% (P 0.001), the proportion of diabetes mellitus was 19.0%, 25.9%, 26.4%, 31.7% respectively. (P 0.001), the proportion of dyslipidemia was 46.3%, 48.1%, 53.1%, 53.1%, 56.5% (P 0.001). The ratio of hyperBMI group with hypertension, diabetes mellitus, hyperlipidemia was 2.69 (95% CI 2.35-3.06), 1.97 (95% CI 1.73-2.25, 95% CI 1.73-2.25), 1.45 (95% CI 1.45 (95% CI 1.29-1.29-1.29-1.63), 2.00 (95% CI 1.78-78-2.78-2.26), 1.92 (95% CI 1.68-1.68-2.18), 1.44 (95% CI 1.44 (95% CI 2.45-95% CI 1.35-Group Among men, ROC curve analysis of obesity indicators diagnosed (> 1 metabolic disease curve area: BMI 0.604 (95% CI0.591-0.616), BMI 0.604 (95% CI0.591-0.616), WC 0.582 (95% CI0.569-0.594), WHtR 0.583 (95% CI0.560.570.570-0.590-0.595), WHtR 0.583 (95% CI0.583 (95% CI0.570.570.570-0.570-0.595) in women, BMI 0.620.629 (95% CI0.629-95% CI0.619-95% CI0.619-95% CI0 644), WC 0. 609 (95%CI0.593-0.624), WHtR was 0.610 (95%CI0.594-0.626), and there was no difference in the area under the three curve.
Among the 1 033 patients with ischemic stroke, 9 342 (93.1%) completed 12-month follow-up and 691 (6.9%) lost follow-up. Among the survivors, the high BMI group had a higher percentage of good neurological prognosis (mRS0-1). The proportion of mRS0-1 at 3 months was 51.7% in the emaciated group, 54.9% in the normal weight group, 60.0% in the overweight group, 59.3% in the obese group, 59.5% in the severe obesity group (P 0.001). Multivariate logistic regression analysis showed that overweight was independently associated with a good prognosis of neurological function at 3 months (OR = 1.26; 95% CI, 1.13-1.39), BMI was not associated with a 12-month prognosis of neurological function. The 3-month mortality rates in lean and severe obesity groups were 15.7% in emaciation group, 8.3% in normal weight group, 7.7% in overweight group, 7.3% in obesity group, 12.1% in severe obesity group (P 0.001). The 12-month mortality rates were 25.3% in emaciation group, 14.2% in normal weight group, 12.3% in overweight group, 11.3% in obesity group and 16.7% in severe obesity group (P 0.001). Weight and obesity were independently associated with 3-month mortality (OR2.13; 95% CI 1.15-3.68) and 12-month mortality (OR1.46; 95% CI 1.09-2.50). Multivariate logistic regression analysis showed that BMI was not associated with 12-month stroke recurrence. Central obesity was not associated with stroke prognosis.
Conclusion:
1. Overweight and obesity are prevalent among ischemic stroke patients in China. The obesity rate of male patients aged 18-45 is high. In northern China, the obesity rate is higher among those with high income and high education level.
2. Obesity increases the prevalence of hypertension, diabetes, lipid metabolism disorders in patients with ischemic stroke. Obesity is closely related to metabolic diseases. However, obesity indicators have limited predictive value for metabolic diseases. Risk factors should be examined in all patients with ischemic stroke.
3. In ischemic stroke patients, although overweight patients have good short-term neurological prognosis, severe obesity increases the risk of death. More research is needed to clarify the relationship between obesity and stroke prognosis, so as to guide secondary prevention of stroke.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R743.3;R589.2

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