發展與測試運用SMART設計運動介入對降低肥胖社區居民內臟脂肪之成效

Developing and Testing the Effect of Exercise Intervention Using a SMART Design on Reducing Visceral Adipose Tissue in Community Residents with Obesity

張祐瑄(Yu-Hsuan Chang)

指導教授 ： 孫秀卿

國立臺灣大學/醫學院/護理學研究所/博士(2022年)

https://doi.org/10.6342/NTU202200020

摘要

背景：內臟脂肪堆積與肥胖有高度相關且會導致高血壓、心血管疾病及胰島素阻抗，根據文獻可知藉由運動可以有效改善。然而，目前最佳降低內臟脂肪的運動策略仍無一致的共識。
目的：本研究主要的目的為發展與測試針對肥胖的社區民眾有效降低內臟脂肪的運動種類和處方內的運動次序。研究目標包含確認最佳降低內臟脂肪的運動策略，以及探討降低內臟脂肪的重要因素。
方法：以立意取樣招募台灣南部40至64歲、無飲食熱量限制之男性體脂超過25%及女性體脂超過30%的社區居民。以序貫多重隨機試驗方法(sequential multiple assignment randomized trial, SMART)進行為期共16週、二階段各8週的運動介入。受試者於第一階段接受隨機分配至每週3次(含兩次監督下的運動和一次在家運動)、為期8週的30分鐘至少中強度有氧運動組或20分鐘間歇運動組。以身體組成分析儀進行測量，若其內臟脂肪比起受試前未降低大於3%，則於第二階段1:1隨機分配至中強度有氧運動合併額外的10分鐘抗阻力運動組或交換進入第一階段另一組的治療組(高強度間歇運動或有氧運動)。若受試者於第一階段介入後內臟脂防降低大於3%，則持續維持第一階段的運動直至16週。內臟脂肪測量的時間點包含研究介入前(T0)、第一階段結束後(T1)及第二階段結束後(T2)。所收集的資料以廣義估計式(Generalized estimating equations) 和羅吉斯迴歸 (logistic regression) 分析最佳降低內臟脂肪的運動種類及探討預測第一階段內臟脂肪降低的重要因素。
研究結果：本研究共招募116位個案並接受第一階段的隨機分派至有氧運動組(58位)及高強度間歇運動組(58位)。共有53位個案完成第一階段的有氧運動，其中34人有氧運動在第一階段結束後內臟脂肪下降3%以上，故第二階段持續有氧運動直至16週結束(組別A)；無明顯效果者則接受第二次的隨機分派至有氧合併抗阻力運動組(9位，組別B)或高強度間歇運動組(10位，組別C)。共有54位個案在第一階段完成高強度間歇運動，其中29人內臟脂肪下降3%以上，故第二階段持續高強度間歇運動直至16週結束(組別D)；無明顯反應者則接受第二次的隨機分派至有氧合併抗阻力運動組(14位，組別E)或有氧運動組(11位，組別F)。研究整體的流失率為12.93%，包含9位在第一階段和6位在第二階段過程中退出。各組個案對於運動的遵從性為68.18%至80.15%。第一階段8週後的運動結果顯示，有氧運動降低內臟脂肪的效果優於高強度間歇運動(β = −4.10, P = 0.029)。針對第一階段對有氧運動無明顯效果者，組別C的內臟脂肪下降成效在第二階段優於組別B (β = -7.36, P = 0.006)；針對第一階段對高強度間歇運動無明顯效果者，第二階段中組別E和組別F降內臟脂肪則無明顯差異。為期二階段16週最佳的運動策略，組別A和組別D兩組無統計上差異，並且在第一和第二階段皆優於其他四組。羅吉斯迴歸結果顯示接受有氧運動的個案在運動介入前內臟脂肪≧100 cm2者，比起內臟脂肪< 100 cm2有較高的勝算比(OR = 8.80, p = 0.019)、以及三酸甘油脂 <150 mg/dl者，比起三酸甘油脂 ≧150 mg/dl者有較高的勝算比(OR = 0.10, p = 0.007)在第一階段後內臟脂肪降低3%以上。
結論：結果顯示中年肥胖社區居民(男性體脂≧25%、女性體脂≧30%)進行每週三次，每次30分鐘至少中等強度的有氧運動或高強度間歇運動20分鐘，在平均運動遵從性75%，有氧運動是短期8週降內臟脂肪較佳的運動種類。若居民對於第一階段的有氧運動無明顯效果，則第二階段進行高強度間歇運動的效果優於有氧合併抗阻力運動。針對為期二階段16週最佳的運動策略，二階段維持相同的有氧運動或高強度間歇運動的效果，比起16週中曾有變更運動種類的效果較佳。居民於運動介入前內臟脂肪≧100 cm2及三酸甘油脂<150 mg/dl是顯著影響8週有氧運動是否降低內臟脂肪的重要因素。
臨床應用：健康專業人員針對中年肥胖社區居民設計降內臟脂肪的運動處方，短期8週的處方可設計每周三次、每次30分鐘的至少中強度有氧運動；若拉長至16週的處方，除持續執行有氧運動外，20分鐘的高強度間歇亦為有效降內臟脂肪的運動策略。研究結果可供健康政策決策者制定運動指引之參考。

關鍵字

內臟脂肪 ； 運動 ； 序貫多重隨機試驗方法 ； 有氧運動 ； 高強度間歇運動 ； 抗阻力運動

並列摘要

Background: Exercise is the most effective method of reducing visceral adipose tissue (VAT), which is strongly associated with obesity, hypertension, cardiovascular disease, and insulin resistance. However, consensus has not been reached on the optimal exercise modality for reducing VAT.
Objectives: The aims of this study were to develop and test the optimal exercise modality and sequence for reducing VAT in community residents with obesity. The research objectives included identifying the optimal sequence of exercise regime strategies for maximum VAT reduction and exploring the crucial factors predicting VAT reduction.
Methods: Purposive sampling was used to enroll 40–64-year-old male and female community residents from southern Taiwan with body fat percentages of ≧25% and ≧30%, respectively, and without calorie-restricted diets. The sequential multiple assignment randomized trial (SMART) design was used to conduct a 16-week, two-stage (8 weeks each) adaptive exercise intervention for the community residents. In the first stage, the participants were randomly allocated to groups in which they performed 30 minutes of aerobic exercise (AE) or 20 minutes of high-intensity interval training (HIIT) three times per week (two supervised sessions and one home-based workout) for 8 weeks, maintaining at least a moderate intensity of exercise. The participants whose VAT did not decrease ≧3% (measured using a body composition analyzer) were randomly reallocated into a group that performed AE combined with an additional 10 minutes of resistance exercise (RE) or one that performed the opposite of the first-stage treatment (HIIT or AE) in the second stage. Those who responded to the first-stage intervention (VAT reduction of ≧3%) continued the same exercise treatment until 16 weeks. VAT measurements were performed three times: at baseline (T0), the end of the first stage (T1), and the end of second stage (T2). Generalized estimating equations and logistic regression were used to identify the optimal exercise strategy and the significant baseline factors to predict VAT reduction at T1.
Results: A total of 116 participants were recruited and were randomly allocated to the first-stage AE (58 participants) or HIIT (58 participants) group. At the end of the first stage, 53 participants had completed the AE training, 34 of whom had responded to the exercise with ≧3% VAT reductions and continued AE until 16 weeks (Group A). The others were randomly reallocated to an AE combined with RE (nine participants, Group B) or HIIT (10 participants, Group C) group for the second stage. Similarly, 54 participants completed the first-stage HIIT, 29 of whom responded with ≧3% VAT reductions and continued HIIT until 16 weeks (Group D). The others were randomly reallocated into the AE combined with RE (14 participants, Group E) or AE (11 participants, Group F) group. The overall attrition rate was 12.93%, with nine and six participants withdrawing from the study during the first and second exercise stages, respectively. The total rates of adherence to exercise sessions for the six exercise-regime-based groups ranged from 68.18% to 80.15%. During the first 8-week stage, AE was more effective than HIIT in reducing VAT (β = −4.10, p = .029). For the participants who did not respond to AE, Group C exhibited effects superior to those of Group B (β = −7.36, p = .006) in the second 8-week period. By contrast, the participants who did not respond to HIIT during the first stage (Groups E and F) did not differ in their effects on VAT over the following 8 weeks. Regarding the optimal sequence of exercise regimes over the 16 weeks, Groups A and D exhibited similar effects related to the reduction VAT over time and significantly outperformed Groups B, C, E, and F in the data recorded at T1 and T2. Logistic regression indicated that the participants who completed AE in the first stage with baseline VAT of ≧100 cm2 had higher odds ratios (ORs) than did the participants with baseline VAT of <100 cm2 (OR = 8.80, p = .019). Moreover, the participants with baseline triglyceride (TG) of <150 mg/dL had higher ORs than those with baseline TG of ≧150 mg/dL to reduce VAT ≧3% over the first stage of exercise.
Conclusion: With an approximate 75% rate of adherence to a well-designed exercise regime (30 minutes of AE or 20 minutes of HIIT per session) three times per week, AE was superior to HIIT for reducing VAT in middle-aged community residents with obesity over an initial 8-week stage. For the residents who did not respond (<3% VAT reduction) to AE over the first stage of the program, HIIT was the superior alternative exercise strategy rather than a combination of AE and RE. The optimal overall 16-week exercise strategy involved performing the same exercise modality (either AE or HIIT), rather than altering the modality to reduce VAT during 16 weeks. VAT of ≧100 cm2 and TG of <150 mg/dL at baseline were significant factors for predicting ≧3% VAT reduction at the end of 8 weeks of AE.
Clinical implications: Health professionals should design 8-week exercise prescriptions involving thrice-weekly, 30-minute sessions of at least moderate-intensity AE to reduce VAT in middle-age community residents with obesity. In cases where a 16-week program is essential, 30-minute AE or 20-minute HIIT is the optimal exercise strategy for VAT reduction. The results of this study can serve as a reference for health policy-makers developing exercise guidelines.

並列關鍵字

visceral adipose tissue ； exercise ； sequential multiple assignment randomized trial ； aerobic exercise ； high-intensity interval training ； resistance exercise

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