背景與研究目的
2018全球疾病負擔研究顯示糖尿病是失能相關疾病第四名。全球糖尿病人口估計有4.75億，糖尿病預防延緩失能刻不容緩。文獻顯示健康行為改善血糖控制與病程。反之，心理因子惡化之。但對行為因子減少或增加糖尿病失能的風險探討多為橫斷性研究，除憂鬱與運動外，鮮少縱貫性研究探討這些行為對糖尿病失能速度的影響。本研究透過長期觀察資料了解健康行為是否可預防延緩糖尿病患失能，以及心理因子是否有相反的效果，藉此了解各行為對糖尿病進展到失能長期和短期的影響。過往研究通常只採一兩個變項分析，本研究建立多因子同時存在模型，這些因子在現實社會往往並存且互相影響，本研究分析行為因子共存時是否仍獨立對糖尿病失能有影響力，
研究方法
本研究為回溯性世代研究(Retrospective cohort study) ，採用多層次模型(multilevel modeling)建構和混和效果模型(Mixed effect model)來進行迴歸 (regression)分析，資料採用1996年Taiwan Longitudinal Study in Aging(TLSA) 台灣地區中老年身心社會生活狀況長期追蹤調查內50歲到97歲的自評有或無糖尿病為受訪者為研究族群，糖尿病患者581人，無糖尿病者3934人，比較這兩群人，在1999年、2003年、2007年測量其生理失能(活動力失能Mobility ,日常生活評估Activities of Daily Living [ADL] & 工具性日常生活評估Instrumental activities of daily living [IADL]) 作為依變項，再推前到1996年、1999年、2003年測量健康促進行為( 運動，飲食，社會參與，社會支持）和心理因子（壓力，憂鬱）作為隨機效應模型的滯後時變(lagged time-varying)的共變項。
研究結果
所有失能模型都受糖尿病顯著影響，糖尿病患比一般人提前5年在57-58歲開始活動力失能，提前10在73-74歲ADL失能，提前9年在61-62歲IADL失能。糖尿病隨年齡進展的失能只有活動力失能顯著，速度是沒有糖尿病1.5倍(=(0.162+0.088)/0.088)，（βDM*age=0.088, p<0.001, βage=0.162, p<0.001）。運動減緩糖尿病患9.9-13年ADL失能(βDM*Exercise1=-1.134,p=0.022,βDM*Exercise3=-0.872, p<0.001)。對活動力和IADL而言，運動有劑量效應，每週運動大於六次顯著減緩活動力5.7年失能(βDM*Exercise3=-1.248, p=0.011)以及IADL失能4.4年(βDM*Exercise3=-0.799, p=0.034)。所有因子共存活動力模型，每周運動六次的糖尿病患隨年齡進展的失能速度和沒有運動者相比減少七成(-0.129 /0.177=-0.729)，(βDM*Exercise3*age=-0.129, p=0.013)。飲食雖沒直接影響糖尿病患失能，但控制健康飲食後，糖尿病隨年齡增加的失能係數由0.088到0.113，表沒健康飲食者，糖尿病隨年齡造成失能的速度是一般糖尿病患的1.3倍(=1.113/0.088)，(βDM*age=1.113, p=0.014。)社會支持對每上升一分可減緩糖尿病患ADL模型4.3年(βDM*socialsupport=-0.081, p=0.001)，及IADL模型1.2年失能(βDM*socialsupport=-0.114, p=0.003)。憂鬱至少增加15年失能(βDM*CES-D=0.052, p=0.004)，並隨年齡增加4.5年失能 (βDM*CES-D*age=0.008, p<0.001)。運動，社交支持，憂鬱，共同存在時，對失能還是有獨立顯著影響。壓力在所有因子共同存在時，反而可以延緩ADL(βDM*stress=-0.348, p=0.026)和IADL(βDM*stress=-0.465, p=0.040)失能。
討論與結論
本研究可看出運動和社會支持是失能最強的影響因子，運動不只延緩糖尿病患者失能，還可減慢之後隨年齡衰退的失能速度。適度的壓力對減緩失能也有保護力。憂鬱在ADL模型中顯著提早失能發生，並加快隨年齡衰退的失能速度。臨床上應加強糖尿病患運動促進，建議每週要運動六次以上。未來可進一步研究和建構適合糖尿病患預防失能運動處方。公共衛生系統應建立良好社會支持網絡，篩檢憂鬱的糖尿病患者，積極轉介治療。

Diabetes, the disease lead to disability, is a global problem. Previous study showed health behaviors might reduce the disability risk, while psychological correlates increased it. However, few longitudinal studies discussion mentioned were mentioned. The present study used longitudinal and repeated measure data to find out that health promotion behavior and psychological correlates postpone or accelerate disability in diabetic patients. The current study shows that exercise (Activities of Daily Living [ADL] model [βDM*Exercise1=-1.134, P=0.022; βDM*Exercise3=-0.872, p<0.001]) and social support (postponed ADL disability for 4.3 years [βDM*socialsupport=-0.081, p<0.001]) and Instrumental activities of daily living [IADL] disability for 1.2 years [βDM*socialsupport=-0.114, p=0.003]) play important roles in postponing disability in diabetic patients. Diabetic patients exercise more than six times a week have extra benefits [IADL postponed mobility impairments for 5.7 years (βDM*Exercise3=-1.248, p=0.011), and IADL disability for 4.4 years (βDM*Exercise3=-0.799, p=0.034)]. Adequate stress could decrease disability risk in diabetic patients in coexisted model. Depression accelerated ADL disability for 4.6 years (βDM*CES-D=0.052, p=0.004) and the speed of disability 1.7 times faster every year (βDM*CES-D*age=0.008, p<0.001) in diabetic patients. In conclusion, diabetic patients are strongly suggested to exercise more than six times a week. Compiling exercise prescriptions to prevent disability in diabetic patients is an important topic for further study. The public health system should construct social support network, screen depression in diabetic patients and transfer them for further treatment.

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