··论著·

·福建地区膳食因素与牙龈癌的关系研究

·刘凤琼1,鄢灵君1,陈法1,黄江峰1,刘芳萍1,邱宇2,林李嵩2,何保昌1*   

·基金项目:福建省教育厅资助省属高校项目(JK2015017);中央财政支持地方高校发展专项资金环境与健康表观遗传学研究创新团队项目(1003-03900130);福建省科技厅科研项目(2015J01304)

·1.350108 福建省福州市,福建医科大学公共卫生学院流行病与卫生统计学系 环境因素与肿瘤福建省重点实验室

·2.350004 福建省福州市,福建医科大学附属第一医院口腔颌面外科

·*通信作者:何保昌,副教授,硕士生导师;E-mail:hbc517@163.com

·【摘要】目的探讨福建地区膳食因素与牙龈癌的关系。方法选取2010年12月—2016年6月在福建医科大学附属第一医院口腔颌面外科就诊的牙龈癌患者133例,为病例组;另于同期在福州市西湖、罗星等社区选取与病例组性别、年龄(±3岁)匹配的健康成年人321例,为对照组。由经过统一培训的调查员,采用InterCHANGE生活方式调查问卷对两组受试者进行面对面调查,主要内容包括一般情况、膳食习惯、口腔及卫生情况等。以一般情况、口腔及卫生情况为协变量,采用多因素Logistic回归分析探讨膳食因素对牙龈癌的影响,并进一步分析海鲜和饮茶的交互作用。结果两组畜肉类、鱼类、海鲜、绿叶蔬菜、非绿叶蔬菜、水果的摄入情况比较,差异有统计学意义(P<0.05);两组加工肉类、禽肉类、奶类及奶制品、蛋类、豆类及豆制品、腌制食品的摄入情况比较,差异无统计学意义(P>0.05)。多因素Logistic回归分析结果显示,畜肉类、鱼类、海鲜、绿叶蔬菜、非绿叶蔬菜、水果的摄入情况是牙龈癌的影响因素(P<0.05)。根据是否饮茶进行分层,在非饮茶者中海鲜摄入≥3次/周可以降低牙龈癌的发病风险〔调整OR=0.33,95%CI(0.17,0.66)〕。海鲜与饮茶存在正相乘交互作用〔调整OR=0.70,95%CI(0.49,0.98)〕。与不饮茶且海鲜摄入<3次/周者相比,不饮茶且海鲜摄入≥3次/周者〔调整OR=0.39,95%CI(0.21,0.74)〕、饮茶且海鲜摄入<3次/周者〔调整OR=0.45,95%CI(0.24,0.85)〕、饮茶且海鲜摄入≥3次/周者〔调整OR=0.35,95%CI(0.17,0.74)〕的牙龈癌发病风险均降低。结论膳食因素可以在一定程度上影响牙龈癌的发病,养成健康的饮食习惯,经常摄入新鲜蔬菜水果,适量进食鱼类和海鲜,可降低牙龈癌的发病风险。  

·【关键词】牙龈肿瘤;膳食;福建

·【中图分类号】R 739.8【文献标识码】ADOI:10.3969/j.issn.1007-9572.2017.07.014

·刘凤琼,鄢灵君,陈法,等.福建地区膳食因素与牙龈癌的关系研究[J].中国全科医学,2017,20(7):828-833.[www.chinagp.net]

·LIU F Q,YAN L J,CHEN F,et al.Association between dietary factors and gingival carcinoma in Fujian Province[J].Chinese General Practice,2017,20(7):828-833.   

·Association between Dietary Factors and Gingival Carcinoma in Fujian Province

·LIU Feng-qiong1,YAN Ling-jun1,CHEN Fa1,HUANG Jiang-feng1,LIU Fang-ping1,QIU Yu2,LIN Li-song2,HE Bao-chang1*

·1.Department of Epidemiology and Health Statistics,Key Laboratory of Environment Factors and Cancer of Fujian Province,School of Public Health,Fujian Medical University,Fuzhou 350108,China

·2.Oral and Maxillofacial Surgery,the First Affiliated Hospital of Fujian Medical University,Fuzhou 350004,China

·*Corresponding author:HE Bao-chang,Associate professor,Master supervisor;E-mail:hbc517@163.com  

·【Abstract】ObjectiveTo explore the relationship between dietary factors and gingival carcinoma in Fujian.

·MethodsA total of 133 patients with gingival carcinoma in Oral and Maxillofacial Surgery in the First Affiliated Hospital of Fujian Medical University from December 2010 to June 2016 were selected as the case group;in the same period,321 healthy adults whose gender and age(±3 years) matched with those of the case group were selected from Xihu and Luoxing community of Fuzhou and taken as the control group.The investigators after unified training conducted a face-to-face survey to the subjects in two groups with the InterCHANGE Lifestyle Questionnaire.The main survey contents included the general situation,dietary habits,oral and health conditions.The effects of dietary factors on gingival carcinoma were analyzed by multivariate Logistic regression analysis,and the interaction between seafood and tea was further analyzed by taking the general situation,dietary habits,oral and health conditions as covariates.

·ResultsThe intake of meat,fish,seafood,green leafy vegetables,non-green leafy vegetables and fruits were significantly different between two groups(P<0.05).There was significant difference in the intake of processed meat,poultry meat,milk and dairy products,eggs,beans and soy products and pickled foods between two groups(P>0.05).Multivariate Logistic regression analysis showed that the intake of meat,fish,seafood,green leafy vegetables,non-green leafy vegetables and fruits was the influencing factor of gingival carcinoma(P<0.05).Stratify the subjects according to whether they drinking tea or not,and the result showed that the intake of seafood equal to or over 3 times a week among those who were not tea drinkers can reduce the risk of gingival carcinoma〔adjusted OR=0.33,95%CI(0.17,0.66)〕.There was a positive interaction between seafood and tea drinking 〔adjusted OR=0.70,95%CI(0.49,0.98)〕.Compared with those non-tea drinkers whose intake of seafood less than 3 times a week,the risk of gingival carcinoma of those non-tea drinkers whose intake of seafood equal to or over 3 times a week〔adjusted OR=0.39,95%CI(0.21,0.74)〕,tea drinkers whose intake of seafood less than 3 times a week 〔adjusted OR=0.45,95%CI(0.24,0.85)〕,and tea drinkers whose intake of seafood equal to or over 3 times a week 〔adjusted OR=0.35,95%CI(0.17,0.74)〕 had all lowered.

·ConclusionDietary factors can affect the incidence of gingival carcinoma to a certain degree,and healthy eating habits,regular intake of fresh vegetables and fruits,moderate consumption of fish and seafood can reduce the risk of gingival carcinoma.

·【Key words】Gingival neoplasms;Diet;Fujian     

·牙龈癌是一种较为常见的口腔癌,在亚洲地区口腔癌的发病率中仅次于舌癌[1],我国的男女发病率均为0.3/10万[2]。虽然近几十年来提出了多种改善牙龈癌患者生存质量的方法,但其5年生存率仍徘徊在50%左右,其中采用单纯放射疗法治疗患者的5年生存率仅为20%[3],且并发症发生情况不容乐观[4],因此探讨牙龈癌的影响因素十分重要。近期研究结果显示,膳食因素与口腔癌的发病密切相关[5-6]。随着居民生活水平的提高,不良饮食习惯对牙龈损伤的影响也在不断增加,而不同程度的牙龈损伤经久不愈最终可能会增加牙龈癌的发病风险,但目前我国鲜有针对膳食因素与牙龈癌关系的研究。本研究在福建地区开展了病例对照研究,旨在探讨膳食因素与牙龈癌的关系。由于福建地区地处沿海、海产品丰富,且盛产茶叶、饮茶文化历史悠久,故本研究进一步分析了膳食因素和饮茶对牙龈癌发病的影响,以期为进一步预防和控制牙龈癌提供科学依据。

·1对象与方法

·1.1研究对象选取2010年12月—2016年6月在福建医科大学附属第一医院口腔颌面外科就诊的牙龈癌患者133例,为病例组。牙龈癌的确诊主要根据牙龈活组织检查,病理学改变符合恶性病变则诊断为牙龈癌[2]。纳入标准:(1)首次发病;(2)年龄>20岁;(3)在福建省居住>10年;(4)可清晰回答问题。排除标准:继发性肿瘤、良性病变及病危患者。另于同期按性别、年龄(±3岁)进行频数匹配,在福州市西湖、罗星等社区选取健康成年人321例,为对照组。纳入标准:(1)在福建省居住>10年;(2)可清晰回答问题。排除标准:既往或现患肿瘤疾病。本研究通过了福建医科大学伦理委员会的批准,纳入者均知情同意。

·1.2研究方法由经过统一培训的调查员,采用InterCHANGE生活方式调查问卷[7],对两组受试者进行面对面调查。主要内容包括:(1)一般情况,如性别、年龄、民族、文化程度、婚姻状况、BMI、吸烟情况(以累计吸烟量≥100支为吸烟[8])、饮酒情况(以每周至少1次,持续半年以上为饮酒[9])、饮茶情况(以每周至少饮1杯,持续6个月以上为饮茶[10])、居住地;(2)膳食习惯:如畜肉类、加工肉类、禽肉类、鱼类、海鲜、奶类及奶制品、蛋类、绿叶蔬菜、非绿叶蔬菜、水果、豆类及豆制品、腌制食品的近1年摄入频率,统计时根据对照组摄入频率的中位数进行划分;(3)口腔及卫生情况:如刷牙频率、牙齿缺失数、是否有口腔不良修复体、是否有复发性口腔溃疡。调查结束后,由专人负责调查表的审核,发现问题及时予以纠正,剔除不合格者(如调查内容不齐全、配合度不高导致调查质量较差)。共发放问卷465份,回收460份,剔除不合格问卷6份,最终纳入有效问卷454份,问卷有效回收率为97.6%。

·1.3统计学方法采用EpiData 3.1软件进行数据双核录入,逻辑纠错,并随机抽样10%复查;采用STATA 13.0统计软件进行数据分析。计数资料组间比较采用χ2检验;采用多因素Logistic回归分析估算各变量与牙龈癌发病风险的调整OR及其95%CI以及交互作用。以P<0.05为差异有统计学意义。

·2结果

·2.1两组一般情况比较两组性别、年龄、民族、婚姻状况、饮茶率比较,差异无统计学意义(P>0.05);两组文化程度、BMI、吸烟率、饮酒率、居住地比较,差异有统计学意义(P<0.05,见表1)。

·2.2两组膳食情况比较两组畜肉类、鱼类、海鲜、绿叶蔬菜、非绿叶蔬菜、水果的摄入情况比较,差异有统计学意义(P<0.05);两组加工肉类、禽肉类、奶类及奶制品、蛋类、豆类及豆制品、腌制食品的摄入情况比较,差异无统计学意义(P>0.05,见表2)。

·2.3膳食因素对牙龈癌影响的多因素Logistic回归分析以是否患牙龈癌为因变量,以表2中的膳食因素为自变量,进行多因素Logistic回归分析。各变量赋值情况见表3。结果显示,畜肉类、鱼类、海鲜、绿叶蔬菜、非绿叶蔬菜、水果的摄入情况是牙龈癌的影响因素(P<0.05)。将表1中的一般情况和口腔及卫生情况纳入协变量进行调整后,结果显示,畜肉类、鱼类、海鲜、绿叶蔬菜、非绿叶蔬菜、水果的摄入情况仍是牙龈癌的影响因素(P<0.05,见表4)。

·2.4海鲜、饮茶和牙龈癌的关系研究

·2.4.1海鲜和牙龈癌关系按是否饮茶的分层分析根据是否饮茶进行分层,对海鲜和牙龈癌的关系进行分析。经一般情况、口腔及卫生情况进行调整后结果显示,在非饮茶者中海鲜摄入≥3次/周可以降低牙龈癌的发病风险〔调整OR=0.33,95%CI(0.17,0.66)〕;在饮茶者中海鲜摄入情况对牙龈癌的发病风险无影响〔调整OR=0.76,95%CI(0.33,1.76),见表5〕。    

·2.4.2海鲜和饮茶对牙龈癌的交互作用经一般情况、口腔及卫生情况进行调整后结果显示,海鲜与饮茶存在正相乘交互作用〔调整OR=0.70,95%CI(0.49,0.98)〕。与不饮茶且海鲜摄入<3次/周者相比,饮茶且海鲜摄入≥3次/周者的牙龈癌发病风险降低〔调整OR=0.35,95%CI(0.17,0.74),见表6〕。
 


·3讨论

·国际癌症研究中心(IARC)和美国癌症研究协会(AICR)指出,进食水果和蔬菜对口腔癌的发生具有预防作用,大量进食水果和/或蔬菜可使口腔癌的发病风险减少30%[11-12]。PETRIDOU等[13]的研究结果也表明,食用蔬菜、水果等抗氧化剂可降低口腔癌的发病风险。本研究结果显示,食用绿叶蔬菜、非绿叶蔬菜、水果是牙龈癌的保护因素。新鲜水果和蔬菜中富含维生素E、维生素C、胡萝卜素、叶酸、多酚等多种抗氧化剂,可通过抗氧化、抑制DNA和蛋白质损伤、抑制细胞增殖等多种途径抑制肿瘤的发生[14-15]。

·福建省位于我国东南沿海地区,鱼类和海鲜是当地居民日常饮食中喜爱的食物。本研究发现,进食鱼类≥3次/周、海鲜≥3次/周是牙龈癌的保护因素,其调整OR值分别为0.37〔95%CI(0.23,0.59)〕和0.48〔95%CI(0.29,0.79)〕,这与近期的一项病例对照研究结果一致[16]。鱼类和海鲜中多含有丰富的多不饱和脂肪酸〔奥米茄-3(omega-3)、二十二碳五烯酸等〕、矿物盐(锌、铁、钙、磷等)及蛋白质,具有抗感染、抑制氧自由基、调节机体免疫等作用,能有效预防肿瘤的发生[17]。

·福建省除了海产品丰富外,饮茶文化也是其一大特色。已有研究结果表明,饮茶在口腔癌的发生发展中起着重要的保护作用[18]。本研究的交互作用分析结果发现,海鲜与饮茶存在正相乘交互作用〔调整OR=0.70,95%CI(0.49,0.98)〕,提示进食海鲜与饮茶在预防牙龈癌的发生发展中可能存在协同作用。GIUNTA等[19]和ZHONG等[20]的实验室研究结果证明,鱼类、海鲜中富含的多不饱和脂肪酸能够在一定程度上增强茶叶中表没食子儿茶素没食子酸酯(EGCG)的抗感染、抗肿瘤等生物活性。其可能的机制是EGCG和多酚类等物质可以抑制由各种炎性刺激诱导的核转录因子Kappa B(NF-κB)通路活化,同样的,omega-3等多不饱和脂肪酸不仅能改变T细胞细胞膜的结构成分,也能抑制包括NF-κB在内的信号转导通路,两者的共同作用途径可进一步减轻炎性反应,从而进一步降低癌症的发生风险[21]。

·近年来关于进食肉类与口腔癌关系的研究结果存在争议[22-24]。近期meta分析结果表明,进食畜肉和禽肉类对口腔癌发病无影响,而大量进食加工肉类则能够增加口腔癌和口咽癌的发病风险〔RR=1.91,95%CI(1.19,3.06)〕[25]。本研究结果显示,畜肉类的摄入情况是牙龈癌的影响因素,但并未发现进食禽肉类是牙龈癌的影响因素。因此该结果有待于进一步加大样本量进行明确。

·综上所述,养成健康的饮食习惯,经常摄入新鲜蔬菜水果,适量进食鱼类和海鲜,可降低牙龈癌的发病风险。另外,本研究也存在着一定的不足之处,包括:(1)本研究仅分析了各膳食因素的摄入频率与牙龈癌的关系,并未对各膳食因素进行定量分析,因此在今后的研究中还需通过食物频数问卷开展更加详细的膳食摄入调查,以探讨各膳食因素的摄入量与牙龈癌的关系。(2)本研究为病例对照研究,选择偏倚和回忆偏倚难以避免,因此所得结果仍需前瞻性研究加以验证。  

·作者贡献:刘凤琼撰写论文、成文并对文章负责;鄢灵君、陈法、黄江峰、刘芳萍进行试验实施、评估、资料收集;邱宇、林李嵩进行材料支持和技术指导;何保昌进行试验设计与实施、质量控制和审校。

·本文无利益冲突。

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·(收稿日期:2016-11-14;修回日期:2017-01-23)

·(本文编辑:王凤微)