摘要
21世纪全球超重和肥胖病的发生率均呈上升趋势,与肥胖病相关的高血压病患病率也急剧升高。高血压病流行广泛,是危害人类最严重的一种心脑血管疾病。因此,肥胖病并发高血压已成为我国常见病多发病。比较单纯性肥胖病和高血压病的病机,结合临床研究,总结出肥胖病并发高血压的病机：是肥胖病患者由于先天禀赋异常、情志失调、饮食不节、体虚年高等因素作用,致使肝、脾、肾三脏功能失调。多种致病因素相互作用导致脏腑气血阴阳失调,形成风、火、湿、痰、淤等病理性因素扰乱血脉导致气血运行失常,诱发高血压,形成肥胖病并发高血压。目前中医理论对单纯性肥胖病和高血压病均有相应论述,而对于肥胖病并发高血压的论述甚少。重视和及早开展对本病的研究,寻找安全有效的方法对其进行干预,有着重大的现实意义。本研究以中医基础理论为指导,结合现代医学统计方法,通过大样本回顾性调查研究和临床疗效分析,对肥胖病并发高血压的证候分型、诊断标准和针刺施治的效应进行初步探讨。
目的：通过对临床资料的回顾性调查分析和临床观察,总结单纯性肥胖病并发高血压的常见证型及证型内涵；通过观察针刺对本病的临床效应。探讨建立单纯性肥胖病并发高血压中医证候量化诊断标准,为本病的辨证和治疗提供有效可行的依据。
方法：1.根据文献研究和大样本病例调研获得单纯性肥胖病并发高血压中医四诊信息,将440例临床病例资料纳入运算组,将102例临床病例资料纳入考核组,应用因子分析,方差最大化正交旋转和聚类分析相结合进行统计学处理,分析证候之间组合规律,确立症状对证候的贡献度,得到证候分型及内涵,初步建立诊断标准,并用所得标准对考核组进行前瞻性检验。
2.通过对400例单纯性肥胖病并发高血压患者辩证施以耳针体针结合疗法。观察针灸治疗前及治疗3个月后患者的症状、体征、肥胖指标、血压的变化和疗效。采用SPSS17.0软件进行统计学处理,计量资料组间比较采用t检验,计数资料组间比较采用卡方检验。
结果：1.回顾性资料分析结果显示临床上单纯性肥胖病并发高血压的常见症状和体征有：形体肥胖,消谷善饥,口渴多饮,多汗,腹胀,疲乏无力,烦躁易怒,水肿,胸胁胀闷,头胀眩晕,头痛,耳鸣,舌暗红,苔白腻,脉细炫,出现频率在40%以上。本病的常见证型为肝火亢盛、阴虚阳亢、肝郁脾虚、痰湿壅盛、阴阳俱虚5型。肝火亢盛型：主症为形体肥胖,口渴喜冷饮,面红,发热,胸胁灼痛,耳鸣,口苦,尿黄,便秘,便干,月经色鲜红,舌红,苔黄,脉数。阴虚阳亢型：主症为形体肥胖,自汗,盗汗,手足心汗,五心烦热,腰膝酸软,手足心热,面红,多梦,头胀眩晕,耳鸣,心悸,舌红。肝郁脾虚型：主症为形体肥胖,消谷善饥,嗜睡,烦躁易怒,胸乳胀痛走窜,疲乏无力,畏寒,尿少,月经量少,色暗红有血块,脉弦,舌暗。痰湿壅盛型：主症为形体肥胖,烦躁易怒,胸胁胀闷,疲乏无力,畏寒,尿少,带下色白清稀,脉细。阴阳俱虚型：主症为形体肥胖,消谷善饥,嗜睡,口渴多饮,胸胁胀闷,疲乏无力,畏寒,带下色白清稀,尿少,舌暗,脉濡缓。
2.针灸治疗3个月后,肥胖病并发高血压组痊愈率14.0%,显效率66.0%,有效率12.5%,无效率7.5%。单纯肥胖组患者的总有效率高于并发高血压组[95.83%,92.50%(X2=78.57,P<0.01)]。两组患者治疗前及治疗后临床病证指标比较：单纯肥胖组及并发高血压组患者治疗后均显著低于治疗前(P<0.01)。两组各证型之间差异则无显著性意义(P>0.05)
结论：1.本研究通过文献研究及大样本的病历调研,全面收集肥胖病并发高血压患者中医四诊信息,采用严谨的设计思路和先进的统计学方法,结合专家意见,分析肥胖病并发高血压的临床信息,通过临床验证,获得肥胖病并发高血压的中医证候证型为肝火亢盛、阴虚阳亢、肝郁脾虚、痰湿壅盛、阴阳俱虚5型。
2.针灸疗法对单纯肥胖病及肥胖病并发高血压患者均具有良好的干预效果,表明针灸疗法同时具有减肥和降压的双重作用。
3.本研究将因子分析和聚类分析联合运用到证型的研究中,充分发挥了多元统计方法的作用并避免了两种方法各自的不足,使证型和证候内涵的归纳更科学。提供了一种新的思路和方法,为临床辨证施治提供依据,提高临床疗效的可重复性。
During the 21st century, the incidence of overweight and obesity rate showed an upward trend, and obesity-related hypertension rate increased rapidly. High prevalence of hypertension is the most serious harmful factor on humanity as a cardiovascular and cerebrovascular diseases. Therefore, obesity complicated with hypertension has become a common disease frequently occurring in China. Compare the pathogenesis of simple obesity with hypertension,also accord to the clinical research,the pathogenesis of obesity complicated with hypertension is:the obese patients because of congenital abnormalities, emotional disorders, improper diet, weak health factors in venerable age, result in the disturbance on liver, spleen and kidney. Interaction of multiple risk factors lead to imbalance in blood and viscera of yin and yang, the formation of wind, fire, damp, phlegm, silt and other pathologic factors that disrupt abnormal blood vessels cause blood to run, induced hypertension, lead to obesity complicated with hypertension finally. Currently TCM theory about simple obesity and hypertension both have the corresponding paper, but the part for obesity complicated with hypertension is little. Attention and early implementation of the research on this disease, to find safe and effective way to interfere with it have important meanings to this disease. In this study, based on TCM Theory, statistical methods of modern medicine is used, which is worked by a large sample of retrospective research and clinical analysis, syndrome classification, diagnostic criteria and the effect of treatment of acupuncture on obesity complicated with hypertension is discussed.
Objective:Summarize in simple obesity complicated with hypertension syndromes, and their contents through studying the retrospective study of clinical data analysis and clinical observations. Explore the establishment of the quantitative diagnostic criteria of syndrome of TCM on simple obesity complicated with hypertension and provide effective practical basis through the observation of clinical effect of acupuncture on this disease.
Method:1. Got the Chinese medical information on simple obesity complicated with hypertension according to the literature research and large sample case studies, put 440 cases of clinical data into the computing group, put 102 patients with clinical data into the assessment group, factor analysis, variance maximize the orthogonal rotation and cluster analysis were statistically analyzed between the combination of law syndrome, to establish the contribution of symptom check against candidates received syndrome type and content of the initial establishment of diagnostic criteria and use the standards for forward-looking assessment group test.
2. Through the 400 cases of simple obesity complicated with hypertension dialectical impose ear and body acupuncture therapy. Observation of acupuncture treatment before and after 3 months the symptoms, signs, obesity index, blood pressure changes and effects. By SPSS17.0 software for statistical treatment, measurement data between the two groups using t test, count data between the two groups by chi-square test
3. According to the fundamental of Chinese medicine treatment,patients in two groups all received combination therapy of auricular and body acupuncture. Symptoms,physical signs,obesity indexs,blood pressure in the patients were observed before and after the treatment by using SPSS17.0 software for statistical treatment, using t test for measurement data between the two groups count data between the two groups by using chi-square test
Results:1. Retrospective data analysis showed that patients with simple obesity complicated with hypertension on the common signs and symptoms include:polyorexia, thirst, polydipsia, sweating, abdominal distension, fatigue, irritability, edema, chest threat of inflation nausea, dizziness, headache, tinnitus, dark red tongue, greasy coating, thready pulse-hyun, more than 40% frequency. The disease syndromes are sthenia of liverfire deficiency of Yin leads to hyperactivity of Yang,stagnation of liver-QI with deficiency of the spleen,the overabundance of phlegm-wetness, deficiency of both Yin and Yan.2. Comparison of clinical symptom indexes between the two groups after the treatment:The indexes were significantly lower than those before the treatment.Comparison between the two groups after the treatment:Tatal effective rate in the simple obesity group was higher than that in the other group[95.83%,92.50%(X2=78.57,P<0.01)].
Conclusion:1. The methods of literature research and large sample of medical research, a comprehensive collection of patients with hypertension complicated by obesity in Chinese medical information, using precise design ideas and advanced statistical methods, combined with expert advice on the Concurrent high obesity blood pressure, clinical information, through clinical validation, access to obesity syndromes associated with hypertension in the content of the anger Kang Sheng, yin, stagnation and spleen deficiency, phlegm dampness, yin and yang, all virtual type 5.
2. Acupuncture has both weight-reducing and reducible blood pressure effects for obesity disease complicated with hypertension.It indicated that Acupuncture therapy is an effective method for obesity disease complicated with hypertendion.
3. In this study, factor analysis and cluster analysis to permit the joint use of research-based, full play the role of multivariate statistical methods and to avoid the two methods and their shortcomings, so that evidence-based and summarize syndrome concept is more scientific. Provides a new way of thinking and methods, provide the basis for the clinical syndrome differentiation and improve the repeatability of clinical efficacy.
引文
[1]周仲瑛.中医内科学[M].北京：中国中医药出版社,2003：459-460
[2]胡大一,黄峻.实用临床心血管病学[M].北京：科学技术文献出版社,2009
[3]王清海.论高血压的中医概念与病名[J].中华中医药学刊,2006,26(11)：2321-2323
[4]国家技术监督局.中华人民共和国国家标准.中医临床诊疗术语[S].北京：中国标准出版社,1997.7
[5]杨年红,胡虞志,黄艳.我国11城市儿童单纯性肥胖症调查及影响因素分析[J].同济医科大学学报,1999,28(5)：394-396
[6]张超.中药治疗单纯性肥胖症72例临床观察[J].云南中医杂志,1989,(5)：46
[7]杨若俊.儿童单纯性肥胖症中医认识概况[J].云南中医学院学报,2002,25(4)：3841
[8]龚海洋,骆斌.浅谈《黄帝内经》对肥胖的认识[J].北京中医药大学学报,2006,29(3)：149-151
[9]苏庆民,王琦.肥胖人痰湿型体质血脂、血糖、胰岛素及红细胞Na+-K+-ATP酶活性的检测及特征[J].中国中医基础医学杂志,1995,1(2)：3941
[10]王琦,叶家农.肥胖人痰湿型体质的血液流变学及甲皱微循环研究[J].中国中医基础医学杂志,1995,1(1)：52
[11]陈贵海.肥胖与血瘀证形成的相关性研究[J].山东中医药大学学报,2002,26(2)：129-131
[12]危北海,贾葆鹏.单纯性肥胖病的诊断及疗效评定标准[J].中国中西医结合杂志,1998,18(5)：317-319
[13]王永炎.中医内科学[M].第6版.上海：上海科学技术出版社,1997：337
[14]刘志诚,孙凤岷,胡葵.针灸治疗单纯性肥胖的临床研究[J].中医杂志,1997,38(3)：155-157
[15]刘志诚,洪承允,孙志,等.针灸治疗单纯性肥胖病并发痛经的疗效观察[J].中国针灸,2003,23(9)：521-523
[16]刘志诚,孙凤岷,闫润虎,等.针刺治疗女性肥胖伴更年期综合征的临床研究[J].中国中西医结合杂志,2004,24(6)：491495
[17]翁维良,徐铭渔,包晓峰,等.中医治疗单纯性肥胖44例疗效观察[J].中医杂志,1988,29(1)：41
[18]袁灿宇.袁海波教授辨证论治肥胖病[J].中医研究,2004,17(6)：13
[19]俞娜珍.中医辨证治疗单纯性肥胖病[J].江苏中医,1995,16(5)：4041
[20]郭义然.罗四维治疗肥胖症经验[J].江苏中医,2000,31(2)：6
[21]邓俊,刘雪萍,刘潮.中医辨证治疗单纯性肥胖病机探讨[J].甘肃中医,1997,10(1)：7-8
[22]魏群利,刘志诚.耳针、体针、耳体针结合治疗单纯性肥胖病临床疗效比较[J].南京中医药大学学报(自然科学版),2002,18(1)：45-47
[23]张中亮,傅乐之.推拿气功中药治疗的减肥效果[J].按摩与导引,1995,11(5)：21-22
[24]王永炎.中医内科学(第6版)[M].上海：上海科学技术出版社,1997：337
[25]傅世垣.中医康复学[M].上海：上海科学技术出版社,143-146
[26]陈维铭,钱涯邻,王馨然.单纯性肥胖患者胰岛素抵抗与中医辨证分型的相关性研究[J].中华实用中西医杂志,2004,4(17)：3273-3275
[27]赵恒侠,李培.单纯性肥胖患者血清瘦素、脂联素、肿瘤坏死因子、胰岛素、TT4与中医辨证分型的相关性探讨[J].广东医学,2008,2,29(2)：181-183
[28]古炽明,丁有钦.高血压病证候文献分析述评[J].中医药学刊,2003,7(21)：1156-1157
[29]蔡光先,朱克俭,等.高血压病常见证候临床流行病学观察[J].中医杂志,1999,40(8)：492493
[30]任敏之,符德玉,颜乾麟.高血压病患者中医证型与靶器官损害关系的临床研究[J].四川中医,2006,(9)：4748
[31]王爱珍,蔡治宾,吴罗杰.原发性高血压病中医辨证分型与肾素、血管紧张素Ⅱ初探[J].中国现代医学杂志,1998,8(5)：43
[32]张臣,邢之华,谭海彦,等.血浆一氧化氮及血压在不同中医证型高血压病患者中的变化[J].实用医学杂志,2005,21(5)：542-543
[33]沈毅,张继东,胡连海,等.原发性高血压病中医辨证分型与胰岛素抵抗的相关性研究[J].山东大学学报(医学版),2005,43(2)：142-144
[34]雷燕,胡锡衷.高血压病虚实辨证与性激素及p2-微球蛋白关系的探讨[J].中国中西医结合杂志,1994,14(11)：675-676
[35]张玉金.高血压病辨证分型和血液动力流变学的关系[J].辽宁中医杂志,1998,25(11)：507
[36]刘华,周君富.高血压病不同证型血液LPO和血液流变学及血小板聚集功能的研究[J].现代中西医结合杂志,1995,4(3)：66
[37]赵津辉,杨利军,王翠平,等.高血压人群及正常人群血流变学指标变化的实验研究[J].现代中西医结合杂志,2000,9(18)：1752
[38]张琳,马峰,方亚伦,等.高血压病人中医辨证分型与甲襞微循环变化的关系[J].微循环学杂志,1995,5(1)：39-40
[39]段开骏,刘洁,白春锦,等,中医辨证分型高血压病病人颅内动脉脑血流动力学变化[J],中西医结合心脑血管病杂志,2006,4(2)：101-103
[40]梁东辉,张瞀,李小敏等.高血压病中医辨证分型与血脂水平关系的探讨[J].辽宁中医杂志,1996,23(4)：148
[41]刘志诚.肥胖病的中医治疗[M].北京：人民卫生出版社,2008.7.(第一版)
[42]刘志诚,孙凤珉,徐斌,等.针灸治疗肥胖病并发高血压116例临床观察[J].针灸临床杂志,2005,21(2)：11-13
[43]刘志诚,孙凤岷,袁锦虹,等.针灸治疗肥胖病并发高血压116例临床观察[J].针灸临床杂志.2005,21(2)：11-13
[44]徐炳国,刘志诚.针灸对肥胖并发高血压瘦素胰岛素抵抗的影响[J].上海中医药杂志.2005,39(10)：37-39
[45]徐炳国.针刺对肥胖并发高血压患者一氧化氮和一氧化氮合酶含量的影响[J].浙江中医杂志.2006,41(3)：134-135
[46]胡大一,黄峻.实用临床心血管病学[M].科学技术文献出版社,2009
[47]WHO.Obesity:Preventing and managing the gloabal epedemic·Geneva:World Health Organization, 1998
[48]Larsson B.Obesity and body fat distribution as predictors of coronary heart disease-New York:Oxford University Press,1992:233-241
[49]Stem M.Metabolism,1995,44 (Suppl 3):1-3
[50]Stein CJ. and Colditz GA. (2004) The epidemic of obesity[J].Clin EndocrinolMetab,89,2522-5.
[51]Anne M.Am J Clin Nutr,1996,63 (Sup-pl):4665-4695
[52]Wolf AM.Obes Res,1998,6:97-106
[53]Flegal KM.Int J Obes Relat Metab Disord,1998,22:39-47
[54]王文绢.中华流行病学杂志,1999,22(2)：129-132
[55]中华人民共和国卫生部、科技部、国家统计局.中国居民营养与健康现状[J].中国保健营养,2004,13(11)：8-11
[56]Sturm RA. (2002) The effects ofobesity, smoking and drinking on medical problems and costs. Obesity outranks both smoking and drinking in its deleterious effects on health and health costs. Health Af,f 21,245-53
[57]Kaplan NM. The deadly quartet; Upper-body obesity, glucoseintolerance,hypertriglyceridemia and hypertension. Arch Intern Med,1989,149:1514-1520
[58]Hubert HB.Circulation,1983,67:968-977
[59]Stamler R.J Am Med Assoc,1978,240:1607-1611
[60]Higgins M.Acta Med Scand,1987,723:233-365
[61]Ducimetiere P-Int J Obesity,1986,10:229-240
[62]MacMahon SW.N Engl J Med,1986,314:334-339
[63]吴琼.肥胖并发症的临床流行病学调查分析[J].湖南中医学院学报,2005,25(4)：49-52
[64]封苏琴,郝超,沈洪兵,姜维平.肥胖与糖尿病、高血压关系的流行病学研究[J].江苏预防医学,2000,11(4)：3-5
[65]马力宏.肥胖与遗传[J].天津体育学院学报,2003,13(3)：1-7
[66]方忠宏.肥胖治疗现状与肥胖发生机理假说[J].上海医药,2003,24(9)：402-406
[67]Pickering TGObesity and hypertension:What should we do[J].Ann InternMed,2001,134:72-74
[68]FariaAN,Ribeiro Filho FF,LerarioDD, et al Effect of sibutramine on the treatment of obesity in patients with arterial hypertension[J].BrasCardio,2002,78:172-180
[69]叶世伟,尚惺杰,黎红光.奥利司他联合二甲双胍治疗肥胖并发高血压24例[J].Herald of Medicine2006,25(9):886-887
[70]Guy-Grand B,Drouin P,Eschwege E, et al Effects of orlistaton obesity-related disease-a six month randomized trial[J]. Diabetes Obes Metab,2004,15:375-383
[71]Tack CJJ, OngMKE, Lutterman JA, et a.l Insulin induced vasodilatation and endothelial function in obesity/insulin resistance:effects of troglitazone[J].Diabetologia,1998,41:569-576
[72]Lind L,Berne C,Andersson PE, et a.l Is insulin resistance a predictor of the blood pressure response to anti-hypertensive treatment[J] J HumHypertens,1995,9:759-763
[73]WHO.Obesity preventing and managing the global epidenmic-report of a WHO conclution on obesity.Greneva:WHO,1997.9-43
[74]International Obesity Taskforce.The Asia-Pacific perspective:redefining obesity and its treatment.Milan:Health Communication Australia Pty Limited,International Association for the Study of Obesity,2008.8-14
[75]中国肥胖问题工作组数据汇总分析协作组.我国成人体重指数和腰围对相关疾病危险因素异常的预测价值：适宜体重指数和腰围切点的研究[J].中华流行病学杂志,2002,23(1)：5-10
[76]翁维良,焦东海.实用中西医结合肥胖病学[M].学苑出版社,1997,6
[77]Chalmers J.WHO-ISH Hypertension Guidelines Committee.1999 World Health Organization-International Society of Hpertension Guidelines Management of Hypertension.Hypertens 1999; 17:151-85
[78]郑筱萸.中药新药临床研究指导原则(试行)[M].北京：中国医药科技出版社.2002：87,99
[79]梁茂新,洪治平.中医症状量化的方法初探[J].中国医药学报,1994,9(3)：37
[80]徐迪华,徐剑秋.中医量化诊断[M].南京：江苏科学技术出版社,1997：50
[81]邓铁涛.中医诊断学[M].上海：上海科学技术出版社,1984
[82]白晓菊,宋树立.中医证候规范化定量化研究述评[J].中国医药学报,2002,17(1)：37
[83]姚魁武,王阶.血瘀证证候量化诊断流行病学调查研究[J].北京中医药大学学报,2007,30(3)：206-209
[84]汪东生,朱文锋.眼科血瘀证诊断标准的探讨[J].承德医学院学报.1998,15(4)：304-307
[85]凌玲.245例脑卒中急性期中医证候关系研究分析[J].陕西中医,2002,23(8)：69
[86]寺泽捷年(陈可冀等译).瘀血证的证候分析与诊断标准刍议.国外医学,中医中药分册,1984,6(1)：1
[87]陈国林,潘其民,赵玉秋,等.中医肝病证候临床辨证标准的研究[J].中国医药学报.1990,5(1)：66-70,73
[88]金益强.《中医肝脏象现代研究与临床》[M].北京：人民卫生出版社,2000：239-242
[89]邱向红.脾虚证计量诊断的探讨[J].广州中医学院学报,1990,7(1)：24-27