先天性心臟病學童之能量平衡相關行為、健康體位及相關因素探討

楊馥菱

doi:10.6342/NTU201603694

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先天性心脏病学童之能量平衡相关行为、健康体位及相关因素探讨

Energy Balance-Related Behaviors, Body Mass Index and Related Factors in School-aged Children with Congenital Heart Disease

杨馥菱 , 硕士　　导师：高碧霞　　

繁体中文 DOI： 10.6342/NTU201603694

先天性心脏病；身体活动；健康行为；身体质量指数；能量平衡相关行为； congenital heart disease ； physical activity ； health behaviors ； body mass index ； energy balance-related behaviors

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摘要 │ 参考文献 (221) │ 国际计量

摘要〈TOP〉

研究背景及目的：随着医疗科技的进步，有先天性缺损的儿童在密集照护下，存活率提升，造成慢性病儿童比例逐年提升；而先天性心脏病因手术技术和照护方式的改善，存活率提高至85%以上，探讨的重点不再只拘泥於发生率及死亡率，更要关心各种健康及社会心理等议题，需要长期追踪及了解。因此，本研究针对轻度及中至重度先天性心脏病学童分为两群体进行能量平衡相关行为、健康体位及相关因素之探讨。

研究方法：本研究采以横断性研究设计法﹙cross-sectional designs﹚，采量性研究法﹙quantitative study﹚设计，以结构式问卷测试。问卷内容参考高碧霞等人2013年所发展儿童版「健康生活型态」与父母版「健康生活型态」，内容包含健康情况、家庭社会环境因素和能量平衡相关行为。此外，实际测量儿童及父母的身高、体重，计算出身体质量指数，根据2010年陈伟德和张美惠教授发表台湾地区儿童及青少年生长曲线作为连续型资料，本研究采此资料公布之中位数(50th)为标准，减去先天性心脏病学童BMI得到调整後BMI，将调整後的BMI区分为BMI < 50th及BMI ≥ 50th两组，来了解这两组先天性心脏病学童在能量平衡相关行为及其相关因素之间的差异。收案期间为2014年6月3日至2014年10月31日，在台湾北部某儿童医院儿童心脏科门诊、病房及心脏超音波室筛选符合收案条件的先天性心脏病学童及其父母，纳入条件：(一)经心脏专科医师诊断为轻度先天性心脏病（心室中膈缺损、心房中膈缺损及开放性动脉导管）与中至重度先天性心脏病（法洛氏四重症、大动脉转位及心内膜垫缺损）先天性心脏病之7-12岁学童及其父母；(二)可用国台语沟通及识中文阅读且学童及父母皆同意参与访谈及问卷调查。以R version 3.1.3版进行描述性、推论性统计分析及回归模式做预测分析。

结果：
一、	参与本研究共123组，实际有效个案为97组，其中，诊断为轻度先天性心脏病学童及其父母共72组，而诊断为中至重度先天性心脏病学童及其父母共25组，回应率78.86%。本研究中97位先天性心脏病学童平均年龄为9.73 ± 1.49岁，皆介於7-12岁的国小学童，男童占53.61%（n = 52）、女童占46.39%（n = 45）。过轻学童占19.6%、过重至肥胖者占14.43%。
二、	轻度先天性心脏病学童体重过重及肥胖比例高於中重度先天性心脏病学童族群，而中重度族群过轻比例高於轻度族群。经中位数50th调整後儿童BMI平均值为-0.09 ± 3.61kg/m2，显示身体质量指数平均低於健康状况一般之学童。在心脏大小为正常及介於边缘值者身体质量指数与水分摄取有显着相关。
三、	能量平衡相关行为方面，轻度先天性心脏病学童在摄取优酪乳、养乐多、高油零食及饼乾类多於中重度先天性心脏病学童；两组在动态活动相对时间及静态活动时间上无显着差异，但中重度先天性心脏病学童在睡眠时数显着短於轻度先天性心脏病学童。
四、	综合探讨健康状况、家庭社会环境及能量平衡相关行为与学童身体质量指数作线性回归模式分析，考虑自变项与依变项的相互作用下，最终，以模式4为最佳精简预测模式，预测因子之解释变异量为73.49%。显着正相关的因子，包括：自觉健康状况与水分摄取之交互作用、心脏扩大与水分摄取之交互作用、服用Aspirin、自觉活动习惯普通、自觉饮食习惯普通、父母之身体质量指数、父亲教育程度为高中职、母亲职业为专业人员、宵夜外食及从事静态活动时间。显着负相关的因子，包括：先天性心脏病疾病分类为中重度、心脏大小为边缘值、患气喘、父母教育程度为国中、乘载学童上下学及摄取蔬果。

结论：先天性心脏病除了疾病治疗外，在生活方面仍面临许多挑战，在照护上需有整体性且持续性的观点。本研究预测结果可使医疗人员了解影响先天性心脏病学童身体质量指数的可能因素，包括：自身的疾病、家庭社会环境的影响和自身能量平衡的相关行为等三大部分。针对研究结果预测之因素，可提供对於有过重及肥胖风险的学童及其照顾者予以适当的建议；对於BMI过轻之学童可邀请营养师等进行跨团队的健康指导。在临床及学校方面，可提供对於先天性心脏病学童有正确的疾病，增进照护上的一致性及连贯性，促使学童有更健康的生活型态。

并列摘要〈TOP〉

Background and Purpose: With advances in medical technology and improvement in medical care, survival rates of children with congenital heart disease (CHD) have improved. The survival rate of these children has increased to 85%. The focus is no longer on reporting the incidence and mortality rates related to CHD but on following up health and psychosocial issues in these children. Therefore, this study focused on children with mild and moderate-to-severe CHD to understand energy balance-related behaviors, body mass index (BMI) and other related factors.
Methods: A hospital-based cross-sectional study design and quantitative research were performed to collect data for this study. The structured-questionnaire included a children’s version of “healthy life style” and a parents’ version of “healthy life style”. The questionnaire consisted of health parameters, environmental factors, and energy balance-related behaviors developed by Gau et al. (2013). Body height, body weight, waist-circumference and triceps skinfold were measured. BMI was calculated based on the continuous growth curve data of children and adolescents published by Chen and Chang (2010). This study used the median (50th) as the standard and subtracted the BMI of children with CHD to obtain the adjusted median BMI. The adjusted median BMI was divided into BMI < 50th and BMI ≥ 50th groups to understand these two groups of children with CHD in terms of energy balance-related behaviors and the difference between related factors. Data were collected at a medical center in northern Taiwan from the outpatient clinics of pediatric cardiology and pediatric wards from June 3, 2014 to October 31, 2014. The study included 7-12-year-old children with mild and moderate-to-severe CHD, and their parents. The inclusion criteria were as follows: (1) Children with mild CHD diagnosed by a cardiologist (ventricular septal defect [VSD], atrial septal defect [ASD], or patent ductus arteriosus [PDA]). (2) Children with moderate-to-severe CHD (tetralogy of Fallot [TOF], transposition of great arteries [TGA] or endocardial cushion defect [ECD]), and their parents. (3) Children and their parents who could understand Chinese and had agreed to participate in interviews and questionnaires. The data were analyzed by the Software R version 3.1.3 to version descriptive and inferential statistical analysis and regression models were used for predictive analysis.
Results: A total of 123 child-parent groups participated, of which 97 cases comprised the study group. A total of 72 children with mild CHD (ASD, VSD, or PDA) and their parents and 25 children with moderate-to-severe CHD (TOF, TGA, or ECD) and their parents were included. Thus, a response rate of 78.86% was achieved. The average age of participants was 9.73 ± 1.49 years, and 53.61% (n = 52) were boys and 46.39% (n = 45) were girls. In all, 19.6% (n = 19) had BMI < 15th and 14.43% (n = 14) had BMI ≥ 85th. More children with mild CHD were found to be overweight and obese than those in the moderate-to-severe CHD. However, the number of underweight children was higher in the moderate-to-severe CHD than the mild CHD. The average adjusted median of BMI (50th) was -0.09 ± 3.61 kg/m2. This showed that school-aged children with CHD had BMI below the normal average. Water intake is significant in children with normal heart size and borderline BMI. With respect to energy balance-related behaviors, children with mild congenital heart disease have higher consumption of yogurt, Yakult, high-fat snacks, and crackers than do children with moderate-to -severe congenital heart disease. No significant difference was found in physical activity relative time and sedentary behaviors, but the number was significantly lower in children with moderate-to -severe than in those with mild congenital heart disease.
In a comprehensive investigation of health status, generalized additive models (GAM) analysis of the associations between environment factors, energy balance-related behaviors and the children’s body mass index was performed. Considering the interaction between the independent and dependent variables, model 4 is the best predictor and explained a total variance of 73.49%. The variables which were significantly positive were: health states and interaction of water intake, heart enlargement and interaction of water, aspirin use, being aware of active habits, being aware of dietary habits, parents’ BMI, father’s education level (senior high school), mothers being working professionals, snacking at midnight and indulging in sedentary activities. Significant negative variables were: being diagnosed with moderate-to-severe CHD, borderline heart size, suffering from asthma, parental education level (junior high school), transporting children to and from school and intake of fruits and vegetables.
Conclusion: Besides receiving treatment for congenital heart disease, patients encounter numerous challenges in their daily lives, and nursing care must be both comprehensive and persistent. The predictions of this study can help medical personnel understand the possible factors that affect the body mass index of children with congenital heart disease, including their own disease, their family and social environment, and their own behavior related to energy balance. The predictive factors identified in this study can provide suggestions for children who are at risk of becoming overweight or obese and their appropriate care. For children with body mass indexes that are too low, nutritionists or other professionals can be consulted for cross-team health guidance. Clinics and schools can provide consistent and coherent care for accurate treatment for children with congenital heart disease, and promote healthier lifestyles for children.

参考文献 ( 221 ) 〈TOP〉

吕立（2012）．肥胖与气喘研究．未发表的博士论文．台北：国立台湾大学临床医学研究所．
连结：
林正常、王顺正、吴忠芳（2004）．国人日常生活身体活动量与热量消耗之参考资料研究．取自http://www.hpa.gov.tw/BHPNet/Web/HealthHouse/attachments/
连结：
邱靖雯﹙2005﹚．术後先天性心脏病学龄期儿童身体活动之探讨．未发表的硕士论文．台北：台北医学大学护理研究所．
连结：
洪佳仪、黄翊婷、吴汶玲、吴韦奕、唐锐哲、陈正伦（2014）．主观肥胖认知、运动及饮食行为对身体质量指数之影响研究．德明学报，38（2），47-62．
连结：
符明伶（2007）．注意力缺陷过动症与营养状况及过敏关系之探讨．未发表的博士论文．台北：国立台湾大学微生物与生化学研究所．
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