基于结构方程模型的糖代谢影响因素分析以及基于动机谈话技术的社区糖尿病前期人群干预研究

发布时间：2018-04-28 06:15

本文选题：2型糖尿病 + 有序多分类Logistic回归分析　；参考：《南京医科大学》2015年硕士论文

【摘要】：糖尿病(diabetes mellitus,DM)是一种由多种病因引起的,以慢性高血糖为特征的代谢性疾病。国际糖尿病联盟(International Diabetes Federation,IDF)的数据显示:2014年,全球DM患病率约为8.3%,约有490万人死于DM及其并发症,与DM有关的医疗支出占全球医疗总支出的11%。我国属于DM高患病率国家,据估计,目前已有DM患者1.139亿。该病已成为继恶性肿瘤和心血管疾病之后,又一严重危害我国居民生命健康的慢性非传染性疾病。2型糖尿病(type 2 diabetes mellitus,T2DM)约占全部DM的90%。其发病机理涉及胰岛素抵抗和/或胰岛素分泌绝对或相对不足两个方面,二者具有遗传学基础,同时受诸多环境因素的影响。遗传和环境因素对该病的作用方式复杂,这对该病的病因研究带来挑战,尤其是在多元统计分析方法上。20世纪70年代,以J?reskog为代表的学者提出了结构方程模型(Structural Equation Modeling,SEM)。该方法是一种验证性的思维方法和分析技术,可以构建网状病因分析结构,明确各个因素在结构中的位点和各个位点之间的资源流向,并通过样本数据进行验证。最终,通过路径图清晰地表达因素或潜变量之间的作用方式,通过路径系数评价作用大小,这比传统统计方法更具优势。将该方法应用到T2DM的病因研究中将会丰富病因研究的方法学内容。另外,人群中还存在着大量的糖尿病前期或称糖调节受损(impaired glucose regulation,IGR)者,即血糖升高但未达到DM诊断标准者。IGR群体是DM的高危人群,我国现在约有4.934亿的IGR者,多达70%的IGR者最终会进展为DM。因此,在IGR群体中进行有效的DM危险因素干预具有重要意义。健康的生活方式是dm防治的基石。然而,如何提高个体行为改变的依从性一直是dm等慢性病管理领域的难题。在1983年,miller博士在一项戒酒的研究中提出了动机谈话(motivationalinterviewing,mi)技术—一种以客户(患者)为中心的指导性咨询方式,通过激发和化解客户的内心矛盾,促成客户的行为改变。该方法在西方国家已被广泛的应用于临床医疗机构,在改善患者的自我管理行为方面取得了一定效果。在国内,对mi技术应用的研究报道相对匮乏,将mi技术用于igr群体生活方式的干预研究未见报道。因此有必要探讨mi技术在我国社区igr群体管理中应用的效果,为社区dm高危人群以及患者生活方式管理提供新的思路和方法,进而丰富我国的dm等慢性病防治的方法学内容。第一部分基于结构方程模型的糖代谢影响因素分析通过对南京市某区无dm病史人群的横断面调查,获取可能影响t2dm发病的生活方式、生理状况与其他疾病、家族dm遗传史等资料,进行ogtt,检测个体的血糖、hba1c、胰岛素抵抗、胰岛分泌功能等指标,分别采用有序多分类累积比数logistic回归分析和sem分析探索血糖水平影响因素。主要结果如下:1.血糖水平相关因素的有序多分类累积比数logistic回归分析有效样本4727人,其中新诊断t2dm584人,igr1518人,ngt2625人。年龄30~89岁,男性占32.85%,女性占67.15%。血糖水平(以t2dm、igr、ngt划分等级)的多因素累积比数logistic回归分析显示:年龄增长、超重或肥胖、中心性肥胖、高血压、血脂异常、胰岛素抵抗以及dm家族史均是血糖水平升高的独立危险因素(均p0.05),inr30、inr120水平升高是血糖水平的保护因素(均p0.05),未发现性别、饮酒及体力活动与血糖水平存在统计学关联(均p0.05)。2.基于sem的糖代谢相关因素分析将全部因(自)变量(16个)纳入分析,基于探索性因子分析构建了三个潜变量:肥胖(包括bmi和wc),胰岛β细胞分泌功能(包括inr30和inr120)和血糖水平(包括fbg、pbg和hba1c)。采用加权最小二乘法(wls)进行sem拟合,估计各相关因素对胰岛素抵抗和胰岛β细胞分泌功能的效应,以及这些因素对最终血糖水平的效应。结果显示:年龄、体力活动不足、肥胖、高血压、血脂异常和dm家族史通过直接或间接作用于胰岛素抵抗或胰岛β细胞分泌功能对最终血糖水平产生效应,总体效应均为正向,相应的效应系数(β)分别为0.16、0.02、0.13、0.17、0.10和0.20。吸烟通过对胰岛β细胞分泌功能的负效应而对最终血糖水平起到正效应(β=0.07)。胰岛素抵抗对血糖水平既有直接正向效应(β=0.99),也可以通过正向作用于胰岛β细胞分泌功能进而对血糖水平产生负效应(β=-0.65),其对最终血糖水平的总效应为正向(β=0.34)。胰岛β细胞分泌功能对血糖水平为直接负效应(β=-0.97)。第二部分基于动机谈话技术的社区糖尿病前期人群干预研究采用随机对照试验设计,在南京市某社区卫生服务中心服务辖区招募糖尿病前期(糖调节受损,igr)者160名,年龄在40~79岁,随机分配到干预组(mi组)和对照组(传统健康教育组)各80例,开展为期1年的干预,最终随访到158名研究对象。对研究对象基线、干预6个月及1年时的各项指标进行综合评价。主要结果如下:1.干预组与对照组的自我管理知识与自我管理效能比较采用重复测量数据的方差分析,对两组的自我管理知识与自我管理效能得分进行组别、不同时间以及组别和时间交互效应分析,并进行组内和组间差异两两比较,以性别、年龄和文化程度为协变量。结果显示:干预6个月及1年时,两组研究对象的自我管理知识与自我管理效能平均得分较基线时均显著升高(均p0.05);干预1年时,干预组的自我管理效能平均得分显著高于对照组(p0.05)。2.干预组与对照组的行为改变效果比较本研究主要关注研究对象的7个目标健康行为。结果显示:干预6个月及1年时,除对照组在“减压”条目外,两组采取目标健康行为的比例较基线时均显著提高(均P0.05)。干预6个月时,干预组在“控制热量”和“监测”2个条目采取目标健康行为的比例均显著高于对照组(均P0.05);干预1年时,干预组在“控制热量”、“增加膳食纤维摄入”、“控制体重”和“锻炼”4个条目采取目标健康行为的比例均显著高于对照组(均P0.05)。3.干预组与对照组IGR转归情况以及其他健康指标变化比较干预1年时,干预组转化为NGT的比例(55.1%)显著高于对照组(36.6%),调整RR为2.03(P0.05)。干预组进展为DM的比例(5.1%)虽然低于对照组(12.7%),但其差异无统计学意义(P0.05)。干预1年时,干预组的FBG、PBG、BMI、SBP、DBP和TG平均水平较基线时分别下降0.37 mmol/L、1.59 mmol/L、0.64 kg/m2、2.78 mmHg、2.28mmHg和0.34 mmol/L,干预前后差异均有统计学意义(均P0.05);对照组的FBG、PBG、BMI和DBP平均水平较基线时分别下降0.20 mmol/L、0.79mmol/L、0.23 kg/m2和2.19 mmHg,干预前后差异均有统计学意义(均P0.05)。干预组的FBG、PBG、BMI平均下降水平高于对照组,其差异有统计学意义(均P0.05)。4.干预组和对照组的生活质量改善效果比较与基线相比,干预1年时,干预组在除躯体疼痛之外的其他7个维度的平均得分均显著提高,干预前后差异均有统计学意义(均P0.05);对照组在生理机能和社会功能2个维度的平均得分显著提高,干预前后差异有统计学意义(均P0.05)。干预1年时,MI组的生活质量总分、情感职能和生理职能的得分升高水平显著高于对照组(均P0.05)。
[Abstract]:Diabetes mellitus (DM) is a metabolic disease characterized by multiple causes of chronic hyperglycemia. The International Diabetes Federation (International Diabetes Federation, IDF) data show that in 2014, the global DM prevalence rate was about 8.3%, about 4 million 900 thousand people died of DM and its complications, and DM related medical expenditure accounted for the world. The 11%. in China is a country with high prevalence of DM. It is estimated that 113 million 900 thousand of the patients with DM have already become a chronic non communicable.2 diabetes mellitus (type 2 diabetes mellitus, T2DM), which is one of the most DM of 90%., after malignant tumor and cardiovascular disease. Two aspects of the absolute or relative deficiency of insulin resistance and / or insulin secretion, the two have the genetic basis and are affected by many environmental factors. Genetic and environmental factors have a complex role in the disease, which challenges the etiology of the disease, especially in the multivariate statistical analysis in the 70s.20 century, with J? Res KOG is a representative of the Structural Equation Modeling (SEM). This method is a verifying thinking method and analysis technique, which can construct the network etiological analysis structure, make clear the source flow between the loci and the loci in the structure, and verify by the sample data. Finally, through the sample data, The over path graph clearly expresses the interaction between the factors or the latent variables, which is more advantageous than the traditional statistical method. The application of this method to the etiological study of T2DM will enrich the methodological content of the etiological study. In addition, there are a large number of prediabetes or sugar regulation in the population. Impaired glucose regulation (IGR), which is the high risk population of DM, which is the.IGR group that has increased blood sugar but does not reach the DM diagnostic standard, our country now has about 493 million 400 thousand IGR people, and up to 70% of IGR will eventually advance to DM. therefore, it is of great significance to carry out effective DM risk factors in the IGR population. The cornerstone. However, how to improve the compliance of individual behavior changes has been a difficult problem in the management of chronic diseases such as DM. In 1983, Dr. Miller proposed motivationalinterviewing (MI) in a study of alcohol abstinence, a customer (patient) centered counseling approach by stimulating and dissolving customers. This method has been widely used in clinical medical institutions in western countries and has achieved certain effects in improving patients' self management behavior in the western countries. In China, the research reports on the application of MI technology are relatively scarce, and the intervention study of MI technology in IGR group life style has not been reported. It is necessary to explore the effect of MI technology in the community management of community IGR in China, provide new ideas and methods for the high risk population of community DM and the management of patients' life style, and then enrich the methodological content of the prevention and control of chronic diseases such as DM in China. The first part is based on the analysis of the influence factors of the structure Fang Chengmo type of sugar metabolism to Nanjing A cross-sectional survey of people without DM medical history in a district to obtain the lifestyle, physiological status and other diseases, other diseases, family DM genetic history and other data, OGTT, to detect the blood glucose, HbA1c, insulin resistance and islet secretory function of the individual, and to obtain the orderly multi classification cumulative ratio logistic regression analysis and SEM analysis respectively. To explore the influence factors of blood glucose level, the main results are as follows: 1. the orderly multi classification cumulative ratio of blood glucose levels is 4727 logistic regression analysis, of which the new diagnosis of t2dm584, igr1518, ngt2625, age 30~89, male 32.85%, and female 67.15%. blood glucose level (T2DM, IGR, NGT division grade) Logistic regression analysis showed that age growth, overweight or obesity, central obesity, hypertension, dyslipidemia, insulin resistance, and DM family history were independent risk factors for elevated blood glucose levels (all P0.05), inr30, inr120 levels were the protective factors for blood glucose levels (all P0.05), no sex, alcohol and physical activity were found. There was a statistical correlation between blood glucose levels (all P0.05).2. based on SEM based analysis of glucose metabolism related factors, all of the (16) variables were analyzed, and three latent variables were constructed based on exploratory factor analysis: obesity (including BMI and WC), islet beta cell secretory function (including inr30 and inr120) and blood glucose levels (including FBG, PBG and HbA1c). Weight least-squares (WLS) SEM fitting to estimate the effects of related factors on insulin resistance and islet beta cell secretory function, and the effects of these factors on the final blood glucose level. The results show that age, lack of physical activity, obesity, hypertension, dyslipidemia and DM family history are directly or indirectly involved in insulin resistance or pancreas. The secretory function of islet beta cells has a positive effect on the final blood glucose level, and the overall effect is positive. The corresponding effect coefficient (beta) is 0.16,0.02,0.13,0.17,0.10 and 0.20. smoking, respectively, through the negative effect on the secretory function of islet beta cells, which has positive effect on the final blood glucose level (beta = 0.07). Insulin resistance has direct positive positive effects on blood glucose level. The effect (beta =0.99) can also have a negative effect on the level of blood glucose (beta =-0.65) by positive effect on the secretory function of islet beta cells, and the total effect on the final blood glucose level is positive (beta =0.34). The secretory function of islet beta cells has a direct negative effect on blood glucose level (beta = -0.97). The second part of community diabetes based on motivational talk technology In a community health service center of Nanjing, 160 people, aged 40~79, were randomly assigned to 80 cases in the intervention group (Group mi) and the control group (the traditional health education group) in a community health service center of Nanjing. The intervention was conducted for a period of 1 years and followed up to 158. The main results were as follows: 1. the self management knowledge and self-management effectiveness of the intervention group and the control group were compared with the variance analysis of the repeated measurement data, and the difference between the self-management knowledge and self-management efficacy scores of the two groups was different. 1. Time and group and time interaction effect analysis, and the difference between group and group 22, with sex, age and educational level as covariate. The results showed that the average score of self-management knowledge and self-management efficacy of two groups of subjects increased significantly at 6 months and 1 years (P0.05), and intervention for 1 years, dry. The average score of self-management effectiveness of pre group was significantly higher than that of the control group (P0.05).2. intervention group and the control group. The study mainly focused on the 7 target health behaviors of the subjects. The results showed that the proportion of target healthy behavior in the two groups was compared to the baseline except the control group in the "decompression" entry for 6 months and 1 years. At 6 months, the ratio of the intervention group to the 2 items of "control heat" and "monitoring" was significantly higher than that of the control group (P0.05). In the 1 year intervention group, the intervention group took 4 items of "controlling heat", "increasing dietary fiber intake", "controlling weight" and "exercise". The proportion of healthy behavior was significantly higher than that of the control group (all P0.05) in the.3. intervention group and the control group, as well as the other health index changes in the 1 years, the proportion of the intervention group converted to NGT (55.1%) was significantly higher than that of the control group (36.6%), and the adjustment RR was 2.03 (P0.05). The proportion of the intervention group to DM (5.1%) was lower than the control group (12.7%). But the difference was not statistically significant (P0.05). At 1 years, the average levels of FBG, PBG, BMI, SBP, DBP and TG in the intervention group decreased by 0.37 mmol/L, 1.59 mmol/L, 0.64 kg/m2,2.78 mmHg, 2.28mmHg and 0.34 respectively. Do not decrease 0.20 mmol/L, 0.79mmol/L, 0.23 kg/m2 and 2.19 mmHg (P0.05) before and after intervention. The average decrease level of FBG, PBG, BMI in the intervention group was higher than that of the control group. The difference was statistically significant (all P0.05) in the.4. intervention group and the control group, the improvement effect of life quality was compared with the baseline, and the intervention group was in the intervention group at 1 years. The average scores of the other 7 dimensions except for somatic pain were significantly increased, and the differences before and after intervention were statistically significant (P0.05); the average scores of the 2 dimensions in the physiological function and social function were significantly increased in the control group, and the difference before and after intervention was statistically significant (P0.05). The total score of quality of life in group MI and emotional function at 1 years. And the score of physiological function was significantly higher than that of the control group (P0.05).

【学位授予单位】：南京医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1

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