大腸直腸癌住院病患之營養狀況評估與飲食型態之研究

營養與攝食是大腸直腸癌住院病患最常面對的問題，然而國人目前鮮少對此問題進行深入探討。故本研究藉由南部某醫學中心一般外科大腸直腸癌開刀病患之營養狀況及經由飲食行為評量評估，進行病例對照研究，以了解食物中營養素的攝取與大腸直腸癌之關係。首先以「台灣地區食品營養成分資料庫」為主要來源，並依食物類別及生活型態設計出食物頻率問卷。同時收集45名經大腸鏡檢查及病理切片証明為大腸直腸癌患者為病例組，另以45名經性別、年齡配對且無相關疾病史之健檢者為對照組，進行食物頻率問卷評估。且病例組再依病患基本資料、症狀嚴重程度、身體體位檢查、血液生化檢查及營養狀況評量工具以主觀整體評估（Subjective Global Assessment, SGA）、營養不良普遍篩選工具（Malnutrition Universal Screening Tool, MUST）及營養風險指數（Nutritional risk index, NRI）評估病患之營養狀況並加以比較。結果發現，參與研究之45名大腸直腸癌病患，平均年齡為62.1 ± 11.5歲，以SGA為〝良好評量標準〞（good standard）MUST的敏感度（sensitivity）為93.8%，特異性為82.8%。而MUST有較高的陽性預測率（Positive Predictive Rate）（75%）和陰性預測率（Negative Predictive Rate）（96%），在一致性係數方面，SGA和MUST（k = 0.724， P < 0.001）具顯著相關。研究對象術前近6個月內體重流失大於10%者有6名（13%），5~10%者有11名（24%）。平均住院天數17.1 ± 10.6天，住院期間體重平均下降3.02 ± 1.39公斤，住院期間體重流失5~10%者有15名（33%），大於10%者有1名（2.2%）。在營養不良風險評估方面，三種評量工具都以體重流失為主要評估重點項目，由本研究結果亦可看出，隨術前體重流失愈多，患者住院天數愈長（P = 0.039）。本研究將SGA、MUST與NRI等篩選工具所評之營養狀況與病患住院天數、醫療費用間進行史皮爾曼相關分析，結果發現隨SGA、MUST與NRI評出之營養狀況越差者，其住院天數越長；僅SGA量表評出之患者營養狀況與其住院花費間具顯著統計差異。本研究再以史皮爾曼相關分析SGA、MUST、NRI評量工具，比較其與體位測量值之術前體重、術前身體質量指數、皮層厚度及血液生化值如血清白蛋白（albumin）、前白蛋白（Prealbumin）、轉運鐵蛋白（Transferrin）、總淋巴球計數（TLC）、血紅素（Hb）、鋅（Zn）等之相關性，結果發現隨SGA與MUST評出之營養狀況越差者，其營養指標之相關變項數值越低，且具顯著差異。在食物頻率問卷分析得知脂肪酸來源及攝取量對大腸直腸癌相對危險性相關，結果發現多攝取紅肉中之飽和脂肪酸會增加罹癌風險（OR=1.09；95%CI=1.01-1.18；P<0.05）；在纖維來源方面，水果來源的纖維可降低罹患風險（OR=0.84；95%CI=0.74-0.95；P<0.05）。另外在大腸直腸癌組罹癌前與對照組在魚肉豆蛋類的攝取量明顯高於國人建議量，在奶類及蔬菜類皆低於國人建議量。綜合本研究結果，攝取紅肉飽和脂肪可能增加大腸直腸癌之相對危險性，而多攝取水果膳食纖維可降低大腸直腸癌之相對危險性。研究結果建議國人之飲食型態應以低脂、高纖為原則，增加蔬果、奶類之攝取，並對住院大腸直腸癌病患術前營養狀況篩選。在有限的醫療人力、篩選時間下，仍建議可使用MUST快速篩選住院病患之營養風險或作為評估住院病患營養狀況的良好工具，並於住院期間再視臨床需要進行血液營養指標值檢查，作為評估病患營養不良風險之輔助，以提昇營養篩選成效。

關鍵字

大腸直腸癌；營養篩檢；主觀整體評估；營養不良普遍篩選工具；營養風險指數；食物頻率問卷

並列摘要

The most frequent problem the colorectal inpatients face is concerning nutrition and intake and rarely deeply investigated in Taiwan. Therefore, the general surgery subjects of colorectal cancer in a southern medical center were evaluated regarding nutritional status and food intake for understanding the relationship compared between the nutrient intake and colorectal cancer. First, in light of the Taiwan Nutrient Data Laboratory database as the main resource, the questionnaire based on the types of foods and lifestyle was designed for the risk factors of colorectal cancer. For the food frequency questionnaire, the 45 patients of colorectal cancer proved colonoscopically and pathologically were in the study group; the 45 healthy testers of no history of related illness after age and sex matching, in the control group. The Subjective Global Assessment (SGA)-, Malnutrition Universal Screening Tool (MUST)-, and Nutritional Risk Index (NRI)- assessed nutrition related problems in the study group were assessed, based on the basic data, symptom severity, physical examination, and blood biochemistry. Resultantly, the MUST-assessed sensitivity and specificity of the colorectal cancer participants who had rectal cancer and whose average age was 62.1 ± 11.5 years were 93.8% and 82.8%.However, the MUST had a higher positive predictive rate (75%) and a negative predictive rate（96%）; the SGA and MUST（k = 0.724， P < 0.001）, significantly different consistent coefficients. The 6 subjects （13%） had a 10% weight loss preoperatively within 6 months; the 11 subjects（24%）, a 5-10% weight loss. During the average hospital days (17.1 ± 10.6), the average weight loss was 3.02 ± 1.39 kg; the number of the patients with the 5-10% weight loss, 15（33%）; that of those with the weight loss greater than 10%, 1 (2.2%). For the malnutrition risk assessment, the three screening tools focused upon the weight loss. In the findings, the more weight loss the patients had, the more hospital days they spent（P = 0.039）. In the Spearman correlation analysis using the nutritional status compared with the hospital days and medical cost: the worse the SGA-, MUST-, and NRI-assessed nutritional status was, the more hospital days the patients spent; the SGA-assessed nutritional status compared with the medical cost for hospitalization was significantly different. Additionally, in the analysis, after the SGA-, MUST-, and NRI-assessed nutritional status was compared with the associated variables like the preoperative weight, preoperative body mass index (BMI), cortex thickness, albumin, prealbumin, transferrin, total lymphocyte count, Hemoglobin, and Zinc, the worst the SGA- and MUST- assessed nutritional status was, the smaller the significant different variables were. In the food frequency questionnaire, the relative risk between the source of fatty acids and their intake was identified: the increase in saturated fatty acids in red meat increased cancer risk （OR=1.09；95%CI=1.01-1.18；P < 0.05）; fruit fiber intake decreased cancer risk （OR=0.84；95%CI=0.74-0.95；P < 0.05）. Moreover, the pre-cancer sufferer intake of fish, meat, beans, and eggs in the colorectal cancer group was much higher than the average intake in the control group. The intake of dairy products and vegetables was lower in the former group than the latter group. Conclusively, to eat more saturated fatty acids in red meat might increase the risk of colorectal cancer which was decreased by the more fruit fiber diet. The nutritional status screening of in-hospital colorectal cancer patients who pre-operated had some limitations of medical support and time. Still, it was proposed that to use MUST to quickly screen in-patient patients’ nutrition risk or to be the instrument of in-hospital malnutrition patients and if there is a need depending upon the clinical condition to offer blood test as the aid of assessing patients’ malnutrition.

並列關鍵字

colorectal cancer ； Nutritional Screening ； Subjective Global Assessment ； Malnutrition Universal Screening Tool ； Nutritional risk index ； food frequency questionnaire