35卷1期

• Link 公衛今與昔 Public Health Now and Then
• 台灣推行家庭計畫成功經驗對公衛施政的啟示Lessons for public health programs from the successful experience of Taiwan Family Planning Program
• 林惠生、李孟智
  Hui-Sheng Lin, Meng-Chih Lee
• 無
  none
• 無
  none
• 1-8
• 10.6288/TJPH201635104097

• Link 綜論 Review Article
• 我國食品香料之安全性與管理問題芻議An initiative on the safety and management of food flavorings in Taiwan
• 余旭勝、江宏哲、李志恒
  Hsu-Sheng Yu, Hung-Che Chiang, Jih-Heng Li
• 食品安全 ； 食品香料 ； 香料及萃取物製造協會 ； 毒性 ； 安全性評估
  food safety ; food flavoring ; FEMA ; toxicity ; safety assessment
• 香料在食品加工及家庭烹調常用來增強食品的風味，然而隨著消費者保護意識的抬頭，香料的食用安全性已成為社會大眾所關注的民生議題。世界各國對食品香料的管理法規雖不一致，但美國香料及萃取物製造協會(Flavor and Extract Manufacturers Association, FEMA)的香料安全評價結果為重要參考，現今香料經FEMA評價為安全而列為FEMA GRAS (Generally Recognized As Safe)香料者接近3,000品項。惟目前我國表列合法的食品香料僅有90品項，雖然安全資料亦主要來自FEMA，且該些列管人工香料物質的安全性都有經過檢視，照說在合理劑量下人工香料是安全的；但是從另一個角度而言，我國現行法規並未明確訂定香料的完整品項及其使用劑量，且對香料的管理主要都是參考國外的法規，缺少國人的攝取資料進行安全風險確認，以致風險評估尚無法完全落實。為使我國標準與國際接軌，衛生福利部刻正修訂「香料品項建議清單(草案)」，研議增加香料項目。未來也建議建立香料安全評估標準，進行風險評估，落實香料單體化合物品項之即時納管及其安全性評估，以確保食品香料使用的安全性。
  Food flavorings are preparations widely used for food processing and home cooking to enhance the smell and taste of food. Because of increasing demand for consumer protection, the general population has recently paid much greater attention to the safety of food flavors. Legislation controlling the use of food flavors vary among countries. The US Flavor and Extract Manufacturers Association (FEMA) has evaluated and approved near 3,000 substances as FEMA GRAS (Generally Recognized as Safe) flavors. In Taiwan, there are only 90 items of food flavorings complying with the safety rules of the US FEMA, and Taiwan FDA has officially approved these substances for use as food flavors. Currently, many of flavors used in food businesses and industries, and home cooks remain unevaluated and not fully regulated in Taiwan. Information on daily intakes or exposures to these flavorings are yet unavailable for a risk assessment. In line with the international standards, the Ministry of Health and Welfare has started to propose an updated additive list with a greater variety of flavors. To better consolidate the safety of food flavoring use in Taiwan, it is imperative in the future to update the items of food flavorings for control and to establish the safety criteria by conducting a risk assessment for all flavoring substances.
• 9-16
• 10.6288/TJPH201635104059

• Link 綜論 Review Article
• 台灣校園近視防治軌跡Trajectory of myopia prevention in Taiwanese schools
• 張麗春、吳佩昌、牛玉珍、陳敏麗、廖梨伶
  Li-Chun Chang, Pei-Chang Wu, Yu-Zhen Niu, Min-Li Chen, Li-Ling Liao
• 近視防治 ； 校園 ； 政策
  vision care ; school ; policy
• 學童視力惡化的情形一直是台灣教育與衛生主管機關所關注的健康議題，釐清校園推動視力保健的過去以及當前遭遇的困難乃為當務之急。本文針對歷年來台灣政府單位推動校園視力保健相關的官方文件、統計資料以及重要研究報告或調查等資料的分析，系統性的呈現出校園近視防治的軌跡。本文首先呈現全國學童視力不良率的嚴峻情形，並歸納出政府單位自1980年起至今，為了應對此問題所執行的視力保健政策的五個階段歷程，而自2010年起，學校開始運用實證性戶外活動保護因子做為校園視力保健的推動主軸後，國小學童視力不良情形已有改善之趨勢。本文進一步探討全國的眼科醫療資源不足與分布不均的現象，此為未來學童控度防盲上的重要挑戰。建議由中央成立跨部會小組推動近視防治，有效處理學童視力篩檢與複診的就醫問題、建立近視治療與控制之共識、結合校園與醫療之高度近視風險個案管理、積極推動近視防治之社區宣導、大眾媒體宣導與家長教育等，唯有透過中央與地方的協助合作，學校教師、家長與學童視力保健知能的提升，方能有效遏止台灣學童近視惡化的問題。
  Worsening vision among school-age children has been a topic of concern for Taiwanese education and healthcare authorities. Hence, clarifying schools’ existing vision-care promotion strategies and their current difficulties has gained importance. This study systematically illustrates the trajectory of myopia prevention in schools based on an analysis of information on promotion of vision care polices in schools by Taiwan governmental units, including official documents, statistical data, and major research reports and surveys. This paper first presents the high prevalence rates of poor vision among school-age children across Taiwan. The measures adopted by governmental units to solve this problem since 1980 are summarized and categorized into five stages. After 2010, when schools began implementing an evidenced strategy of eye protection during outdoor activities, an improvement in poor vision among primary school children was observed. This paper further explores the nationwide phenomenon of insufficient and unevenly distributed ophthalmological medical resources that poses a significant challenge to controlling and preventing near-sightedness and blindness among school-age children. Finally, we suggest that the central government set up cross-departmental task forces to promote myopia prevention, effectively address difficulties in finding medical assistance for children’s vision problems, establish a consensus on the importance of myopia prevention, integrate school and medical myopia case management, actively promote myopia prevention in local communities, conduct outreach through mass media, and educate parents. By ensuring cooperation between the central and local governments, as well as improving the health knowledge and ability of teachers, parents and children, the increasing prevalence of myopia in Taiwanese schoolchildren can be effectively contained.
• 17 - 30
• 10.6288/TJPH201635104051

• Link 綜論 Review Article
• 仰臥起坐動作對下背痛的潛在風險Potential risks of sit-up exercise to low back pain
• 林政東
  Jenq-Dong Lin
• 仰臥起坐 ； 仰臥半起 ； 起坐動作範圍 ； 動作節奏 ； 雙足支撐
  sit-up ; curl-up ; range of motion ; tempo ; leg support
• 下背痛是世界性公衛議題之一，國際著名下背痛及脊椎專家建議，不宜以屈膝雙足支撐的仰臥起坐作為訓練或檢測腹肌肌耐力的動作。其爭議可從雙足之支撐、上半身起坐範圍及動作節奏等三方面加以修正。經過修正，建議的腹肌肌耐力檢測動作為雙足無支撐的慢速仰臥半起訓練動作，此一動作可以激活更高的腹肌肌電水準、較低的屈髖肌群肌激活水準及減緩腰椎壓力，似乎較能避開下背痛的潛在風險。修正動作除了產生較佳的預防下背痛之效度，也具有蠻高的信度水準，足以作為檢測屈腹肌耐力的動作，已廣為美、加等國體適能協會所採用。為了減少大眾曝露於下背痛的風險中，建議學校教育與國家考試不宜採仰臥起坐動作，改採仰臥半起動作。
  Low back pain is a persistent global problem in public health. World-renowned experts on low back pain and the spine suggest that it may not be suitable for people to perform sit-ups to exercise the abdominal muscles or test their endurance. However, the public, school physical education programs, and the national fitness-education examinations in Taiwan continue to use sit-ups as a means for exercising or testing the endurance of the abdominal muscles. This study proposed three recommendations to enable modifying and improving the leg support, range of upper body motion, and pace of sit-ups. The modified exercise, the curl-up, is suggested as a safer alternative to the sit-up for abdominal-muscle endurance testing. This exercise can activate high levels of myoelectric activity in the abdominal muscles while keeping the activation level of the hip flexor muscles low, thus alleviating lumbar stress and likely lowering the risk of low back pain. Therefore, to lower the risk of low back pain, this paper recommends that school organizations and the national fitness-education examinations use the curl-up to replace the conventional sit-up for abdominal-muscle endurance testing.
• 31 - 38
• 10.6288/TJPH201635104050

• Link 綜論 Review Article
• 系統性文獻回顧－探討太極拳在慢性阻塞性肺疾病患運動耐力、生活品質及健康狀態之成效Effects of Tai Chi on exercise tolerance, quality of life, and health status in patients with chronic obstructive pulmonary disease—a systematic review
• 沈雪珍、郭素娥
  Hsueh-Chen Shen, Su-Er Guo
• 太極拳 ； 慢性阻塞性肺疾病 ； 運動處方 ； 運動耐力 ； 生活品質
  Tai Chi ; chronic obstructive pulmonary disease ; exercise prescription ; exercise tolerance ; quality of life
• 肺部復健已是公認慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease, COPD)有效的管理策略，但臨床使用不高。太極拳運動是國內外專業學會建議的運動，但目前資料顯示各研究對太極拳運動的運動處方、拳法招式等皆有所不同，以致對COPD病患之健康成效至今尚無定論。本系統性文獻回顧的目的旨在評估太極拳運動的成效及運動處方，以作為日後推廣肺部復健替代運動的參考。本文獻回顧使用下列太極拳(Tai Chi)、慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease)等關鍵字和醫學主題詞(Medical Subject Headings, MeSH)術語，搜尋9個電子資料庫成立以來至2014年12月29日止的所有出版發表的文獻，共158篇，選取符合篩選標準並排除重複出現的文獻，最後剩12篇隨機對照試驗，再針對相同的成效變項進行彙整、討論與分析。本回顧顯示最佳運動處方為50-60分鐘/次，每週5.5次，中等強度，至少運動3個月。多數研究表明太極拳組與不運動的控制組或呼吸訓練搭配步行的運動組相比，在運動耐力及生活品質有顯著改善；但在健康狀態上，則仍無一致性。太極拳運動能提升COPD病患的運動能力及生活品質，是一種有效的替代運動方案。
  Although pulmonary rehabilitation is recognized as an effective strategy for patients with chronic obstructive pulmonary disease (COPD), it remains underused. Tai Chi is recommended as an appropriate exercise by the American Thoracic Society and the European Respiratory Society. However, current evidence-based studies examining the effects of Tai Chi on health and quality of life in patients with COPD differ in exercise frequency, intensity, duration, etc.; therefore, these effects differed across studies. This systematic review evaluates the effects of Tai Chi and its exercise prescription. It is also expected to be as a reference for the development of future alternative exercise programs for pulmonary rehabilitation. This systematic review searched randomized control trials (RCTs) in nine electronic databases from their inception to December 2014, with key words and MeSH terms including “Tai Chi”, “chronic obstructive pulmonary disease” and “COPD”. Twelve RCTs were included; after screening inclusion and exclusion criteria, the outcome variables exercise tolerance, quality of life, and health status were analyzed. The best exercise prescription was found to be 50–60 min per session, moderate intensity, 5.5 times per week, and for at least 3 months. Most studies showed that the Tai Chi group had better exercise tolerance and quality of life than the non-exercise and walking exercise groups. However, the positive effect of Tai Chi on health status was inconsistent. Tai Chi significantly improves exercise tolerance and quality of life and could be an effective alternative exercise program for pulmonary rehabilitation.
• 39 - 52
• 10.6288/TJPH201635104072

• Link 原著 Original Article
• 慢性腎臟病對全髖關節置換術病患預後情形之影響Impact of chronic kidney disease on outcome of total hip replacement patients
• 張祺君、陳威明、陳正豐、吳肖琪
  Chi-Chun Chang, Wei-Ming Chen, Cheng-Fong Chen, Shiao-Chi Wu
• 慢性腎臟病 ； 全髖關節置換術 ； 醫療品質
  chronic kidney disease ; total hip replacement ; surgery outcome
• 目標：慢性腎臟病病患因腎性骨病變導致骨密度變低，故全髖關節置換術發生率高於常人，且慢性腎臟病病患因免疫系統失調較容易發生感染，但目前國內缺乏慢性腎臟病病患接受全髖關節置換術預後情形之相關研究，故本研究之目的為探討慢性腎臟病對全髖關節置換術預後之影響。方法：採用回溯性世代研究法，以全民健保2009年至2011年接受全髖關節置換術之成年病患為研究對象，以術前一年是否罹患慢性腎臟病，區分為慢性腎臟病組及無慢性腎臟病組。本研究使用邏輯斯迴歸計算病患罹患慢性腎臟病之傾向分數後進行配對，並以Cox proportional hazard model進行分析。結果：慢性腎臟病病患接受全髖關節置換術後90日內感染、再住院及死亡發生率與風險皆顯著高於腎功能正常者。結論：慢性腎臟病病患接受全髖關節置換術後，感染、再住院與死亡風險均較腎功能正常者高。建議醫院加強照護接受全髖關節置換術之慢性腎臟病病患，多留意易造成感染之因素；骨科醫師應於術前評估時，向慢性腎臟病病患說明其術後發生併發症之風險較高。
  Objectives: Chronic kidney disease (CKD) has been shown to cause osteoporosis because of renal bone disease, thus CKD patients are at higher risk for total hip replacement (THR) than patients without CKD; however, there are few studies which have determined whether or not the outcomes are positive or negative when CKD patients undergo THR. Therefore, the aim of this study was to explore the influence of CKD on THR patient outcomes. Methods: The study adopted a retrospective cohort study design, and the subjects were adult THR patients. Data were derived from the National Health Insurance Research Database between 2009 and 2011. According to the patients who did or did not have CKD the year prior to the THR, the patients were divided into two groups (CKD and non-CKD groups), and a propensity score was used to match subjects. Cox proportional hazards regression was used to analyze the outcomes. Results: In the CKD group, the 90-day post-operative infection, readmission, and death rates were higher than the non- CKD group. The 90-day post-operative infection (AHR=1.8), readmission (AHR=1.9), and death risk (AHR=3.5) in the CKD group were also higher than the non-CKD group. Conclusions: CKD patients have higher risks of 90-day post-operative infections, re-admission, and death than people without CKD after THR. Health authorities and medical institutions should strengthen the care for patients with CKD receiving THR to reduce the likelihood of adverse outcomes.
• 53 - 65
• 10.6288/TJPH201635104066

• Link 原著 Original Article
• 心臟衰竭病人出院後照護連續性及就醫機構層級與照護結果及費用之相關性Associations of continuity and level with outcomes and expenses of post-discharge care for patients with heart failure
• 邱翰憶、鄭守夏、董鈺琪
  Han-Yi Chiu, Shou-Hsia Cheng, Yu-Chi Tung
• 心臟衰竭 ； 照護連續性 ； 就醫機構層級 ； 照護結果 ； 醫療費用
  heart failure ; continuity of care ; level of care ; outcomes of care ; medical expenses
• 目標：心臟衰竭住院治療1年內住院率、死亡率及醫療費用均很高。為改善出院後照護結果及控制費用，出院後之門診照護逐漸受重視。本研究目的係探討心臟衰竭病人出院後，門診照護連續性及層級與照護結果及費用之相關性。方法：本研究使用全民健康保險研究資料庫全國代表性樣本，總計2007年至2011年出院之2,909位心臟衰竭病患納入分析。本研究使用廣義估計方程式及群集存活分析控制病人、醫師及機構特性，以檢測出院後門診照護連續性及層級與出院後1年內照護結果及費用之相關性。結果：出院後照護連續性較高與1年內再住院次數較低有關，照護連續性高與1年內死亡率較低有關，而照護連續性較高與總費用(門診、急診及住院照護)較低有關。出院後門診照護於區域醫院、地區醫院及診所的總費用低於醫學中心。結論：出院後照護連續性較高，照護結果較佳且總費用較低；除此，出院後主要於社區醫院或診所接受門診照護之病患結果與醫學中心無差異，但總費用較低。
  Objectives: One-year readmission and mortality rates, and medical expenses after hospitalization for heart failure are very high. To improve outcomes and control costs of post-discharge care, outpatient care after discharge has been increasingly emphasized. The objective of this study was to examine the associations of continuity and level with outcomes and expenses of post-discharge outpatient care for heart failure patients. Methods: This study used data from a nationwide representative sample through the National Health Insurance Research Database. A total of 2909 heart failure patients discharged from hospitals between 2007 and 2011 were selected for analysis. Generalized estimating equation and clustered survival models were performed after adjustment for patient, physician, and institution characteristics to examine the associations of outpatient continuity and level with 1-year outcomes and expenses of post-discharge care. Results: Higher continuity of care after discharge was associated with fewer re-hospitalizations within 1 year after discharge. High continuity of care was associated with lower 1-year mortality rates. Higher continuity of care was associated with lower total expenses for ambulatory, emergency room, and inpatient care. Patients who received outpatient care in regional hospitals, district hospitals, and clinics had lower total expenses compared with patients in academic medical centers. Conclusions: Higher continuity of care after discharge is associated with better outcomes and lower total expenses. Moreover, patients who mainly receive post-discharge outpatient care in community hospitals or clinics have similar outcomes and lower total expenses compared with patients in academic medical centers.
• 66 - 79
• 10.6288/TJPH201635104065

• Link 原著 Original Article
• 花蓮縣萬榮鄉與卓溪鄉居民之飲酒型態Drinking patterns of residents in Wanrung and Zhuoxi townships of Hualien County
• 孫亦君、朝巾玲
  Yi-Chun Sun, Chin-Ling Cha
• 飲酒行為 ； 節制飲酒 ； 山地鄉 ； 原住民
  drinking pattern ; temperate drinking ; remote area ; indigenous
• 目標：花蓮縣萬榮與卓溪鄉均長期致力於節制飲酒活動。為瞭解居民的飲酒型態及對節制飲酒的看法，我們以自編問卷針對兩鄉居民進行訪問。方法：我們依戶籍資料在兩鄉共12個村中，各隨機選取50名居民進行問卷調查。收集的600份問卷資料中，排除對問題內容不夠瞭解或未按實際情況回答的受訪者資料後，有效可供分析的資料共426份。結果：兩鄉居民的飲酒型態不同。萬榮鄉受訪者中超過六成為飲酒者，但沒有人每天喝；卓溪鄉中飲酒者僅約四成，但是約兩成飲酒者每天喝。不過，兩鄉居民的飲酒時機差異不大。在節酒議題上，多數受訪者不同意「少喝一點就是戒酒」，但是，萬榮鄉受訪者對這個陳述不同意的程度，因個人飲酒現況不同而不同；卓溪鄉受訪者間的差異未達顯著。結論：兩鄉居民飲酒型態不同，因此節酒活動的設計和重點也應不同。此外，節酒活動如果可以獲得教會團體支持，對活動成效應有很大助益。另外，深入瞭解已戒酒者的心路歷程，應可運用於強化未來的節酒活動設計。
  Objectives: Promoting temperate drinking has been an important health promotion task in the Wanrung and Zhuoxi townships of Hualien County. We conducted a survey to determine the drinking pattern of residents in these two townships and their views on temperate drinking. Methods: Fifty residents from each village in Wanrung and Zhuoxi townships were randomly selected and interviewed with a structured questionnaire. Valid data from 426 residents were analyzed. Results: The drinking patterns of these 2 townships were different. In Wanrung, more than 60% of the residents who were interviewed were drinkers, but none of the residents drank daily. In Zhuoxi, 40% of the residents who were interviewed were drinkers and nearly 20% of the residents drank every day. The majority of residents interviewed in these 2 townships disagreed “drinking less means quitting.” The extent of the disagreement was different among non-drinkers, ex-drinkers, and drinkers in Wanrung, but no differences existed in Zhuoxi. Conclusions: Due to the difference in resident drinking patterns in Wanrung and Zhuoxi, approaches to promote temperate drinking should be different in these two townships. Survey results also revealed that church is likely to be an important force in promoting temperate drinking. Further investigation of the quitting process of ex-drinkers may also be useful. The experiences of ex-drinkers may provide a different perspective in approaches to promote temperate drinking.
• 80 - 93
• 10.6288/TJPH201635104071

• Link 原著 Original Article
• 台灣中老年人閱讀與認知衰退之關聯性分析Association between reading and cognitive decline in older Taiwanese people
• 陳姿蓉、王俊毅
  Tzu-Jung Chen, Jiun-Yi Wang
• 閱讀 ； 認知衰退 ； 認知儲備 ； 休閒活動 ； 中老年人
  reading ; cognitive decline ; cognitive reserve ; leisure activities ; older adults
• 目標：在高齡化人口中，伴隨老化而來的認知障礙益發受到重視。如何維持中老年人認知功能是一重要課題。本研究欲藉國內大型世代資料，分析台灣中老年人閱讀與認知衰退的關聯性。方法：本研究分析「台灣地區中老年身心社會生活狀況長期追蹤調查」2003及2007年資料。以2003年為基礎點，排除有認知功能缺損或不識字者，及非本人作答或資料不全者，得3,147位?50歲之研究個案。以羅吉斯迴歸(logistic regression)控制社會人口學、健康狀況及健康行為等變項，分析高低閱讀頻率與四年後認知衰退之關聯。結果：若將閱讀活動保留在所有休閒活動(共十項)中，結果顯示高休閒參與者(?3項/週)的認知衰退風險較低(OR=0.56, p＜0.001)。若將閱讀活動從休閒項目中個別獨立出來，結果顯示高休閒參與者的認知衰退風險雖仍較低(OR=0.73, p=0.050)，但關聯性較弱；而有高閱讀頻率者的衰退風險則明顯低於低閱讀頻率者(OR=0.51, p＜0.001)。另依教育程度分群分析，發現高休閒參與或高閱讀頻率(OR=0.57, 0.50;p＜0.01)皆對低受教育年數(0-6年)受訪者的認知衰退有延緩作用，但對高教育年數受訪者的影響則不明顯。結論：本研究凸顯閱讀對預防中老年人認知退的重要性。建議中老年人養成每週至少閱讀一次的習慣，以促進認知功能健康及延緩衰退。
  Objectives: Cognitive impairment in the aging process has become increasingly critical, especially in aging populations. Thus maintaining the cognitive function of older adults is crucial. The present study aimed to determine the association between reading and cognitive decline in older Taiwanese people by using national cohort survey data. Methods: The data sets of the Taiwan Longitudinal Survey on Aging from 2003 and 2007 were analyzed. After we excluded those who were cognitively impaired or unable to read in 2003 (baseline), in addition to proxy-reported or incomplete data, a total of 3,147 eligible participants ?50 years old remained. The logistic regression model was used to determine the association between reading and the subsequent 4-year cognitive decline, adjusted for sociodemographic variables, health status, and health behaviors. Results: When reading was included in the 10 types of leisure activities, our results showed that the likelihood of cognitive decline was lower for participants with a higher level (?3 types/week) of leisure activities (OR=0.56, p<0.001). When reading was excluded from the leisure activities, the results still suggested a lower likelihood of cognitive decline for participants with a higher level of leisure activities (OR= 0.73, p=0.050); however, the strength of the association was apparently lower. Nevertheless, participants exhibiting a higher frequency of reading were less likely to suffer from cognitive decline compared with those having a lower frequency of reading (OR=0.51, p<0.001). Furthermore, our results of subgroup analysis showed that a higher level of leisure activities or reading (OR=0.57, 0.50; p<0.01) could delay cognitive decline of participants with a lower educational level (0-6 years of formal education), while the effects were not significant for those with higher educational levels. Conclusions: Our findings demonstrate the advantage of reading to delay cognitive decline in older adults. We suggest that older adults read once a week or more to promote health and delay cognitive decline.
• 94 - 104
• 10.6288/TJPH201635104060

• Link 評論 Commentary
• 評論：學到老，活到老Commentary: live and learn
• 楊浩然
  Hao-Jan Yang
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  none
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  none
• 105 - 105
• 10.6288/TJPH20163510406001