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Interpretation of the Chinese Guidelines on Medical Nutritional Therapy for Overweight/Obesity(2021)
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摘要: 肥胖已成为一种全球性“流行病”，现阶段超重/肥胖已成为严重影响人们身心健康的主要公共卫生问题。医学营养治疗既是肥胖治疗的基础，也是肥胖病程中任何阶段预防和控制必不可缺的措施。2021年12月，《中国超重/肥胖医学营养治疗指南(2021)》发布，指南内容涵盖医学营养减重干预方法中不同膳食模式及代餐食品、生物节律、肠道微生态、代谢手术等与减重的关系，并对特殊人群的减重进行了阐述。本文将对该指南的重点内容进行解读，以期为超重/肥胖的规范化诊疗及管理提供临床借鉴。Abstract: Obesity has become a global "epidemic".At this stage, overweight/obesity has become a major public health problem that seriously affects the physical and mental health of Chinese people. Medical nutritional therapy is the basic treatment for obesity and an indispensable measure for prevention and control at any stage in the course of obesity.In December 2021, the Chinese Guidelines on Medical Nutritional Therapy for Overweight/Obesity (2021) was published, which covers the relationship of weight loss with different dietary patterns, meal replacement foods, biorhythms, intestinal microecology, metabolic surgery, and medical nutritional intervention, as well as weight loss in special populations. With a view to providing clinical reference for the standardized treatment and management of overweight/obesity, this paper makes a detailed interpretation of the key points of the guidelines.
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Keywords:
- overweight /
- obesity /
- nutritional therapy /
- guideline
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肺癌的发病率和死亡率居恶性肿瘤首位，由于早期无明显症状，多数患者确诊时已处于中晚期，失去了最佳治疗时机，5年总生存率仅为19.7%[1]。近年来，随着手术方式的改进，术后放化疗、靶向治疗、免疫治疗[2]等快速发展，肺癌患者的生存期及生活质量有望得到进一步改善。但放化疗在杀灭肿瘤细胞的同时，对机体正常组织也会造成损伤，如化疗药物导致的药物性肺损伤(drug induced lung injury, DILI)[3]及放疗导致的放射性肺损伤(radiation induced lung injury, RILI)[4]是肺癌患者术后辅助治疗的常见并发症，如不及时诊断与治疗，可发展为肺间质纤维化，严重者可因呼吸衰竭而死亡。
涎液化糖链抗原-6(kreb von den lungen-6, KL-6)是分子量约为200 kD的大分子量黏液糖蛋白，生理状态下主要表达于Ⅱ型肺泡上皮细胞、细支气管上皮细胞，具有促进肺纤维细胞存活、迁移和增殖的作用，有望成为特发性肺纤维化(idiopathic pulmonary fibrosis, IPF)的药物治疗靶点[5-6]。与目前应用的肺损伤诊断、病情监测工具如高分辨率计算机断层扫描(high resolution computed tomography, HRCT)、支气管镜检查、肺活检、连续肺功能测试等相比，血清KL-6检测具有创伤小、费用低、结果准确、可重复检测等优点。目前血清KL-6在肺癌辅助治疗性肺损伤中的研究主要集中于日本人群，已有文献报道血清KL-6的表达存在种族差异[7]。本研究以206例原发性非小细胞肺癌(non-small cell lung cancer, NSCLC)患者为研究对象，旨在探讨血清KL-6在中国人群NSCLC患者术后辅助治疗性肺损伤中的诊断价值。
1. 资料与方法
1.1 研究对象与分组
1.1.1 研究对象
本研究为回顾性分析，以NSCLC患者(包括术后采用辅助治疗者和仅手术者)及健康成人为研究对象。NSCLC术后辅助治疗、NSCLC手术患者分别来自2017年11月—2020年7月中国医科大学附属盛京医院肿瘤科和胸外科，健康成人来自同期中国医科大学附属盛京医院体检中心(健康对照组)。
辅助治疗性肺损伤诊断标准如下。DILI诊断标准[8]：(1)有致肺损伤药物摄入史；(2)有药物致肺损伤的临床表现，且可排除其他原因；(3)影像学证实肺部有间质性肺损伤改变；(4)停止化疗后患者临床表现得到改善。RILI诊断标准[4]：(1)有肺部放疗史；(2)肺部有相应的影像学改变，其中1级RILI仅有影像学改变，≥2级伴有咳嗽、气短、发热等临床症状；(3)排除其他原因导致的肺损伤。遵循上述诊断标准，由两名肺部肿瘤高年资医生、一名呼吸放射高年资医生共同完成DILI、RILI的诊断。
NSCLC患者纳入标准：(1)NSCLC的诊断标准符合《中国临床肿瘤学会(CSCO)原发性肺癌诊疗指南2019》[9]，且经术后组织病理活检证实；(2) TNM分期为Ⅱ~Ⅲ期；(3)术后辅助治疗患者耐受性较好，可接受化疗、放疗，具体治疗方法符合指南规定[9]；(4)行肺癌切除术患者手术方式包括胸腔镜解剖性肺切除联合肺门纵隔淋巴结清扫术、机器人辅助解剖性肺切除联合肺门纵隔淋巴结清扫术。排除标准：(1)合并精神疾病或认知功能低下，无法配合治疗者；(2)除NSCLC外，合并其他恶性肿瘤、重要器官功能障碍、全身感染患者。
健康对照组纳入标准：(1)表观正常，自觉无身体不适；(2)年龄、性别与NSCLC术后辅助治疗患者匹配；(3)肺部HRCT结果正常，无呼吸系统疾病。排除标准：存在精神疾病、认知功能障碍、结缔组织病、恶性肿瘤及各系统重大疾病者。
1.1.2 肺癌患者筛选流程
NSCLC术后辅助治疗组患者血清标本来自检验科与肿瘤科共同建立的肺癌术后辅助治疗患者血清标本库；首先从该库中筛选肺损伤患者(肺损伤组)，随机选取与肺损伤组患者性别、肺癌分型、TNM分期及术后辅助治疗方式无统计学差异，且年龄相近的无肺损伤患者为无肺损伤组。然后随机选取性别、肺癌分型、TNM分期与肺损伤组、无肺损伤组患者无统计学差异，且均在术前、术后7~10 d采集静脉血的仅手术患者为NSCLC手术组。
本研究已通过中国医科大学附属盛京医院伦理审查委员会审批(审批号：2018PS018J)。
1.2 研究方法
1.2.1 标本采集时间及血清KL-6检测
肺损伤组于肺损伤确诊当日，无肺损伤组于辅助治疗第3~4个月，NSCLC手术组于术前与术后7~10 d，健康对照组于体检当日，采集空腹静脉血3.0 mL，3500 g离心10 min，分离血清于-70 ℃冷冻保存。采用贝克曼库尔特AU5800全自动生化分析仪集中进行血清KL-6检测。试剂盒由日本积水医疗株式会社生产，购于积水医疗科技(中国)有限公司。检测方法为胶乳凝集法。根据试剂盒说明书，正常健康成人血清KL-6的参考区间为105.3~401.2 kU/L。
1.2.2 样本量估算及偏倚控制
本研究根据两独立样本均值比较的样本量计算公式：n1=n2=2[(uα+uβ)/(δ/σ)]2+1/4uα2，其中δ为两总体KL-6均数的差值；σ为总体标准差，双侧检验，检验水准α=0.05，β=0.10，uα=1.96，uβ=1.28。肺损伤组、无肺损伤组总体KL-6均值分别约为628.02、171.62 kU/L，δ=456.40，σ=362.87，δ/σ=1.3，经计算肺损伤组和无肺损伤组所需样本量均约为14例。NSCLC手术组、健康对照组总体KL-6均值分别约为249.69、189.79 kU/L，δ=59.90，σ=102.25，δ/σ=0.6，经计算NSCLC手术组和健康对照组所需样本量均约为60例。
偏倚控制：(1)血清KL-6检测试剂盒均购自同一公司，使用固定的仪器按照标准操作流程进行检测；(2)血清KL-6检测人员均经统一培训。
1.3 统计学处理
采用SPSS 26.0软件进行统计分析。采用Kolmogorov-Smirnov检验及Q-Q图对计量资料进行正态性检验。符合正态分布的计量资料(年龄)以均数±标准差表示，组间比较采用单因素方差分析；不服从正态分布的计量资料(血清KL-6)以中位数(四分位数)表示，组间比较采用Kruskal-Wallis检验或Mann-Whitney U检验。计数资料以频数(百分数)表示，组间比较采用χ2检验。采用受试者工作特征(receiver operating characteristic，ROC)曲线评估血清KL-6诊断NSCLC术后辅助治疗性肺损伤的效能。以P＜0.05为差异具有统计学意义。
2. 结果
2.1 一般临床资料
共206例NSCLC患者及103例健康对照者纳入本研究。其中肺损伤组51例、无肺损伤组52例(图 1)，NSCLC手术组103例。肺损伤组临床表现为咳嗽23例(45.10%)、呼吸困难21例(41.18%)、发热11例(21.57%)、无症状3例(5.88%)。无肺损伤组无症状51例(98.08%)，呼吸困难1例(1.92%)。4组性别(P=0.926)、合并结缔组织病(P=0.166)无统计学差异，年龄(P＜0.001)、合并慢性阻塞性肺疾病(P=0.037)存在统计学差异；肺损伤组、无肺损伤组、NSCLC手术组病理类型(P=0.634)、TNM分期(P=0.756)无统计学差异；肺损伤组、无肺损伤组辅助治疗方式(P=0.780)无统计学差异，见表 1。
表 1 患者一般资料比较指标 肺损伤组(n=51) 无肺损伤组(n=52) NSCLC手术组(n=103) 健康对照组(n=103) P值 年龄(x±s, 岁) 58.51±7.14 53.06±8.70 59.26±7.08 54.61±8.90 ＜0.001 性别(男/女，n) 33/18 32/20 66/37 62/41 0.926 病理类型(腺癌/鳞癌，n) 43/8 40/12 82/21 - 0.634 TNM分期(Ⅱ/Ⅲ期，n) 23/28 27/25 48/55 - 0.756 术后辅助治疗方式(单纯放疗/同步放化疗，n) 18/33 17/35 - - 0.780 合并慢性阻塞性肺疾病[n(%)] 4(7.84) 1(1.92) 3(2.91) 0(0) 0.037 合并结缔组织病[n(%)] 1(1.96) 0(0) 0(0) 0(0) 0.166 NSCLC：同图 1；-：不适用 2.2 血清KL-6比较
单因素方差分析显示，血清KL-6在各组间差异有统计学意义(P＜0.001)。进一步组间比较显示，血清KL-6由高至低依次为肺损伤组[512.40(322.30，819.20)kU/L]、NSCLC手术组(术前)[204.40(162.70，283.20)kU/L]、健康对照组[177.70(154.20，206.40)kU/L]、无肺损伤组[147.80(114.25，229.80)kU/L]和NSCLC手术组(术后)[143.80(111.90，247.80)kU/L]。除无肺损伤组与NSCLC手术组(术后)血清KL-6无统计学差异(P=0.879)外，其余两两比较差异均有统计学意义(P均＜0.05)，见图 2。
2.3 NSCLC术后辅助治疗性肺损伤诊断界值的初步建立
ROC曲线分析显示，以无肺损伤组患者为对照，血清KL-6诊断NSCLC术后辅助治疗性肺损伤的曲线下面积(area under the curve，AUC)为0.972(95% CI：0.948~0.997)，灵敏度、特异度、阳性似然比、阴性似然比分别为86.3%(95% CI：73.0%~94.1%)、96.2%(95% CI：86.2%~98.7%)、22.43(95% CI：5.74~87.69)、0.14(95% CI：0.07~0.28)，最佳诊断临界值为310.15 kU/L(图 3)。
3. 讨论
本研究对NSCLC手术患者、NSCLC术后辅助治疗患者及健康成人的血清KL-6进行了比较，发现NSCLC术后辅助治疗性肺损伤患者的血清KL-6显著高于辅助治疗后无肺损伤的患者、NSCLC手术患者及健康对照人群。ROC曲线分析显示，血清KL-6诊断NSCLC术后辅助治疗性肺损伤的AUC为0.972(95% CI：0.948~0.997)，灵敏度、特异度、阳性似然比、阴性似然比分别为86.3%(95% CI：73.0%~94.1%)、96.2%(95% CI：86.2%~98.7%)、22.43(95% CI：5.74~87.69)、0.14(95% CI：0.07~0.28)，最佳诊断临界值为310.15 kU/L。
肺癌患者术后辅助治疗性肺损伤包括由化疗引起的DILI及由放疗导致的RILI，均属于间质性肺疾病(interstitial lung disease, ILD)，主要累及肺泡壁，表现为Ⅰ型肺泡上皮细胞受损脱落，Ⅱ型肺泡上皮细胞异常增生。影像学检查可见弥漫性浸润阴影，肺活检病理示弥漫性肺实质、肺泡炎症和间质纤维化[10]。肺损伤患者的肺功能进行性降低，不仅严重影响生活质量，且患者可因呼吸衰竭而死亡，极大程度缩短了生存期。因此，早期发现并及时治疗对提高患者的生活质量、延长生存时间至关重要。目前，临床尚缺乏间质性肺损伤诊断的血清学标志物，HRCT是DILI、RILI诊断及病情监测的常用手段，但部分疾病如结核分枝杆菌感染、肺癌等，肺部HRCT表现与DILI、RILI影像学改变类似，单纯依据HRCT易误诊；另一方面，HRCT具有辐射性，不适于NSCLC患者短期内病情的连续监测。因此，探究来源于Ⅱ型肺泡上皮细胞的血清生物标志物在NSCLC患者术后辅助治疗性肺损伤诊断中的应用价值具有重要作用。KL-6是一种主要在Ⅱ型肺泡上皮细胞和细支气管上皮细胞中表达的高分子量黏液糖蛋白，DILI、RILI时肺泡基底膜受损，Ⅱ型肺泡上皮细胞为修复损伤而增生，导致KL-6生成增多并通过受损的基底膜进入血液。因此，血清KL-6作为间质性肺损伤的特异性标志物，在各种以Ⅱ型肺泡上皮细胞增生为特征的ILD如IPF、胶原血管病相关间质性肺炎、超敏性肺炎、急性呼吸窘迫综合征、肺结节[7]及严重急性呼吸综合征所致肺损伤[11-13]的诊断、病情严重程度评估及治疗效果监测中具有重要价值。另有研究报道，血清KL-6是预测依维莫司致肺损伤的生物标志物[3]，亦可准确预测放射性肺炎的发生及评估治疗疗效[14-15]。对于RILI、DILI，既往研究认为血清KL-6是可靠的血清生物标志物之一，但其研究对象主要为日本人群[7]，目前缺乏KL-6在中国人群NSCLC术后辅助治疗性肺损伤诊断价值的相关研究。
本研究结果显示，肺损伤组血清KL-6升高最为显著，且与其他组比较均有统计学差异，提示血清KL-6在NSCLC术后辅助治疗性肺损伤中具有诊断价值；进一步以无肺损伤组为疾病对照组，通过ROC曲线评估其诊断辅助治疗性肺损伤的临床价值，结果显示血清KL-6诊断NSCLC术后辅助治疗性肺损伤的AUC达0.972，且灵敏度和特异度均较高，提示其具有较高的诊断效能，与既往报道的血清KL-6诊断ILD的灵敏度约为70%~100%相符[7]。
本研究ROC曲线分析显示，血清KL-6诊断NSCLC术后辅助治疗性肺损伤的最佳诊断临界值为310.15 kU/L，该诊断临界值在本研究所使用试剂盒说明书提供的正常参考区间范围内。既往文献报道，血清KL-6表达水平存在种族差异[7]。本研究所使用的血清KL-6检测试剂盒说明书提供的参考区间来源于日本人群，是否适用于中国人群尚未可知。为减少偏倚、使结果更客观，本研究团队基于纳入的健康对照人群数据，初步建立中国东北地区50岁以上健康成人的血清KL-6参考区间为112.90 ~311.52 kU/L，其上限值显著低于试剂盒说明书提供的参考区间上限值，且与本研究确定的最佳诊断临界值310.15 kU/L基本一致。
有文献报道，KL-6在肺癌细胞中高度表达，其在肺癌患者中的阳性率约为30%~70%[5, 16-19]。本研究NSCLC手术组(术前)血清KL-6水平高于健康对照组，与KL-6在肺癌中的高表达有关；生理情况下，Ⅱ型肺泡上皮细胞、细支气管上皮细胞是KL-6的主要产生部位，NSCLC手术组(术后)与NSCLC术后辅助治疗无肺损伤组患者的血清KL-6水平显著低于健康对照组，可能与其肺叶切除有关。
研究的局限性：(1)本研究为单中心、单因素回顾性研究，入选病例均为TNM分期Ⅱ~Ⅲ期的NSCLC患者，需扩大肺癌人群进一步探讨。(2)肺损伤患者的HRCT表现较一致，严重肺纤维化的患者较少，无法探究血清KL-6与肺损伤严重程度的关系。(3)文献报道显示，ILD发病后患者血清KL-6水平与基线(治疗开始)的比值可预测表皮生长因子受体酪氨酸激酶抑制剂治疗的晚期NSCLC患者预后[20]。本研究未对患者进行动态监测，无法判断血清KL-6在NSCLC术后辅助治疗性肺损伤患者预后预测中的作用。
综上，NSCLC术后辅助治疗性肺损伤患者血清KL-6显著升高，其在NSCLC术后辅助治疗性肺损伤诊断中具有较高的应用价值，但仍需大样本前瞻性研究进一步验证。
作者贡献：孙铭遥负责查阅文献、撰写论文；陈伟负责审核及修订论文。利益冲突：所有作者均声明不存在利益冲突 -
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