Tap chi THdNG TIN Y Dl/QC So 10 nam 2012
HOI CHIiNG CHUYEN HOA: MOT SO DAC DIEM DjCH T £ HOC VA CAC TIEU CHUAN CHAN DOAN
Ta VSn Binh*, Nguyen Vinh Quang**, Pham Thuy Hu'dng"", Ooan ThaiHu'ng***
Chung chuyen hoa (HCCH) ngay cang trd nen pho doan hoi chuhg nay, tuy nhien cic tieu chuan deu
tfnh thuan Idi trong thi/c hanh lam sang.
Hi^n nay, ed nhieu to chiTe da dUa ra eac tieu chuan chan doan HCCH nhu tieu chuan eiia nhom chuyen gia To chu'c Y te The gidi (WHO), ciia Lien dodn DTD quoc te (IDF), ciia Nhom nghien eii\j ve khdng insulin ehau Au (EGIR), eiia ATP I I I (ndm 2001), tieu chuan ATP I I I cap nhat nam 2005 thupc ChUdng trinh giao due cholesterol quoc gia ciia Hoa Ky (NCEP), tieu chuan ciia Hoi Npi tiet Lam sang My (AACE).
I I . MOT SO DAC D I E M D I C H TE HOC Tren the gidi da cd kha nhieu nghien eUu xac djnh ty Ie HCCH d cae quan the dan cU khac nhau. Theo tieu chuan cua NCEP thi HCCH dUdc Udc tfnh id 24% d ngUdi trUdng thanh d My, trong dd ty Ie nay d ngUdi dp tuoi
>50 chiem 44% [7]. Theo WHO (nam 2000), HCCH cd mat d 7-36% dan dng ehau Au va 5- 22% phu ni/ tuoi 40-55 [1]. 6 cdc nUdc ehau A, ty ie mac HCCH khoang 20-25% [5,9].
Ty Ie mac HCCH tang dan theo tuoi: lii^
tuoi 20-29 Id 6,7%, 60-69 la 43,5% vd >70 tuoi la 42%. 6 cac nhom tuoi 20-<70, HCCH gap d nam nhieu hdn nu', nhuVig tU lUa tuoi
>50 thi niJ lai gap nhieu hdn nam [6].
Nghien culi tren dan eU thanh thi d An Dp (tineo tieu chuan ciia NCEP) (1995), ty Ie HCCH la 4 1 , 1 % , trong dd yeu to HDL-C thap chiem ty Ie cao nhat (65,5%), sau do Id yeu t d huyet ap (55,4%), thap nhat Id yeu td roi loan glucose mdu khi ddi (26,7%) [12].
I^pt nghi§n eiftj eat ngang d Venezuela trong 2 ndm (tiT 1999-2001), da ddnh gia tren 3.108 ddi tUdng tuoi tir >20 eho biet ty Ie mac HCCH (Uieo NCEP ATP III) Id 31,2%, trong dd ty Ie d nam cao hdn d nQ'. Ty Ie mac tang len theo tuoi cung vdi mi^e dp beo phi. Ty Ie ndy thiip hdn d dan dng da do (17%) so vdi dan dng da den (27,2%), da trang (33,3%), nhutig Theo xu hu'dng phat trien cua xa hoi, hoi
bien hdn. Hien cd rat nhieu tieu chuan chan de cap tdi vai trd cua cic yeu to'trong HCCH, I . DAT VAN DE
Hoi ehimg chuyen hda (HCCH) la mdt nhdm cac yeu to nguy cd ve chuyen hda bao gom thira can hay beo phi, khang insulin, ft hoat dpng the chat, cae y§u to di truyin.
NhuTig ngUdi bj hdi chirtig ndy ed nguy cd cao hdn bi mac nhijtig benh lien quan den ti'ch tu cdc chat beo trong thanh ddng mach. NhuTig benh ed lien quan den HCCH thUdng gap la benh dpng mach vanh, dot quy, benh ddng mach ngoai bien, ddi thao dUdng (DTD) typ 2.
Ngdy nay, khi cac benh lay nhiem tuHg budc dUdc khong che vd day lui thi cac benh khdng lay dang dan trd thanh ganh nang eho xa hdi va su'c khde ciia eon ngUdi. Tai My, cd tdi 20-25% ngUdi tnj-dng thanh 6Mc cho Id bj hdi diutig nay. HCCH lien quan tdi beo phi d vLing bung vd ti'nh khang insulin, gop phan lam tang huyet ap (THA), tang eholesteral, giam HDL cholesterol va tang glucose mdu [2].
Nhieu nghien ciru tren the gidi da chi ra mdi lien quan giDs HCCH vd benh DTD. NhiJng ngUdi tien DTD cd ty Ie rat cao mac HCCH.
NhiJng ngUdi mac HCCH cd kha nang rat cao bj rdi loan dung nap dUdng mau hoac mac benh DTO. Theo Reaven G.M., ngUdi bj tien DTD se tang nguy cd benh ly tim mach vd thudng bieu hi|n nhieu yeu tS nguy cd ciia benh tim mach, day la nhdm cac yeu to nguy cd da dUdc gpi la HCCH. Theo Ilanne P., Eriksson J.G. va edng sU, ty IS HCCH tiieo ti§u chuan ciia WHO d doi tUdng suy giam glucose mau luc ddi d nam la 74% vd d nCT Id 52,2%, ty Ie HCCH d doi tUdng rdi loan dung nap glucose (IGT) d nam la 84,8% va d niJ Id 65,4%. Theo Issomaa B., Almgren P. va cong sU, DTD typ 2 vd rdi loan dung nap glucose Il4n quan ch^t che vdi HCCH [8].
•PGS.TS., TrUdng Dai hpc Y Ha Noi; "'TS.,"'ThS., Benli vien Noi tiet Trung uWng
Tap chi THdNG TIN Y DUQC So 10 nam 2012
khdng c6 si/ khde bi§t ndo d nfJ. Nhin chung, cac yeu t d HDL-C (65,3%), b^o byng (42,9%) va cao huyet dp (38,1%) Id thUdng g$p nhSt tnDng HCCH. Ldi sdng khdng Idnh mgnh cDng Idm tdng nguy cd ciia hOi ehirng ndy [11].
(j ViSt Nam, nghi§n ciru eiia Lg Nguyin Trung Ou'c Sdn vd c$ng si/ (ndm 2000) cho thdy, ty l§ HCCH d n$i thdnh Tp. Hd Chi f^inh Id 12%, ed liSn quan d^n tud'i, ty l§ phdn trdm md vd nghg nghiep [9]. Kgt qud nghien culi ciia Trdn Vdn Huy (ndm 2007) cho thdy, ty 1^
mSc HCCH d ngUdi trUdng thdnh Khdnh H6a Id 15,7% (theo tieu chuSn NCEP ATP III), trong dd dd tuoi >54 cd ty Ie cao nhSt Id 21,5%, nam gdp nhi&u hdn niJ vd yeu t d HDL-C thdp gdp nhilu nhdt (37%). Theo nghi§n ciru eiia Vien Dinh dudng Viet Nam (ndm 2000) d 620 ddi tUdng tuoi tir 25-64 cho thay ty Ie mdc HCCH Id 13,1%, rieng tai Hd Ndi vd Tp. Ho Chf Minh id 18% [10].
I I I . CAC T I E U CHUAN CHAN DOAN Hien nay, ed nhieu to chu'c xay dUng cac tieu ehuan chan dodn HCCH dac thii nhSm phuc vu eho mue tieu phdng chdng benh ma nhdm do theo dudi. Cac tieu chuan nay cd nhieu diem gidng nhau, nhUng cung cd nhQ'ng diem khac nhau ve vai trd ciia cac yeu t d trong HCCH, tinh thuan Ipi trong thUc hanh lam sang.
1. Tieu chuan cua WHO (1999) De chan doan xac djnh cd HCCH, budc phai cd tieu chf A (1 trong 4 di^m ciia A) them vdo tCr 2 diem trd len ciia tieu chf B.
1.1. Tieu chi bat buoc: khang insulin (tieu chf A); dUdc xem la khang Insulin khi cd mot trong cde bleu hien sau:
- DTD typ 2.
- Rdi loan dung nap glucose mau.
- Suy gidm dung nap glucose liic ddi.
Glucose mau binh thudng nhUng ed khdng Insulin (danh gia bdng ky thuat kep insulin: ky thuat kep duy tri glucose on djnh - tang insulin mau).
1.2. Cac tieu chf khac (tieu chfB):
THA tam thu >140 mmHg vd/hoac tam tn/dng >90 mmHg.
- ROI loan chuyen hda lipid:
-I- Triglycerid (>1,7 mmol/L; 150 mg/dl) va/hoae.
+ HDL-cholesterol (<0,9 mmol/L; 35 mg/dl dSI vdi nam; < 1 mmol/L; 39 mg/dl ddi vdi nu^.
- B^o byng (ti 1$ vdng eo/vdng hdng: d nam >0,9; d nCf >0,85) vd/hodc BMI>27 vdi ngUdi chdu A.
- Microaibumin ni§u dUdng ti'nh: ty Ie bai xuSft albumin nl$u £20 pg/phiit hodc ti Ie albumin/creatinln nl§u 230 mg/g.
Theo tifiu chuin ndy si/ khdng insulin la cdn thigt. Tuy nhiSn, cung tUdng ti/ nhu ATP I I I , DTD typ 2 khdng bj lo?i tiiT khdi chdn dodn. Trong thi/c hdnh Idm sdng, sU xac dinh khdng insulin cung nhu microaibumin nieu Id khd khdn, khd dp dgng r0ng rdi.
2. TiSu chuMn cua Lien doan DTD quoc te(IDF, 2005)
2.1. Tieu chf bit buoc: phdi cd beo trung tdm (dUdc xac djnh bdng tdng sd do vdng eo), so do ndy khac nhau theo cac chiing toe.
2.2. Cic tieu chf khac: ket hdp vdi bat ky 2 trong 4 tieu chf sau:
- Tdng triglycerid mau : + TG >1,7 mmol/L (150 mg/dl); hoac + E3a dilu tn eac roi ban lipkj mdu bdng thuoc - Gidm HDL-cholesterol mau:
+ Nam: <1,03 mmol/L (150 mg/dl); hoac + Nu': <1,29 mmol/L (50 mg/dl);
+ Hodc da dieu t n cac roi loan lipid mau bdng thuoc.
-THA:
+ Huyet dp tam thu >130 mmHg; hodc + Huyet dp tdm trUdng >85 mmHg; hoac + Dang dieu tn THA.
- Tdng glucose mdu lue ddi:
+ Glucose mau luc ddi >5,6 mmol/L (100 mg/dl) hodc.
+ Da 6yi6c chan dodn DTD typ 2 trUdc dd.
Neu BMI>30 kg/m^ thi beo trung tam la dUdc xdc dinh, cd the khdng can do vdng eo.
Beo trung tdm Id mot tieu ehf bat budc trong tieu chu^n ndy, bieu hien qua s6 do vdng eo. So do nay khac nhau theo cac sac toe va khi danh gia phai duS vao ti§u chuan sinh ly ciia chinh quan the ciia sac toe do. Tieu chuan ciia IDF mdt lan nQ^ xem beo trung tam eo tUdng quan rdt ro vdi khang insulin, do dd khdng can phai xet nghiem ^ n kem d§' danh gia khang insulin.
Tap chi THdNG TIN Y DifQC So 10 ndm 2012
3. TlSu chuin cua Nh6m nghien cutt ve khang insulin ehau Au (EGIR)
3.1. Tieu chf bat bu$c (tieu chf A): cd khdng insulin va/hodc tdng insulin mau luc ddi (nong do insulin mau d khodng tCr phan vl thir nhat cua nhiJng ngudi khdng bj DTD).
3.2. Cic tieu chfkhic (tieu chfB):
- Tdng glucose mdu: glucose mdu luc ddi
>6,1 mmol/L (nhuYig khdng bao gom DTD).
- THA khi:
+ Huyet dp tam thu >140 mmHg vd/hodc + Huyet dp t^m trUdng >90 mmHg hodc + Da di§u tn thuoc ha dp.
- Rdi loan chuyen hda lipid khi:
+ Triglycerid >2,0 mmol/L (178 mg/dl) vd/hode.
+ HDL-cholesterol <1,0 mmol/L (39 mg/dl);
+ Da dieu tri roi loan chuyen hda lipid.
- Beo bung khi: vdng eo >94 cm (ddi vdi nam) vd >80 cm (ddi vdi nU).
D^ eiian dodn xac djnh phai cd tang insulin mau (tieu chi A) vdi it nhat hai diem eiia tieu chf B.
Theo sau su edng bo djnh nghia eiia WHO ve HCCH vdo ndm 1999, EGIR dUa ra mot phien ban siiei doi chi ap dung cho nhUng ngUdi khdng bj DTD. Tieu chuan ciia EGIR de dp dung hdn trcing nghien cCru djch te vi khdng ddi hdi ky thuat kep glucose d ^ danh gid mire dp nhay cam ciia insulin. EGIR da de nghj sir dung nong dp insulin lue ddi de danh gia khang insulin va ap dung suy giam dung nap glucose mau luc ddi (IFG) nhU la mot tieu chuan thay the cho rdi loan dung nap glucose mdu (IGT). Tieu chuan ciia EGIR cung cd sU thay ddi nhd ve cdc chi so ciia THA, rdi loan chuyen hda lipid cung nhU gia trj ciia vdng eo vd da sir dung chu vi vdng eo de danh gid beo bung. Hdn nuS, n§u mot ngUdi da &\Sdz dieu tri THA hoac rdi loan md mdu ho dUdc coi nhU ed cae bat thUdng tUdng ihig.
4. Tieu chui'n cua ATP III thuoc Chwang trinh giao due vi cholesterol quoc gia (NCEP, 2005) cua Hoa Ky
HCCH dUdc xde djnh khi ed bat ky 3 trong 5 tieu dif sau:
- Tdng vdng bung:
+ Nam: £102 cm
+ Nu": >88 cm - Tdng triglycerid khi:
+ TG >1,7 mmol/L (150 mg/dl); hodc + Dieu trj tdng triglycerid.
- Gidm HDL-cholesterol k h i : + Nam: <1,03 mmol/L (40 mg/dl);
+ Nu-: <1,29 mmol/L (50 mg/dl);
+ Hodc dieu trj gidm HDL-cholesterol.
- Huyet dp cao khi:
+ Huyet dp tdm thu >130 mmHg; hoac + Huyet ap tam trUdng >85 mmHg;
+ Hoac dieu trj THA.
- Tang giucose mau luc ddi khi:
+ FBG >5,6 mmol/L (100 mg/dl); hoac + Dieu tri tang glucose mdu.
d ngUdi ehau A, tiSu chuan tang vdng bung la: >90 cm (nam) va >80 cm (nC).
HCCH theo tieu chuan ATP I I I vao ndm 2001, tap trung chii yeu vao yeu t d nguy ed eiia benh tim mach va khdng bat buoc phai CD khang insulin hoac bat thUdng glucose mdu, mac du bat thUdng ve glucose mau Id mdt trong ede tieu ehf de chan dodn HCCH. Ti§u chuan HCCH ciia ATP I I I da dUdc cap nhat vao nam 2005. NhuYig diem cap nhat la:
- Ha thap ngudng ciia glucose mau luc ddi xuong 5,6 mmoi/L (100 mg/dl), tiieo cap nhat eiia ADA ve dinh nghla suy giam glucose mdu iiic ddi (IFG) (gia tri ngUdng glucose mdu luc ddi theo tieu chuan nam 2001 la 6,1 mmoi/L).
Bao gom ed DTD trong tieu chf tang glucose mdu.
- Dieu tn rdi loan lipid vd THA cung dUdc coi Id mdt trong cde tieu chf ve roi loan lipid mdu vd THA.
5. Tieu chuan cua Hoi Noi tiet iSm sang My (AACE)
HCCH dupe xac dinh khi cd it nhat 1 yeu to chfnh vd 2 yeu t d phu:
S.l. Yeu to chinh:
- Jhiia can/beo phi: BMI >25 kg/m^ hoae vdng eo >94 cm (nam), >80 cm (niJ) hoae
- Nguy cd cao ciia tinh trang khang insulin khi cd it nhat mot trong eac bieu hien sau:
dUdc chan dodn benh mach vanh, THA, hdi chutig budng tnjTig da nang, tien sU gia dinh cd ngudi mac DTD typ 2, THA, mde benh tim
Tqp chi THONG TIN Y DUQC So 10 ndm 2012
mach, tien sir DTD thai ky ho$c roi loqin dung n^p glucose, khdng phdi ngUdi da trdng, idi sdng tinh t ^ i , BMI >25 kg/m^ ho^c vdng eo
>94 em (nam) vd >80 em (vdi nO^, tudi >40.
5.2. YeutSph{i:
- Triglycerides: £150 mg/dl (1,7 mmol/L) - HDL cholesterol thSp:
+ Nam: <1,03 mmol/L {40 mg/dl) + NO': <1,29 mmol/L (50 mg/dl) -THA: > 130/85 mmHg - Glucose mdu:
+ Glucose mdu liic ddi: 6,1-6,9 mmol/L (10-126 mg/dl).
+ Glucose 2 gid sau nghiem phdp tdng dudng huyet: 7,8-11 mmol/L (140-200 mg/dl)
Ndm 2003, cac nhd npi tiet hpc Idm sang My (AACE), da dua ra vdn de "Hdi ehimg khdng insulin". Theo hp, mpt s5 yeu t d dUde xem n h u la nhuTig dau hieu bat thudng ciia hoi ehirng bao gom tdng TG, giam HDL- ehoiesteroi, THA vd tdng dudng luc ddi vd sau dn. Ngoai ra, nhiJng yeu t d THA vd beo phi cung dUdc hp ehi ra. Luan diem ciia AACE nhan manh vai trd ciia danh gia lam sang trong chan dodn HCCH.
I V . KET LUAN
Ngdy nay, khi cac benh lay nhiem tirng budc dude khdng che vd day liii thi cdc benh khdng lay dang dan trd thdnh gdnh ndng eho xa hoi va sire khde ciia con ngUcfl. Trong dd, HCCH ngdy edng t r d nen pho bien hdn. SU gia tang ty Ie benh THA, rdi loan chuyen hda lipid, benh mach vanh, beo phi, DTD typ 2 dang Id nhOng thdeh thirc Idn ddi vdi kinh te va xa hdi.
Nghien eiili ve HCCH d Viet Nam v I n cdn ft, vi vay can tien hdnh nhieu nghien cuU hdn, nhat Id tren nhutig doi ti/dng tien DTD, nhSm de ra cac bien phdp can thiep dU phdng lam giam khdng nhijtig ngUdl mdc HCCH md ca ngUdl mde benh DTD. Ben canh do, can tim hieu, ly^
chpn cac tieu ehuan chan dodn HCCH tren the gidi cd the dp dung phii hdp vdi cong dong ngUdi Viet Nam.
TAX L l | U T H A M KHAO
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