ɍɇɂВȿɊɁɂɌȿɌ ɍ ɉɊɂШɌɂɇɂ ɆȿȾɂЦɂɇɋɄɂ ɎАɄɍɅɌȿɌ Јаɞɪаɧка ɋ. Ɇиɬић ɍɌИɐȺЈ 25-ɏИȾɊɈɄɋИɏɈɅȿɄȺɅɐИɎȿɊɈɅȺ ɇȺ ɄɅИɇИɑɄȿ, ɏȿɆȺɌɈɅɈɒɄȿ И ȻИɈɏȿɆИЈɋɄȿ ȼȺɊИJȺȻɅȿ ɄɈȾ ɈȾɈЈɑȺȾИ И ɆȺɅȿ Ⱦȿɐȿ Ⱦɨкɬɨɪɫка ɞиɫɟɪɬација Ʉɨɫɨвɫка Ɇиɬɪɨвица, 2016. ɋАȾɊɀАȳ ɍȼɈȾ ............................................................................................................................. ........................................ 1 ɋɭɩɥɟɦɟɧɬɢ ɡɚ ɨɞɨјɱɚɞ ɢ ɦɚɥɭ ɞɟɰɭ .................................................................................................................... 1 ȼɢɬɚɦɢɧɢ ............................................................................................................................................................... 2 ȼɢɬɚɦɢɧ Д ............................................................................................................................................................. 2 Дɟɮɢɧɢɰɢјɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɞɟɰɟ ............................................................................................................. 3 ɉɊȿȽɅȿȾ ɅɂɌȿɊАɌɍɊȿ 6 Ȼɢɨɯɟɦɢјɚ ɜɢɬɚɦɢɧɚ Д .......................................................................................................................................... 6 ɍɥɨɝɟ ɜɢɬɚɦɢɧɚ Д ɭ ɨɪɝɚɧɢɡɦɭ ........................................................................................................................... 9 Иɧɫɭɮɢɰɢјɟɧɰɢјɚ ɢ ɞɟɮɢɰɢјɟɧɰɢјɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ........................................................ 11 Кɥɢɧɢɱɤɟ ɩɨɫɥɟɞɢɰɟ ɤɨјɟ ɭɤɚɡɭјɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Д .......................................................................... 16 Ȼɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (ɫɩɟɰɢɮɢɱɧɢ ɛɢɨɦɚɪɤɟɪɢ ɦɟɬɚɛɨɥɢɡɦɚ ɤɨɫɬɢјɭ) ........................................................................................................................................... 19 ɍɤɭɩɚɧ ɤɚɥɰɢјɭɦ ................................................................................................................................................... 19 ɇɟɨɪɝɚɧɫɤɢ ɮɨɫɮɚɬ (ɊɈ4-) .................................................................................................................................... 21 Ⱥɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ (ȺLP) ............................................................................................................................. ....... 22 ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ............................................................................................ ................................. 22 Ɍɨɤɫɢɱɧɚ ɞɟјɫɬɜɚ ɩɪɢ ɩɪɟɤɨɦɟɪɧɨɦ ɭɧɨɫɭ ɜɢɬɚɦɢɧɚ Д .................................................................................... 25 Иɧɬɟɪɚɤɰɢјɟ ɫɚ ɥɟɤɨɜɢɦɚ ..................................................................................................................................... 26 ȼɢɬɚɦɢɧ Д ɞɟɮɢɰɢјɟɧɰɢјɚ ɢ ɝɨјɚɡɧɨɫɬ ɭ ɞɟɰɟ .................................................................................................... 26 ɐɂȴȿȼɂ ɂɋɌɊАɀɂȼАȵА ........................................................................................................................... 28 ɆАɌȿɊɂȳАɅ ɂ METOȾɈɅɈȽɂȳА ɊАȾА ................................................................................................... 29 ɊȿɁɍɅɌАɌɂ ɂɋɌɊАɀɂȼАȵА ..................................................................................................................... 33 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ ....................... 44 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Д, ɢ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................................................................................................................ 48 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ....................... 49 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɛɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................ 53 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢјɭɦɚ (ɋɚ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................................................................................................................................................................ 53 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ (ɊɈ4) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................................................................................................................................................................ 54 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALP) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................................................................................................................................................................ 55 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ................................................................................................................................................................ 57 ȾɂɋɄɍɋɂȳА ....................................................................................................................................................... 63 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ........................................... 63 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɢ ɢɫɯɪɚɧɭ ɛɨɝɚɬɭ ɤɚɥɰɢјɭɦɨɦ ............................................................................................................... 64 ɉɪɢɞɪɭɠɟɧɢ ɮɚɤɬɨɪɢ ɤɨјɢ ɭɬɢɱɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ .......................................... 69 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ ................................. 70 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢјɭ ɜɢɬɚɦɢɧɚ Д .. 72 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Д, ɢ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ .................................................................................... 75 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ...... 77 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɛɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 82 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢјɭɦɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ............................................................................................................................................................ 82 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ............................................................................................................................................ 83 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALP) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ............................................................................................................................................ 84 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ .............................................................................................................................. 85 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ ɢ ɚɥɛɭɦɢɧɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ......................................................................................................................................... 88 Дɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Д ɧɚ ɫɩɟɰɢɮɢɱɧɟ ɛɢɨɦɚɪɤɟɪɟ ɦɟɬɚɛɨɥɢɡɦɚ ɤɨɫɬɢјɭ 88 ɁАɄȴɍɑɐɂ ........................................................................................................................................................ 91 ɅɂɌȿɊАɌɍɊА ..................................................................................................................................................... 93 ɉɊɂɅɈȽ................................................................................................................................................................ 101 1 ɍȼɈȾ Ɉɩɬɢɦɚɥɧɚ ɞɟɱʁɚ ɢɫɯɪɚɧɚ ɦɨɪɚ ɞɚ ɫɚɞɪɠɢ ɟɧɟɪɝɟɬɫɤɟ, ɝɪɚɞɢɜɧɟ ɢ ɡɚɲɬɢɬɧɟ ɯɪɚɧʂɢɜɟ ɫɚɫɬɨʁɤɟ ɭ ɬɚɤɜɨʁ ɤɨɥɢɱɢɧɢ ɞɚ ɧɚ ɧɚʁɛɨʂɢ ɦɨɝɭʄɢ ɧɚɱɢɧ ɡɚɞɨɜɨʂɢ ʃɢɯɨɜɟ ɮɢɡɢɨɥɨɲɤɟ ɩɨɬɪɟɛɟ. ɋɩɟɰɢɮɢɱɧɟ ɧɭɬɪɢɬɢɜɧɟ ɩɨɬɪɟɛɟ ɞɟɰɟ ɩɪɨɢɫɬɢɱɭ ɢɡ ɢɧɬɟɧɡɢɜɧɨɝ ɩɪɨɰɟɫɚ ɪɚɫɬɚ, ɤɚɨ ɢ ɮɢɡɢɨɥɨɲɤɢɯ ɩɪɨɦɟɧɚ ɬɨɤɨɦ ɫɚɡɪɟɜɚʃɚ ɨɪɝɚɧɢɡɦɚ. Ⱥɞɟɤɜɚɬɧɚ ɢɫɯɪɚɧɚ ɞɟɰɟ ʁɟ ɧɟɨɩɯɨɞɧɚ ɡɚ ʃɢɯɨɜ ɩɪɚɜɢɥɚɧ ɪɚɫɬ ɢ ɪɚɡɜɨʁ. ȿɧɟɪɝɟɬɫɤɟ ɢ ɧɭɬɪɢɬɢɜɧɟ ɩɨɬɪɟɛɟ ɡɚɜɢɫɟ ɨɞ ɭɡɪɚɫɬɚ ɞɟɰɟ, ɛɪɡɢɧɟ ɪɚɫɬɟʃɚ, ɩɨɥɚ, ɬɟɥɟɫɧɟ ɦɚɫɟ ɢ ɝɟɧɟɬɫɤɢɯ ɮɚɤɬɨɪɚ. ɉɪɜɭ ɝɨɞɢɧɭ ɠɢɜɨɬɚ ɤɚɪɚɤɬɟɪɢɲɭ ɛɪɡɢ ɪɚɫɬ ɢ ɪɚɡɜɨʁ ɢ ɩɪɨɦɟɧɟ ɬɟɥɟɫɧɨɝ ɫɚɫɬɚɜɚ. ɇɚɪɨɱɢɬɨ ɢɧɬɟɧɡɢɜɚɧ ɪɚɫɬ ɫɟ ɨɞɜɢʁɚ ɭ ɩɪɜɚ ɞɜɚ ɦɟɫɟɰɚ ɨɞɨʁɱɟɬɚ ɭ ɨɞɧɨɫɭ ɧɚ ɤɚɫɧɢʁɟ ɞɟɬɢʃɫɬɜɨ. ɉɪɟɩɨɪɭɤɟ ɨ ɟɧɟɪɝɟɬɫɤɢɦ ɢ ɧɭɬɪɢɬɢɜɧɢɦ ɩɨɬɪɟɛɚɦɚ ɭ ɩɪɜɢɯ 6 ɦɟɫɟɰɢ ɠɢɜɨɬɚ ɡɚɫɧɢɜɚʁɭ ɫɟ ɧɚ ɤɨɥɢɱɢɧɢ ɧɭɬɪɢʁɟɧɚɬɚ ɤɨʁɟ ɨɛɟɡɛɟђɭʁɟ ɪɟɮɟɪɟɧɬɧɢ ɫɬɚɧɞɚɪɞ - ɦɚʁɱɢɧɨ ɦɥɟɤɨ (Atkinson and Koletzko, 2007). ɋɭɩɥɟɦɟɧɬɢ ɡɚ ɨɞɨјɱɚɞ ɢ ɦɚɥɭ ɞɟɰɭ ɉɪɜɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɭ ɠɢɜɨɬɭ ɞɟɬɟɬɚ ʁɟ ɜɢɬɚɦɢɧ Ʉ, ɤɨʁɢ ɫɟ ɞɚʁɟ ɞɟɬɟɬɭ ɨɞɦɚɯ ɩɨ ɪɨђɟʃɭ, ʁɟɪ ɧɨɜɨɪɨђɟɧɱɚɞ ɧɟɦɚʁɭ ɮɨɪɦɢɪɚɧɭ ɰɪɟɜɧɭ ɮɥɨɪɭ ɤɨʁɚ ɦɨɠɟ ɞɚ ɝɚ ɫɢɧɬɟɬɢɲɟ. ɉɪɟɦɚ ɩɨɞɚɰɢɦɚ ɢɡ ɥɢɬɟɪɚɬɭɪɟ (Holland, et al. 1982), ɩɪɨɫɟɱɚɧ ɫɚɞɪɠɚʁ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɱɢɧɨɦ ɦɥɟɤɭ ʁɟ ɨɤɨ 4 µg/L, ɚɥɢ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɢɫɯɪɚɧɟ ɦɚʁɤɟ ɢ ɞɪɭɝɢɯ ɮɚɤɬɨɪɚ ɦɨɠɟ ɞɚ ɜɚɪɢɪɚ. ɉɨɲɬɨ ɦɚʁɱɢɧɨ ɦɥɟɤɨ ɧɟ ɫɚɞɪɠɢ ɞɨɜɨʂɧɟ ɤɨɥɢɱɢɧɟ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨʁɟ ɫɭ ɩɨɬɪɟɛɧɟ ɨɞɨʁɱɟɬɭ, ɨɜɚʁ ɜɢɬɚɦɢɧ ɫɟ ɨɞ 15. ɞɚɧɚ ɠɢɜɨɬɚ ɧɨɜɨɪɨђɟɧɱɟɬɚ ɫɭɩɥɟɦɟɧɬɢɪɚ ɞɨ ɤɪɚʁɚ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ. ɇɚɪɨɱɢɬɨ ʁɟ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɡɧɚɱɚʁɚɧ ɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, ɭ ɡɢɦɫɤɢɦ ɦɟɫɟɰɢɦɚ, ɚɥɢ ɢ ɤɨɞ ɞɟɰɟ ɬɚɦɧɢʁɟ ɩɭɬɢ, ɤɚɤɨ ɛɢ ɫɟ ɫɩɪɟɱɢɥɚ ɩɨʁɚɜɚ ɪɚɯɢɬɢɫɚ. ɉɨɫɥɟ ɧɚɜɪɲɟɧɟ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ, ɪɚɫɬ ɞɟɬɟɬɚ ʁɟ ɭɫɩɨɪɟɧɢʁɢ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɬɯɨɞɧɢ ɩɟɪɢɨɞ. ɍ ɨɜɨɦ ɩɟɪɢɨɞɭ ɞɨɥɚɡɢ ɞɨ ɡɧɚɱɚʁɧɢɯ ɩɪɨɦɟɧɚ ɤɨʁО ɭɫɥɨɜʂɚɜɚʁɭ ɩɪɨɦɟɧɭ ɢɡɝɥɟɞɚ ɞɟɱʁɟɝ ɬɟɥɚ. Ƚɭɛɢ ɫɟ ɜɪɟɦɟɧɨɦ ɦɚɫɧɨ ɬɤɢɜɨ, ɟɤɫɬɪɟɦɢɬɟɬɢ, ɧɚɪɨɱɢɬɨ ɞɨʃɢ, ɩɨɫɬɚʁɭ ɞɭɠɢ, ɞɨɥɚɡɢ ɞɨ ɫɦɚʃɟʃɚ ɤɨɥɢɱɢɧɟ ɜɨɞɟ ɭɨɪɝɚɧɢɡɦɭ, ɚ ɩɨɜɟʄɚɜɚ ɫɟ ʃɟɧɚ ɤɨɥɢɱɢɧɚ ɭɧɭɬɚɪ ʄɟɥɢʁɚ. ɍ ɢɫɬɨ ɜɪɟɦɟ ɮɨɪɦɢɪɚʁɭ ɫɟ ɜɚɠɧɢ ɦɢɲɢʄɢ, ɪɚɫɬɭ ɡɭɛɢ, ɢ ɞɨɥɚɡɢ ɞɨ ɩɨʁɚɱɚɧɟ ɦɢɧɟɪɚɥɢɡɚɰɢʁɟ ɤɨɫɬɢʁɭ, ʁɟɪ ʁɟ ɧɟɨɩɯɨɞɧɚ ʁɚɱɢɧɚ, ɤɚɤɨ ɛɢ ɢɡɞɪɠɚɥɢ ɩɨɜɟʄɚɧɭ ɬɟɥɟɫɧɭ ɦɚɫɭ ɭ ɬɨɤɭ ɪɚɫɬɚ ɢ ɪɚɡɜɨʁɚ ɞɟɬɟɬɚ. ɍ ɨɜɨɦ ɩɟɪɢɨɞɭ ɞɨɥɚɡɢ ɞɨ ɡɧɚɱɚʁɧɢɯ ɮɢɡɢɱɤɢɯ ɢ ɩɫɢɯɢɱɤɢɯ ɩɪɨɦɟɧɚ. Ɂɚɯɬɟɜɢ ɡɚ ɟɧɟɪɝɟɬɫɤɢɦ ɩɨɬɪɟɛɚɦɚ ɭ ɩɪɜɢɯ 6 ɦɟɫɟɰɢ ɫɭ ɜɟʄɢ, ɢ ɢɡɧɨɫɟ 105-120 ФМКХ/ФР ɞɧɟɜɧɨ, ɤɚɫɧɢʁɟ ɫɟ ɫɦɚʃɭʁɭ, ɢ ɬɨ ɡɚ ɨɤɨ 10 2 ɤМКХ/ФР ɡɚ ɫɜɚɤɢ ɬɪɨɝɨɞɢɲʃɢ ɩɟɪɢɨɞ, ɢ ɪɚɫɬɭ ɩɨɫɬɟɩɟɧɨ. ɍ ɩɟɪɢɨɞɢɦɚ ɢɧɬɟɧɡɢɜɧɨɝ ɪɚɫɬɚ ɢ ɪɚɡɜɨʁɚ, ɤɚɨ ɲɬɨ ʁɟ ɩɟɪɢɨɞ ɩɭɛɟɪɬɟɬɚ, ɩɨɬɪɟɛɟ ɡɚ ɟɧɟɪɝɢʁɨɦ ɫɭ ɜɟʄɟ (Roberts, 2000). ɉɪɨɬɟɢɧɢ, ɩɪɜɟɧɫɬɜɟɧɨ ɫɥɭɠɟ ɤɚɨ ɝɪɚɞɢɜɧɟ ɦɚɬɟɪɢʁɟ ɢ ɱɢɧɟ ɡɧɚɱɚʁɚɧ ɞɟɨ ɭɤɭɩɧɢɯ ɟɧɟɪɝɟɬɫɤɢɯ ɩɨɬɪɟɛɚ. Ɉɤɨ 50% ɭɤɭɩɧɟ ɤɨɥɢɱɢɧɟ ɩɪɨɬɟɢɧɚ ɬɪɟɛɚ ɞɚ ʁɟ ɚɧɢɦɚɥɧɨɝ ɩɨɪɟɤɥɚ ɡɛɨɝ ʃɢɯɨɜɟ ɛɢɨɥɨɲɤɟ ɜɪɟɞɧɨɫɬɢ. ɉɪɨɬɟɢɧɢ ɫɭ ɛɢɬɧɢ ɭ ɫɧɚɛɞɟɜɚʃɭ ɨɪɝɚɧɢɡɦɚ ɚɡɨɬɨɦ ɢ ɚɦɢɧɨɤɢɫɟɥɢɧɚɦɚ ɤɨʁɟ ɫɭ ɧɟɨɩɯɨɞɧɟ ɡɚ ɫɢɧɬɟɡɭ ɚɧɬɢɬɟɥɚ, ɟɧɡɢɦɚ, ɯɨɪɦɨɧɚ ɢ ɞɪɭɝɢɯ ɦɚɬɟɪɢʁɚ ɤɨʁɟ ɢɦɚʁɭ ɭɥɨɝɭ ɭ ɪɟɝɭɥɚɰɢʁɢ ɦɟɬɚɛɨɥɢɱɤɢɯ ɩɪɨɰɟɫɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɤɚɨ ɢ ɦɧɨɝɟ ɮɢɡɢɨɥɨɲɤɟ ɮɭɧɤɰɢʁɟ (MКrФТšТć, 2001). Ɂɚ ɦɢɧɟɪɚɥɢɡɚɰɢʁɭ ɤɨɫɬɢʁɭ ɭ ɨɜɨɦ ɭɡɪɚɫɬɭ ɩɨɬɪɟɛɧɚ ʁɟ ɨɞɝɨɜɚɪɚʁɭʄɚ ɤɨɥɢɱɢɧɚ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ. Ⱦɚ ɛɢ ɫɟ ɡɚɞɨɜɨʂɢɥɟ ɩɨɬɪɟɛɟ ɨɪɝɚɧɢɡɦɚ ɭ ɨɜɨɦ ɠɢɜɨɬɧɨɦ ɩɟɪɢɨɞɭ, ɞɟɬɟɬɭ ɬɪɟɛɚ ɩɨɧɭɞɢɬɢ ɲɬɨ ɪɚɡɧɨɜɪɫɧɢʁɟ ɧɚɦɢɪɧɢɰɟ ɢ ɩɚɠʂɢɜɨ ɮɨɪɦɢɪɚɬɢ ɧɚɜɢɤɟ ɢɫɯɪɚɧɟ. Ⱦɟɬɟ ɭ ɨɜɨɦ ɩɟɪɢɨɞɭ ɫɬɢɱɟ ɧɚɜɢɤɟ ɤɨʁɟ ɩɪɟɞɫɬɚɜʂɚʁɭ ɨɫɧɨɜɭ ɡɚ ɩɪɢɫɬɭɩ ɯɪɚɧɢ ɢ ɫɬɚɬɭɫ ɭɯɪɚʃɟɧɨɫɬɢ ɞɟɬɟɬɚ. ȼɢɬɚɦɢɧɢ ȼɢɬɚɦɢɧɢ ɫɭ ɝɪɭɩɚ ɪɚɡɧɨɜɪɫɧɢɯ ɦɨɥɟɤɭɥɚ ɤɨʁɢ ɫɭ ɩɨɬɪɟɛɧɢ ɬɟɥɭ ɭ ɜɟɨɦɚ ɦɚɥɢɦ ɤɨɥɢɱɢɧɚɦɚ ɡɚ ɨɞɪɠɚɜɚʃɟ ɡɞɪɚɜʂɚ, ɪɚɫɬ ɢ ɨɩɫɬɚɧɚɤ ɠɢɜɨɬɚ. ɋɜɚɤɢ ɨɞ ʃɢɯ ɢɦɚ ɫɜɨʁɭ ɭɥɨɝɭ. ɇɚʁɜɚɠɧɢʁɚ ʁɟ ʃɢɯɨɜɚ ɭɥɨɝɚ ɭ ɪɚɡɜɨʁɭ ɧɟɪɜɧɨɝ ɫɢɫɬɟɦɚ, ɜɢɞɚ, ɛɪɨʁɧɢɯ ɮɭɧɤɰɢʁɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɚɥɢ ɢ ɭ ɦɢɧɟɪɚɥɢɡɚɰɢʁɢ ɤɨɫɬɢʁɭ. ȼɢɬɚɦɢɧɢ ɫɟ ɞɟɥɟ ɧɚ ɞɜɟ ɜɪɫɬɟ: ɜɢɬɚɦɢɧɟ ɪɚɫɬɜɨɪʂɢɜɟ ɭ ɜɨɞɢ ɢ ɜɢɬɚɦɢɧɟ ɪɚɫɬɜɨɪʂɢɜɟ ɭ ɦɚɫɬɢ (Ⱥ, Ⱦ, ȿ ɢ Ʉ). Ɉɜɚ ɤɥɚɫɢɮɢɤɚɰɢʁɚ ɫɟ ɧɟ ɨɞɧɨɫɢ ɬɨɥɢɤɨ ɧɚ ʃɢɯɨɜɭ ɮɭɧɤɰɢʁɭ, ɤɨɥɢɤɨ ɧɚ ʃɢɯɨɜɟ ɮɢɡɢɱɤɨ-ɯɟɦɢʁɫɤɟ ɨɫɨɛɢɧɟ. ȼɢɬɚɦɢɧɢ ɫɟ ɭ ɯɭɦɚɧɨɦ ɨɪɝɚɧɢɡɦɭ ɧɟ ɦɨɝɭ ɫɢɧɬɟɬɢɡɨɜɚɬɢ ɞɟ ɧɨɜɨ ɢɥɢ ʁɟ ʃɢɯɨɜɚ ɫɢɧɬɟɡɚ ɧɟɚɞɟɤɜɚɬɧɚ ɩɨɬɪɟɛɚɦɚ ɨɪɝɚɧɢɡɦɚ. ȼɢɬɚɦɢɧ Ⱦ ȼɢɬɚɦɢɧ Ⱦ ɩɨɫɟɞɭʁɟ ɦɧɨɝɚ ɤɨɪɢɫɧɚ ɞɟʁɫɬɜɚ ɤɨʁɚ ɫɭ ɜɚɠɧɚ ɭ ɨɱɭɜɚʃɭ ɡɞɪɚɜʂɚ. ɂɦɚʁɭʄɢ ɭ ɜɢɞɭ ɭɡɧɟɦɢɪɢʁɭʄɭ ɱɢʃɟɧɢɰɭ ɞɚ ɤɨɞ ɩɪɟɤɨ 50% ʂɭɞɢ ɩɨɫɬɨʁɢ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ, ɞɚɧɚɫ ɭ ɫɜɟɬɭ ɫɟ ɢɫɬɪɚɠɢɜɚʃɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ʃɟɝɨɜɨɦ ɭɬɢɰɚʁɭ ɧɚ ɞɚʂɟ ɡɞɪɚɜʂɟ ɞɚʁɟ ɜɟɥɢɤɢ ɡɧɚɱɚʁ, ɢ ɪɚɞɢ ɜɟɥɢɤɢ ɛɪɨʁ ɫɬɭɞɢʁɚ. Ⱦɧɟɜɧɟ ɩɨɬɪɟɛɟ ɡɚ ɜɢɬɚɦɢɧɢɦɚ ɫɭ ɜɟʄɟ ɤɨɞ ɞɟɰɟ, ɲɬɨ ɫɟ ɨɛʁɚɲʃɚɜɚ ʃɢɯɨɜɢɦ ɢɧɬɟɧɡɢɜɧɢɦ ɦɟɬɚɛɨɥɢɡɦɨɦ ɢ ɛɪɡɢɦ ɪɚɫɬɨɦ. ȼɢɫɨɤɚ ɩɪɟɜɚɥɟɧɰɚ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɨɬɤɪɢɜɟɧɚ ʁɟ ɭ ɫɜɢɦ ɞɨɛɧɢɦ ɝɪɭɩɚɦɚ. ɑɟɫɬɨ ʁɟ ɧɟɩɪɟɩɨɡɧɚɬɚ, ʁɟɪ ɫɟ ɪɚɞɢ ɨ ɧɚɨɤɨ ɡɞɪɚɜɨʁ ɞɟɰɢ. 3 Ɋɟɡɭɥɬɚɬɢ ɫɚɨɩɲɬɟɧɢ ɭ ɛɪɨʁɧɢɦ ɱɚɫɨɩɢɫɢɦɚ ɝɨɜɨɪɟ ɨ ɬɨɦɟ ɞɚ ɫɟ ɫɜɟɬ ɫɭɨɱɚɜɚ ɫɚ ɩɚɧɞɟɦɢʁɫɤɨɦ ɩɨʁɚɜɨɦ ɞɟɮɢɰɢɬɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ (Pieree Engel, et al. 2011). ɑɚɤ ɢ ɛɥɚɝɢ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ ɩɪɟɦɚ ɪɟɡɭɥɬɚɬɢɦɚ ɫɚɜɪɟɦɟɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ, ɢɦɚ ɛɪɨʁɧɟ ɲɬɟɬɧɟ ɟɮɟɤɬɟ ɧɚ ɨɪɝɚɧɢɡɚɦ. Ʉɥɢɧɢɱɤɟ ɩɨɫɥɟɞɢɰɟ ɛɥɚɝɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɱɟɫɬɨ ɦɚʃɟ ɩɪɟɩɨɡɧɚɬʂɢɜɟ ɢɥɢ ɭɨɩɲɬɟ ɧɢɫɭ ɢɫɩɨʂɟɧɟ. Ɇɟђɭɬɢɦ, ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɯɪɨɧɢɱɧɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɥɚɡɢ ɞɨ ɫɦɚʃɟʃɚ ɝɭɫɬɢɧɟ ɤɨɫɬɢʁɭ, ɱɚɤ ɢ ɭ ɨɞɫɭɫɬɜɭ ɪɚɯɢɬɢɫɚ. Ⱦɟɮɢɧɢɰɢјɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ Ⱦɟɮɢɧɢɰɢʁɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɩɪɟɞɦɟɬ ɢɧɬɟɧɡɢɜɧɟ ɪɚɫɩɪɚɜɟ ɥɟɤɚɪɚ ɢ ɢɫɬɪɚɠɢɜɚɱɚ. Ɍɟɲɤɚ ɞɟɮɢɰɢјɟɧɰɢјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɟ ɞɟɮɢɧɢɲɟ ɤɚɨ ɧɢɜɨ 25(OH)D ɭ ɫɟɪɭɦɭ <10 ng/ml, ɦɚɧɢɮɟɫɬɭʁɟ ɫɟ ɪɚɯɢɬɢɫɨɦ ɢ ɨɫɬɟɨɦɚɥɚɰɢʁɨɦ. Ɍɪɟɬɢɪɚ ɫɟ ɜɢɫɨɤɢɦ ɞɨɡɚɦɚ ɜɢɬɚɦɢɧɚ Ⱦ. Ⱦɟɮɢɰɢјɟɧɰɢјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɟ ɞɟɮɢɧɢɲɟ ɤɚɨ ɧɢɜɨ 25(OH)D ɨɞ 10-20 ЧР/ЦХ, ɭ ɚɫɨɰɢʁɚɰɢʁɢ ʁɟ ɫɚ ɪɢɡɢɤɨɦ ɨɞ ɛɨɥɟɫɬɢ, ɤɨɪɢɝɭʁɟ ɫɟ ɫɭɩɥɟɦɟɧɬɚɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. ɂɧɫɭɮɢɰɢјɟɧɰɢјɚ (ɫɭɛɨɩɬɢɦɚɥɧɢ ɧɢɜɨ) ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɱʁɟɦ ɨɪɝɚɧɢɡɦɭ ɫɟ ɞɟɮɢɧɢɲɟ ɤɚɨ ɧɢɜɨ 25(OH)D ɨɞ 20-30 ng/ml. Ɉɩɬɢɦɚɥɚɧ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɞɟɮɢɧɢɲɟ ɫɟ ɤɚɨ ɧɢɜɨ 25(OH)D ɢɡɧɚɞ 30 ЧР/ЦХ. Ⱦɟɰɚ ɫɭ ɡɞɪɚɜɚ ɢ ɧɢʁɟ ɧɟɨɩɯɨɞɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ (Pearce and Cheetham, 2010; Guidelines for the treatment, 2012). ɂɚɤɨ ɩɨɫɬɨʁɟ ɪɚɡɥɢɤɟ ɭ ɦɢɲʂɟʃɢɦɚ ɭ ɜɟɡɢ ɫɚ ɧɢɜɨɨɦ 25(OH)D ɤɨʁɢ ɞɟɮɢɧɢɲɭ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɢ ɧɟɞɨɫɬɚɬɚɤ, ɩɨɫɬɨʁɢ ɝɨɬɨɜɨ ʁɟɞɧɨɝɥɚɫɧɚ ɫɚɝɥɚɫɧɨɫɬ ɞɚ ɧɢɜɨ 25(OH)D ɭ ɫɟɪɭɦɭ ≤12 ЧР/ЦХ ɩɪɟɞɫɬɚɜʂɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɋʁɟɞɢʃɟɧɢɦ Ⱦɪɠɚɜɚɦɚ. ȼɪɟɞɧɨɫɬɢ 25(OH)D ɨɞ 12-20 ЧР/ЦХ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɜɨʂɧɨɫɬ (ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ), ɞɨɤ ɫɭ ɜɪɟɞɧɨɫɬɢ 25(OH)D ɢɡɧɚɞ 30 ЧР/ЦХ ɨɩɬɢɦɚɥɧɟ. ɉɪɨɰɟʃɟɧɨ ʁɟ ɞɚ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ 25(OH)D ɢɡɧɚɞ 20 ЧР/ЦХ ɡɚɞɨɜɨʂɚɜɚ ɩɨɬɪɟɛɟ ɧɚʁɦɚʃɟ 97,5% ɫɬɚɧɨɜɧɢɲɬɜɚ ɭ ɫɜɢɦ ɫɬɚɪɨɫɧɢɦ ɝɪɭɩɚɦɚ ɭ ɪɚɡɜɢʁɟɧɢɦ ɡɟɦʂɚɦɚ (SAD IOM-ɤɥɚɫɢɮɢɤɚɰɢʁɚ) (Rossa, et al. 2011). Ⱦɟɮɢɧɢɰɢʁɚ ɨɩɬɢɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ʁɟ ɤɨɧɬɪɚɜɟɪɡɧɚ ɢ ɧɢʁɟ ɞɨɛɪɨ ɩɨɞɪɠɚɧɚ ɨɞ ɫɬɪɚɧɟ ɤɥɢɧɢɱɤɢɯ ɢɫɩɢɬɢɜɚʃɚ, ɩɨɫɟɛɧɨ ɭ ɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɩɨɩɭɥɚɰɢʁɢ. ɍɝɥɚɜɧɨɦ ɫɟ ɦɟɪɢ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D (ɤɚɥɰɢɞɢɨɥɚ) ɭ ɫɟɪɭɦɭ ɡɛɨɝ ɞɭɝɨɝ ɜɪɟɦɟɧɚ ɩɨɥɭɪɚɫɩɚɞɚ ɨɞ 2-3 ɧɟɞɟʂɟ, ɢ ɨɬɩɨɪɧɨɫɬɢ ɧɚ ɩɪɨɦɟɧɟ ɭ ɤɨɧɰɟɧɬɪɚɰɢʁɢ ɊɌɇ. 4 ɇɚ ɬɚɛɟɥɢ ɛɪ. 1 ɫɭ ɩɪɢɤɚɡɚɧɟ ɧɨɪɦɚɥɧɟ ɢ ɩɚɬɨɥɨɲɤɟ ɜɪɟɞɧɨɫɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɤɥɚɫɢɮɢɤɨɜɚɧɟ ɨɞ ɫɬɪɚɧɟ Ⱥɦɟɪɢɱɤɟ ɚɤɚɞɟɦɢʁɟ ɡɚ ɉɟɞɢʁɚɬɪɢʁɭ (ȺȺɊ) ɢ ɂɧɫɬɢɬɭɬɚ ɡɚ ɦɟɞɢɰɢɧɭ (IOM) ɤɨʁɢ ɞɟɮɢɧɢɲɭ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɤɚɨ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D<20 ЧР/ЦХ ɭ ɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɩɨɩɭɥɚɰɢʁɢ. ɇɚɫɭɩɪɨɬ ɬɨɦɟ, Eɧɞɨɤɪɢɧɨ ɞɪɭɲɬɜɨ ɢ ɧɚɰɢɨɧɚɥɧɚ ɮɨɧɞɚɰɢʁɚ ɡɚ ɛɭɛɪɟɠɧɟ ɛɨɥɟɫɬɢ (ɄDOQI) ɤɥɚɫɢɮɢɤɭʁɭ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɩɪɢ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25(Ɉɇ)D<30 ЧР/ЦХ. Ɍɚɛɟɥɚ ɛɪ. 1 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɛɚɡɢɪɚɧ ɧɚ ɜɪɟɞɧɨɫɬɢ ɤɚɥɰɢɞɢɨɥɚ (nР/ml) ȼɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ 25(OH)D - Ʉɚɥɰɢɞɨɥ (ЧР/ЦХ) AAP, IOM ɍɞɪɭɠɟʃɟ ɟɧɞɨɤɪɢɧɨɥɨɝɚ KDOQI Ɍɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ <5 - <5 Ȼɥɚɝɚ ɞɨ ɭɦɟɪɟɧɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ 5-15 <20 5-15 ɂɧɫɭɮɢɰɢʁɟɧɰɢʁɚ 16-20 21-30 16-30 Ɉɩɬɢɦɚɥɧɢ ɧɢɜɨ 21-100 31-60 >30 ȼɢɬɚɦɢɧ Ⱦ ɭ ɜɢɲɤɭ 101-149 - - ɂɧɬɨɤɫɢɤɚɰɢʁɚ >150 - - ɂɚɤɨ ʁɟ ɞɨʃɚ ɝɪɚɧɢɰɚ ɜɪɟɞɧɨɫɬɢ 25(OH)D 10 ЧР/ЦХ, ɤɚɨ ɲɬɨ ʁɟ ɧɚɜɟɞɟɧɨ ɨɞ ɫɬɪɚɧɟ ɚɭɬɨɪК Holicka (Holick, 2002). ɉɨɫɬɨʁɟ ʁɚɤɢ ɞɨɤɚɡɢ ɞɚ ɧɢɜɨɢ 25(OH)D ɭ ɤɪɜɢ ɦɚʃɢ ɨɞ 20 ЧР/ЦХ ɞɨɜɨɞɟ ɞɨ ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ (Holick, 2002; Malabanan, et al. 1998). ɍɫɥɟɞ ɞɨɤɚɡɚ ɞɚ ɜɪɟɞɧɨɫɬɢ 25(OH)D ɭ ɤɪɜɢ ɧɢɠɟ ɨɞ 20 ЧР/ЦХ ɞɨɜɨɞɟ ɞɨ ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ ɭ ɫɜɢɯ ɢɫɩɢɬɚɧɢɤɚ (ɭ 100%), ɞɨɧɟɬ ʁɟ ɡɚɤʂɭɱɚɤ ɞɚ ɭ ɬɢɦ ɫɥɭɱɚʁɟɜɢɦɚ ɩɨɫɬɨʁɢ ɧɟɞɨɜɨʂɧɨɫɬ ɨɜɨɝ ɜɢɬɚɦɢɧɚ ɭ ɨɪɝɚɧɢɡɦɭ. ɍ ɨɜɢɦ ɫɥɭɱɚʁɟɜɢɦɚ ɫɭ ɤɥɢɧɢɱɤɢ ɫɢɦɩɬɨɦɢ ɢ ɡɧɚɰɢ ɜɪɥɨ ɫɭɩɬɢɥɧɢ ɢɥɢ ɧɟɫɩɟɰɢɮɢɱɧɢ. Ɉɜɨ ɩɨɤɚɡɭʁɟ ɞɚ ʁɟ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɜɢɦ ɤɨɥɢɱɢɧɚɦɚ ɞɨɜɟɨ ɞɨ ɫɦɚʃɟɧɟ ɟɮɢɤɚɫɧɨɫɬɢ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ ɭ ɰɪɟɜɢɦɚ, ɧɚɤɨɧ ɱɟɝɚ ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɭ ɫɟɤɪɟɰɢʁɢ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ). Ɉɜɚʁ ɯɨɪɦɨɧ ɩɨɞɫɬɢɱɟ ɛɭɛɪɟɝ ɞɚ ɫɬɢɦɭɥɢɲɟ ɩɪɨɢɡɜɨɞʃɭ 1,25(OH)2D, ɤɨʁɢ ɭɡɪɨɤɭʁɟ ɩɨɜɟʄɚɧɭ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢɡ ɰɪɟɜɚ. ɊɌɇ ɫɬɢɦɭɥɢɲɟ ɩɪɟɤɭɪɡɨɪɟ ɨɫɬɟɨɤɥɚɫɬɚ ɞɚ ɩɨɫɬɚɧɭ ɡɪɟɥɢ ɨɫɬɟɨɤɥɚɫɬɢ, ɱɟɦɭ ɫɥɟɞɢ ɦɨɛɢɥɢɡɚɰɢʁɚ ɞɟɩɨɧɨɜɚɧɨɝ ɤɚɥɰɢʁɭɦɚ ɢɡ ɤɨɫɬɢʁɭ. ɉɨɜɟʄɚɧɚ ɚɤɬɢɜɧɨɫɬ ɨɫɬɟɨɤɥɚɫɬɚ ɱɟɫɬɨ ɩɨɝɨɪɲɚɜɚ ɨɫɬɟɨɩɨɪɨɡɭ ɤɨɫɬɢʁɭ. ɋɭɛɤɥɢɧɢɱɤɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɥɢ, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɱɟɫɬɨ ɫɟ ɩɪɟɞɫɬɚɜʂɚ ɤɚɨ ɫɬɚʃɟ ɨɪɝɚɧɢɡɦɚ ɤɨɞ ɤɨɝɚ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɨɞ 21-29 5 ЧР/ЦХ, ɢ ɱɟɫɬɨ ɞɨɜɨɞɟ ɞɨ ɦɧɨɝɨɛɪɨʁɧɢɯ ɯɪɨɧɢɱɧɢɯ ɛɨɥɟɫɬɢ, ɧɚʁɱɟɲʄɟ ɞɨ ɨɫɬɟɨɦɚɥɚɰɢʁɟ ɢ ɨɫɬɟɨɩɨɪɨɡɟ, ɤɚɨ ɢ ɩɨʁɚɜɟ ɚɭɬɨɢɦɭɧɢɯ ɢ ɦɚɥɢɝɧɢɯ ɨɛɨʂɟʃɚ. ɇɚ ɬɚʁ ɧɚɱɢɧ ɫɟ ɨɛʁɚɲʃɚɜɚʁɭ ɧɨɜɟ ɩɪɟɩɨɪɭɤɟ ɨ ɞɧɟɜɧɨɦ ɭɧɨɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨʁɱɚɞɢ, ɞɟɰɟ ɢ ɨɞɪɚɫɥɢɯ (US IOM 2011. ɢ ɋɦɟɪɧɢɰɟ ɚɦɟɪɢɱɤɨɝ ɟɧɞɨɤɪɢɧɨɝ ɞɪɭɲɬɜɚ) (Lippincott and Wilkins, 2012). Ʉɨɥɢɤɢ ʁɟ ɨɩɬɢɦɚɥɚɧ ɧɢɜɨ 25(Ɉɇ)D, ɭɤɚɡɭʁɟ ɢ ɩɨɞɚɬɚɤ ɞɚ ʁɟ ɝɭɫɬɢɧɚ ɤɨɫɬɢʁɭ ɧɚʁɛɨʂɚ ɭɫɪɟɞ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɡɦɟђɭ 32 ɢ 45 ЧР/ЦХ, ɚ ɨɩɚɞɚ ɢɡɧɚɞ 45 ЧР/ЦХ. ɉɨɫɬɨʁɢ ɦɟɯɚɧɢɡɚɦ ɭ ɬɟɥɭ ɤɨʁɢ "ɨɞɪɠɚɜɚ" ɧɢɜɨ 25(Ɉɇ)D ɧɚ 40 ЧР/ЦХ, ɬɚɤɨ ɲɬɨ ɜɢɲɚɤ ɜɢɬɚɦɢɧɚ Ⱦ3 ɞɟɩɨɧɭʁɟ ɭ ɦɚɫɧɢɦ ʄɟɥɢʁɚɦɚ. ɋɥɢɤɚ ɛɪ. 1 Ɇɚɩɢɪɚʃɟ ɧɟɤɨɥɢɤɨ ɛɨɥɟɫɬɢ ɤɨɫɬɢјɭ ɭ ɨɞɧɨɫɭ ɧɚ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Д (ɤɚɥɰɢɞɢɨɥɚ) ɭ ɤɪɜɢ 6 ɉɊȿȽɅȿȾ ɅɂɌȿɊȺɌɍɊȿ Ȼɢɨɯɟɦɢјɚ ɜɢɬɚɦɢɧɚ Ⱦ ȼɢɬɚɦɢɧ Ⱦ (ɤɚɥɰɢɮɟɪɨɥ) ʁɟ ɟɫɟɧɰɢʁɚɥɧɢ ɱɢɧɢɥɚɰ, ɧɟ ɫɚɦɨ ɯɨɦɟɨɫɬɚɡɟ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ, ɨɞɧɨɫɧɨ ɤɨɫɬɧɨɝ ɢ ɡɭɛɧɨɝ ɬɤɢɜɚ, ɜɟʄ ɢ ʄɟɥɢʁɫɤɟ ɩɪɨɥɢɮɟɪɚɰɢʁɟ, ɞɢɮɟɪɟɧɰɢʁɚɰɢʁɟ ɢ ɚɩɨɩɬɨɡɟ, ɢɦɭɧɟ ɢ ɯɨɪɦɨɧɫɤɟ ɪɟɝɭɥɚɰɢʁɟ ɢ ɞɪɭɝɢɯ ɩɪɨɰɟɫɚ ɭ ɨɪɝɚɧɢɡɦɭ (Hossein-Hezad and Holick, 2013). ɂɚɤɨ ɫɟ ɡɚ ɜɢɬɚɦɢɧ Ⱦ ɡɧɚ ɝɨɬɨɜɨ 100 ɝɨɞɢɧɚ, ɨɧ ɢ ɞɚʂɟ ɨɫɬɚʁɟ ɜɟɥɢɤɚ ɧɟɩɨɡɧɚɧɢɰɚ (Barret and McElduff, 2010). Ɉɜɨ ɫɟ ɨɞɧɨɫɢ ɧɚ ɧɟɤɚɥɰɢɬɪɨɩɧɚ ɫɜɨʁɫɬɜɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɤɚɨ ɢ ɨɩɬɢɦɚɥɧɟ ɩɨɬɪɟɛɟ ɡɚ ɨɜɢɦ ɜɢɬɚɦɢɧɨɦ ɭ ɫɚɜɪɟɦɟɧɢɦ ɭɫɥɨɜɢɦɚ ɠɢɜɨɬɚ ɩɪɚʄɟɧɢɦ ɨɝɪɚɧɢɱɟɧɢɦ ɢɡɥɚɝɚʃɟɦ ɫɭɧɰɭ (Brannon, et al. 2008: Holick and Chen, 2008; Holick, 2008), ɞɨɤ ɫɭ ʃɟɝɨɜɢ ɤɚɥɰɢɬɪɨɩɧɢ ɟɮɟɤɬɢ ɞɨɛɪɢɦ ɞɟɥɨɦ ɩɨɡɧɚɬɢ. ɂɫɬɨɪɢʁɫɤɢ, ɬɪɟɛɚ ɢɡɞɜɨʁɢɬɢ ɧɟɤɨɥɢɤɨ ɢɦɟɧɚ ɢɧɚɭɱɧɢɯ ɨɬɤɪɢʄɚ ɨ ɜɢɬɚɦɢɧɭ Ⱦ: Elmer McCollum, ɢɡɨɥɨɜɚɨ ɝɚ ʁɟ ɢɡ ɪɢɛʂɟɝ ɭʂɚ ɢ ɞɚɨ ɧɚɡɢɜ Ⱦ ɜɢɬɚɦɢɧ (1922); Adolf АТЧНКus УО ɢɡɨɥɨɜɚɨ ɬɪɢ ɨɛɥɢɤɚ: Ⱦ1, Ⱦ2 ɢ Ⱦ3 (1928. ɝɨɞɢɧɟ ɇɨɛɟɥɨɜɚ ɧɚɝɪɚɞɚ); HОМtШr DeLucia MC et al, (1968-1971) ɨɬɤɪɢɨ ʁɟ ɢ ɨɩɢɫɚɨ ɩɭɬ ɫɢɧɬɟɡɟ ɭ ɨɪɝɚɧɢɡɦɭ ɢ ɩɨɜɟɡɚɧɨɫɬ ɫɚ ɩɚɪɚɬɯɨɪɦɨɧɨɦ ɭ ɨɞɪɠɚɜɚʃɭ ɯɨɦɟɨɫɬɚɡɟ ɤɚɥɰɢʁɭɦɚ, ɆɚrФHКussХОr УО 1975. ɝɨɞɢɧɟ ɨɬɤɪɢɨ ɪɟɰɟɩɬɨɪ ɡɚ ɜɢɬɚɦɢɧ Ⱦ. ɍ ɩɨɫɥɟɞʃɢɯ ɞɜɚɞɟɫɟɬɚɤ ɝɨɞɢɧɚ ɡɧɚɬɧɨ ɫɭ ɭɜɟʄɚɧɚ ɫɚɡɧɚʃɚ ɨ ɦɟɬɚɛɨɥɢɡɦɭ ɜɢɬɚɦɢɧɚ Ⱦ, ɨ ɮɭɧɤɰɢʁɢ ʃɟɝɨɜɢɯ ɦɟɬɚɛɨɥɢɬɚ ɢ ɨ ɧɚɱɢɧɭ ʃɢɯɨɜɟ ɩɪɢɦɟɧɟ ɭ ɤɥɢɧɢɱɤɨʁ ɦɟɞɢɰɢɧɢ. Ɂɚɯɜɚʂɭʁɭʄɢ ɨɜɢɦ ɨɬɤɪɢʄɢɦɚ, ɥɟɱɟʃɟ ɩɨɪɟɦɟʄɚʁɚ ɦɟɬɚɛɨɥɢɡɦɚ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɩɨɫɬɚɥɨ ʁɟ ɞɚɥɟɤɨ ɜɢɲɟ ɫɚɨɛɪɚɡɧɨ ʃɢɯɨɜɢɦ ɟɬɢɨɩɚɬɨɝɟɧɟɬɫɤɢɦ ɦɟɯɚɧɢɡɦɢɦɚ, ɲɬɨ ɡɧɚɱɢ ɢ ɥɚɤɲɟ ɢ ɩɪɟɰɢɡɧɢʁɟ. Ɂɚɬɨ ʁɟ ɧɟɨɩɯɨɞɧɨ ɞɚ ɫɟ ɢɡɥɨɠɟ ɞɚɧɚɲʃɚ ɫɯɜɚɬɚʃɚ ɢ ɡɧɚʃɚ ɨ ɩɪɨɛɥɟɦɢɦɚ ɤɨʁɢ ɫɭ ɭɜɟɤ ɚɤɬɭɟɥɧɢ ɭ ɩɟɞɢʁɚɬɪɢʁɢ. ɇɚʁɧɨɜɢʁɚ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɚɥɚ ɫɭ ɞɚ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɯɨɪɦɨɧ ɩɨ ɫɜɨʁɢɦ ɯɟɦɢʁɫɤɢɦ ɨɫɨɛɢɧɚɦɚ, ɧɚɱɢɧɭ ɢ ɪɟɝɭɥɚɰɢʁɢ ɫɢɧɬɟɡɟ ɢ ɞɟɩɨɧɨɜɚʃɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɩɨɫɬɨʁɚʃɭ ɪɟɰɟɩɬɨɪɚ ɧɚ ɰɢʂɧɢɦ ʄɟɥɢʁɚɦɚ ɢ ɩɥɟʁɨɬɪɨɩɧɢɦ ɟɮɟɤɬɢɦɚ (PОtrШЧТУОvТć, 2009; RОТМСrКtС, Оt КХ. 2007). ɇɚɡɢɜ ɜɢɬɚɦɢɧ Ⱦ ʁɟ ɡɚɞɪɠɚɧ ɫɚɦɨ ɢɡ ɢɫɬɨɪɢʁɫɤɢɯ ɪɚɡɥɨɝɚ. ȼɢɬɚɦɢɧ Ⱦ ɢɥɢ ɤɚɥɰɢɮɟɪɨɥ ʁɟ ɚɧɬɢɪɚɯɢɬɢɱɧɢ ɜɢɬɚɦɢɧ ɢɥɢ ɝɚ ɱɟɫɬɨ ɧɚɡɢɜɚʁɭ ɢ ɜɢɬɚɦɢɧɨɦ ɫɭɧɰɚ. Ʌɢɩɨɫɨɥɭɛɢɥɚɧ ʁɟ, ɢɦɚ ɫɬɟɪɨɢɞɧɭ ɫɬɪɭɤɬɭɪɭ (ɫɟɤɨɫɬɟɪɨɢɞ), ɫɥɢɱɧɨ ɩɨɥɧɢɦ ɯɨɪɦɨɧɢɦɚ ɢ ɯɨɪɦɨɧɢɦɚ ɤɨɪɟ ɧɚɞɛɭɛɪɟɠɧɟ ɠɥɟɡɞɟ. ɋɤɭɩɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɩɪɟɞɫɬɚɜʂɚ ɝɪɭɩɭ 7 ʁɟɞɢʃɟʃɚ ɪɚɫɬɜɨɪʂɢɜɢɯ ɭ ɦɚɫɬɢɦɚ, ɨɞ ɤɨʁɢɯ ɫɭ ɧɚʁɜɚɠɧɢʁɢ ɜɢɬɚɦɢɧ 7 Ⱦ2-ɟɪɝɨɤɚɥɰɢɮɟɪɨɥ (ɛɢʂɧɨɝ ɩɨɪɟɤɥɚ) ɢ ɜɢɬɚɦɢɧ Ⱦ3-ɯɨɥɟɤɚɥɰɢɮɟɪɨɥ ɤɨʁɢ ɫɟ ɯɪɚɧɨɦ ɭɧɨɫɢ ɢɡ ɠɢɜɨɬɢʃɫɤɢɯ ɧɚɦɢɪɧɢɰɚ (Lips, 2006). Ɉɛɚ ɫɟ ɦɨɝɭ ɫɢɧɬɟɬɢɱɤɢ ɩɪɨɢɡɜɟɫɬɢ ɢ ɞɨɫɬɭɩɧɢ ɫɭ ɤɚɨ ɫɭɩɥɟɦɟɧɬɢ ɭ ɢɫɯɪɚɧɢ. ɍ ɟɩɢɞɟɪɦɢɫɭ ɫɟ ɧɚɥɚɡɢ ɩɪɢɪɨɞɧɨ ɜɢɬɚɦɢɧ Ⱦ3, ɭ ɨɛɥɢɤɭ ɩɪɨɜɢɬɚɦɢɧɚ 7-ɞɟɯɢɞɪɨɫɬɟɪɨɥɚ, ɤɨʁɢ 80% ɧɚɫɬɚʁɟ ɭ ɤɨɠɢ ɩɨɞ ɞɟʁɫɬɜɨɦ ɭɥɬɪɚɜɢɨɥɟɬɧɢɯ ɡɪɚɤɚ (230-315ЧЦ) ɭ ɩɥɚɡɦɚ ɦɟɦɛɪɚɧɢ ɟɩɢɞɟɪɦɚɥɧɢɯ ɤɟɪɚɬɨɧɢɰɢɬɚ ɢ ɞɟɪɦɚɥɧɢɯ ɮɢɛɪɨɛɥɚɫɬɚ, ɚ 20% ɫɟ ɭɧɨɫɢ ɨɪɚɥɧɨ ɩɭɬɟɦ ɯɪɚɧɟ ɢ/ɢɥɢ ɫɭɩɥɟɦɟɧɚɬɚ (Holick, 2005). ɉɪɢ ɬɨɦɟ ɧɚɫɬɚʁɟ ɩɪɟɯɨɪɦɨɧ, ɤɨʁɢ ɫɟ ɩɪɟɤɨ ɤɪɜɢ ɩɪɟɧɨɫɢ ɭ ʁɟɬɪɭ, ɝɞɟ ɫɟ ɨɞɢɝɪɚɜɚ ɦɟɬɚɛɨɥɢɱɤɚ ɤɨɧɜɟɪɡɢʁɚ ɭ ɤɚɥɰɢɞɢɨɥ ɢɥɢ 25-ɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (25(ɈH)D). ɋɢɧɬɟɡɚ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥɚ ɭ ɤɨɠɢ ɭɫɥɨɜʂɟɧɚ ʁɟ ɢɧɫɨɥɚɰɢʁɨɦ, ɤɨʁɚ ɡɚɜɢɫɢ ɨɞ ɝɟɨɝɪɚɮɫɤɟ ɲɢɪɢɧɟ, ɝɨɞɢɲʃɟɝ ɞɨɛɚ, ɞɨɛɚ ɞɚɧɚ, ɤɨɥɢɱɢɧɟ ɨɡɨɧɚ ɭ ɫɬɪɚɬɨɫɮɟɪɢ, ɨɛɥɚɱɧɨɫɬɢ, ɡɚɝɚђɟʃɚ ɚɬɦɨɫɮɟɪɟ, ɪɟɮɥɟɤɫɢɜɧɨɫɬɢ ɩɨɜɪɲɢɧɟ, ɮɨɬɨɬɢɩɚ ɤɨɠɟ, ɬʁ. ɤɨɥɢɱɢɧɟ ɦɟɥɚɧɢɧɚ ɭ ɤɨɠɢ (ɜɢɲɟ ɦɟɥɚɧɢɧɚ-ɦɚʃɚ ɫɢɧɬɟɡɚ), ɨɞɟʄɟ ɢ ɭɩɨɬɪɟɛɟ ɡɚɲɬɢɬɧɟ ɤɪɟɦɟ. ɋɦɚɬɪɚ ɫɟ ɞɚ ɡɚɲɬɢɬɧɢ ɮɚɤɬɨɪ ≥15 ɞɨɜɨɞɢ ɞɨ ɩɪɟɤɢɞɚ ɫɢɧɬɟɡɟ ɜɢɬɚɦɢɧɚ Ⱦ (Kandolf-SОФuХШvТć Т ГОčОvТć, 2009). ȼɢɬɚɦɢɧ Ⱦ ɱɢɧɟ ɞɜɚ ɩɪɢɪɨɞɧɚ ɢɡɨɦɟɪɚ, ɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (Ⱦ3) ɢ ɟɪɝɨɤɚɥɰɢɮɟɪɨɥ (Ⱦ2). Ɉɧɢ ɫɟ ɪɚɡɥɢɤɭʁɭ ɩɨ ɩɨɪɟɤɥɭ, ɯɟɦɢʁɫɤɨɦ ɫɚɫɬɚɜɭ ɢ ɛɢɨɥɨɲɤɨʁ ɚɤɬɢɜɧɨɫɬɢ. Ɉɛɚ ɢɡɨɦɟɪɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚɫɬɚʁɭ ɮɨɬɨɥɢɬɢɱɤɢɦ ɪɚɫɤɢɞɚʃɟɦ ɐ9-ɐ10 ɜɟɡɟ ɩɪɫɬɟɧɚ Ȼ ɨɞɝɨɜɚɪɚʁɭʄɟɝ ɫɬɟɪɨɢɞɧɨɝ ɩɪɟɤɭɪɡɨɪɚ, ɬʁ. 7-ɞɟɯɢɞɪɨɯɨɥɟɫɬɟɪɨɥɚ (7-DHC) ɢ ɟɪɝɨɫɬɟɪɨɥɚ. ɉɪɨɜɢɬɚɦɢɧ Ⱦ2 (ɟɪɝɨɫɬɟɪɨɥ), ɤɨʁɢ ʁɟ ɛɢʂɧɨɝ ɩɨɪɟɤɥɚ ɫɟ ɭ ɤɨɠɢ ɩɨɞ ɞɟʁɫɬɜɨɦ ɍȼ ɡɪɚɱɟʃɚ ɩɪɟɬɜɚɪɚ ɭ ɤɚɥɰɢɮɟɪɨɥ (ɜɢɬɚɦɢɧ Ⱦ2). ɂɫɬɨ ɬɚɤɨ, ɠɢɜɨɬɢʃɫɤɢ ɩɪɨɜɢɬɚɦɢɧ Ⱦ3 ɢɥɢ 7-ɞɟɯɢɞɪɨɯɨɥɟɫɬɟɪɨɥ ɤɨʁɢ ɩɪɨɞɭɤɭʁɭ ɱɨɜɟɤ ɢ ɜɢɲɟ ɠɢɜɨɬɢʃɫɤɟ ɜɪɫɬɟ (ɜɟɪɬɟɛɪɚɬɟ), ɫɟ ɭ ɤɨɠɢ ɧɚ ɢɫɬɢ ɧɚɱɢɧ ɩɪɟɬɜɚɪɚ ɭ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥ, ɢɥɢ ɜɢɬɚɦɢɧ Ⱦ3. ȿɪɝɨɫɬɟɪɨɥ ɭ ɛɨɱɧɨɦ ɥɚɧɰɭ ɫɚɞɪɠɢ ɧɟɡɚɫɢʄɟɧɭ ɜɟɡɭ ɧɚ ɩɨɡɢɰɢʁɢ ɐ22 ɢ ɐ23 ɢ ɦɟɬɢɥ ɝɪɭɩɭ ɧɚ ɐ24, ɩɚ ɫɟ ɤɚɨ ɩɨɫɥɟɞɢɰɚ ɪɚɡɥɢɤɟ ɭ ɯɟɦɢʁɫɤɨʁ ɫɬɪɭɤɬɭɪɢ ɢɫɬɢɱɟ ɦɧɨɝɨ ɚɤɬɢɜɧɢʁɚ ɛɢɨɥɨɲɤɚ ɚɤɬɢɜɧɨɫɬ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥɚ. Ɏɨɬɨɥɢɡɨɦ 7-DHC ɤɨʁɚ ɫɟ ɨɞɜɢʁɚ ɭ ɤɟɪɚɬɨɰɢɬɢɦɚ ɟɩɢɞɟɪɦɢɫɚ ɢ ɮɢɛɪɨɛɥɚɫɬɢɦɚ ɞɟɪɦɢɫɚ ɩɨɞ ɞɟʁɫɬɜɨɦ Ȼ ɮɪɚɤɰɢʁɟ ɭɥɬɪɚʂɭɛɢɱɚɫɬɢɯ ɬɚɥɚɫɚ (290-315ЧЦ), ɧɚɫɬɚʁɟ ɩɪɟɜɢɬɚɦɢɧ Ⱦ, ɚ ɡɚɬɢɦ ʃɟɝɨɜɨɦ ɬɟɪɦɨɢɡɨɦɟɪɢɡɚɰɢʁɨɦ, ɜɢɬɚɦɢɧ Ⱦ3. ȼɢɬɚɦɢɧ Ⱦ ɫɬɜɨɪɟɧ ɭ ɤɨɠɢ ɞɢɮɭɧɞɭʁɟ ɭ ɤɪɜɨɬɨɤ ɩɪɟɤɨ ɤɨɝɚ ɫɟ, ɭ ɫɩɨʁɭ ɫɚ ɜɢɬɚɦɢɧ Ⱦ ɜɟɡɭʁɭʄɢɦ ɩɪɨɬɟɢɧɨɦ (vТtКЦТЧ D ЛТЧНТЧР prШtОТЧ, DBP), ɬɪɚɧɫɩɨɪɬɭʁɟ ɭ ʁɟɬɪɭ ɢ ɞɪɭɝɟ ɨɪɝɚɧɟ. ȼɢɬɚɦɢɧ Ⱦ2 ɢ Ⱦ3 ɫɟ ɢɡ ɯɪɚɧɟ ɚɩɫɨɪɛɭʁɭ ɭ ɰɪɟɜɭ ɢ ɩɪɟɤɨ ɯɢɥɨɦɢɤɪɨɧɚ ɫɟ ɩɪɟɧɨɫɟ ɭ ɤɪɜɨɬɨɤ. ɍ ɦɢɤɪɨɡɨɦɚɥɧɨʁ ɮɪɚɤɰɢʁɢ ʁɟɬɪɟ ɜɪɲɢ ɫɟ ɯɢɞɪɨɤɫɢɥɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɨɥɨɠɚʁɭ 25 ɢ ɧɚɫɬɚʁɟ 25-ɯɢɞɪɨɤɫɢ ɜɢɬɚɦɢɧ Ⱦ (ɢɥɢ ɤɚɥɰɢɞɢɨɥ). ȼɢɬɚɦɢɧ Ⱦ ɫɟ ɭ ɮɨɪɦɢ ɤɚɥɰɢɞɢɨɥɚ ɞɟɩɨɧɭʁɟ ɭ ʁɟɬɪɢ 2-4 ɦɟɫɟɰɚ. 25(OH)D ɩɭɬɟɦ ɤɪɜɢ ɞɨɫɩɟɜɚ ɞɨ ɩɪɨɤɫɢɦɚɥɧɢɯ 8 ɬɭɛɭɥɚ ɛɭɛɪɟɝɚ, ɝɞɟ ɫɟ, ɭɱɟɲʄɟɦ ɟɧɡɢɦɚ 1-α-ɯɢɞɪɨɤɫɢɥɚɡɟ, ɩɨɧɨɜɨ ɯɢɞɪɨɤɫɢɥɢɲɟ ɢ ɫɬɜɚɪɚ ɫɟ 1,25-ɞɢɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (ɤɚɥɰɢɬɪɢɨɥ), ɤɨʁɢ ʁɟ ɚɤɬɢɜɧɚ ɮɨɪɦɚ ɜɢɬɚɦɢɧɚ Ⱦ-ɯɨɪɦɨɧ (1,25(OH)2D) (Lips, 2006; Holick, 2005). Ɂɚ ɯɢɞɪɨɤɫɢɥɚɰɢʁɭ ɭ ɛɭɛɪɟɝɭ ʁɟ ɧɟɨɩɯɨɞɧɨ ɩɪɢɫɭɫɬɜɨ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ), ʁɟɪ ɨɧ ɫɬɢɦɭɥɢɲɟ ɚɤɬɢɜɧɨɫɬ ɟɧɡɢɦɚ 1-α-ɯɢɞɪɨɤɫɢɥɚɡɟ. Ɇɟɬɚɛɨɥɢɡɚɦ ɜɢɬɚɦɢɧɚ Ⱦ3 ɢ Ⱦ2 ʁɟ ɢɞɟɧɬɢɱɚɧ. ɋɥɢɤɚ ɛɪ. 2 Ɇɟɬɚɛɨɥɢɱɤɢ ɩɭɬ ɜɢɬɚɦɢɧɚ Д Ƚɥɚɜɧɚ ɭɥɨɝɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɭ ɨɞɪɠɚɜɚʃɭ ɯɨɦɟɨɫɬɚɡɟ ɤɚɥɰɢʁɭɦɚ. Ɍɨ ɱɢɧɢ ɧɚ ɬɪɢ ɧɚɱɢɧɚ: 1) ɭ ɰɪɟɜɢɦɚ ɩɨɜɟʄɚɜɚ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ (ɝɥɚɜɧɚ ɭɥɨɝɚ) 2) ɭ ɛɭɛɪɟɝɭ ɩɨɜɟʄɚɜɚ ɪɟɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ (ɦɢɧɨɪɧɚ ɭɥɨɝɚ) 3) ɭ ɤɨɫɬɢɦɚ, ɞɟɥɭʁɭʄɢ ɧɚ ɨɫɬɟɨɤɥɚɫɬɟ, ɩɨɜɟʄɚɜɚ ɪɚɡɝɪɚɞʃɭ ɤɨɫɬɢʁɭ ɢ ɨɫɥɨɛɚђɚʃɟ ɤɚɥɰɢʁɭɦɚ (ɤɚɞɚ ʁɟ ɬɨ ɩɨɬɪɟɛɧɨ). ɇɚ ɨɜɚʁ ɧɚɱɢɧ, ɜɢɬɚɦɢɧ Ⱦ ɩɨɜɟʄɚɜɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɭ ɤɪɜɢ ɢ ɩɨɦɚɠɟ ɧɨɪɦɚɥɚɧ ɪɚɫɬ, ɦɢɧɟɪɚɥɢɡɚɰɢʁɭ ɢ ɪɟɦɨɞɨɥɨɜɚʃɟ ɤɨɫɬɢʁɭ, ɨɛɟɡɛɟђɭʁɭʄɢ ɞɨɜɨʂɧɭ ɤɨɥɢɱɢɧɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ. Ʉɚɥɰɢɬɪɢɨɥ ʁɟ ɫɬɟɪɨɢɞɧɢ ɯɨɪɦɨɧ, ɤɨʁɢ ɫɟ ɭ ɟɧɬɟɪɨɰɢɬɢɦɚ ɜɟɡɭʁɟ ɡɚ ɰɢɬɨɩɥɚɡɦɚɬɫɤɢ ɪɟɰɟɩɬɨɪ. Ɉɜɚʁ ɤɨɦɥɟɤɫ, ɯɨɪɦɨɧ-ɪɟɰɟɩɬɨɪ, ɭɥɚɡɢ ɭ ʁɟɞɪɨ ʄɟɥɢʁɟ ɢ ɜɟɡɭʁɟ ɫɟ ɡɚ ɫɩɟɰɢɮɢɱɧɨ ɦɟɫɬɨ ɭ ɯɪɨɦɚɬɢɧɭ (ȾɇɄ), ɢ ɧɚ ɬɚʁ ɧɚɱɢɧ ɩɨɦɚɠɟ ɬɪɚɧɫɤɪɢɩɰɢʁɭ ɝɟɧɚ 9 ɢ ɬɪɚɧɫɥɚɰɢʁɭ, ɩɪɢ ɱɟɦɭ ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚɧɟ ɫɢɧɬɟɡɟ ɤɚɥɰɢʁɭɦ-ɜɟɡɭʁɭʄɟɝ ɩɪɨɬɟɢɧɚ (ɤɚɥɛɢɧɞɢɧɚ). Ʉɚɥɰɢʁɭɦ ɢɡ ɰɪɟɜɚ ɫɟ ɜɟɡɭʁɟ ɡɚ ɤɚɥɛɢɧɞɢɧ ɢ ɬɚɤɨ ɭɥɚɡɢ ɭ ɟɧɬɟɪɨɰɢɬɟ. ɇɚ ɬɚʁ ɧɚɱɢɧ ɜɢɬɚɦɢɧ Ⱦ-ɯɨɪɦɨɧ ɩɨɜɟʄɚɜɚ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɭ ɰɪɟɜɢɦɚ. Ɋɟɰɟɩɬɨɪɢ ɡɚ 1,25-ɞɢɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ ɫɟ ɧɚɥɚɡɟ ɭ ɜɟʄɢɧɢ ɨɪɝɚɧɚ (ʄɟɥɢʁɚɦɚ ɤɨɫɬɢʁɭ, ɦɢɲɢʄɚ, ɦɚɫɬɢ, ɫɪɰɚ, ɤɨɠɟ, ɬɚɧɤɨɝ ɢ ɞɟɛɟɥɨɝ ɰɪɟɜɚ, ɛɭɛɪɟɝɚ, ɦɨɡɝɚ, ɩɪɨɫɬɚɬɟ, ɝɨɧɚɞɚ ɢ ɞɨʁɤɢ, β ʄɟɥɢʁɚɦɚ ɟɧɞɨɤɪɢɧɨɝ ɩɚɧɤɪɟɚɫɚ, Ɍ ɢ Ȼ ɥɢɦɮɨɰɢɬɢɦɚ, ɦɨɧɨɰɢɬɢɦɚ, ɢ ɞɟɧɞɪɢɬɢɱɧɢɦ ʄɟɥɢʁɚɦɚ (Holick, 2004), ɚɥɢ ɩɪɢɦɚɪɧɚ ɭɥɨɝɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɭ ɨɥɚɤɲɚɜɚʃɭ ɢɧɬɟɫɬɢɧɚɥɧɟ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ. Wasserman ɢ Taylor (Taylor JA, Geyer LJ, Feldman KW 2010) ɫɭ ʁɨɲ 1966. ɝɨɞɢɧɟ ɭɬɜɪɞɢɥɢ ɩɨɫɬɨʁɚʃɟ ɩɪɨɬɟɢɧɚ ɭ ʄɟɥɢʁɚɦɚ ɟɩɢɬɟɥɚ ɢɧɬɟɫɬɢɧɚɥɧɨɝ ɬɪɚɤɬɚ ɤɨʁɢ ɨɦɨɝɭʄɭʁɟ ɬɪɚɧɫɩɨɪɬ ɤɚɥɰɢʁɭɦɚ ɢɡ ɥɭɦɟɧɚ ɰɪɟɜɚ ɭ ɨɪɝɚɧɢɡɚɦ, ɡɚɬɢɦ ɪɟɧɚɥɧɟ ɚɩɫɨɪɩɰɢʁɟ ɮɨɫɮɨɪɚ ɤɨʁɭ ɫɭ ɞɨɤɚɡɚɥɢ ɏɚɪɢɫɨɧ ɢ ɏɚɪɢɫɨɧ ʁɨɲ 1941. ɝɨɞɢɧɟ ɢ ɦɨɝɭʄɢ ɞɢɪɟɤɬɧɢ ɭɬɢɰɚʁ ɧɚ ɞɟɩɨɧɨɜɚʃɟ ɢ ɪɟɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ ɭ ɤɨɫɬɢɦɚ. 1,25-ɞɢɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ, ɡɚʁɟɞɧɨ ɫɚ ɩɚɪɚɬɯɨɪɦɨɧɨɦ ɢ ɤɚɥɰɢɬɨɧɢɧɨɦ, ɢɦɚ ɝɥɚɜɧɭ ɭɥɨɝɭ ɭ ɯɨɦɟɨɫɬɚɡɢ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ ɭ ɬɟɥɟɫɧɢɦ ɬɟɱɧɨɫɬɢɦɚ ɢ ɬɤɢɜɢɦɚ. Ɋɟɰɟɩɬɨɪ ʁɟ ɭ ʄɟɥɢʁɫɤɨɦ ʁɟɞɪɭ, ɧɚ ɯɪɨɦɨɡɨɦɭ 12 (PОtrШЧТУОvТć, 2009). Ɂɛɨɝ ɬɚɤɜɟ ɥɨɤɚɰɢʁɟ ɪɟɰɟɩɬɨɪɚ, ɜɢɬɚɦɢɧ Ⱦ ɢɦɚ ɩɥɟʁɨɬɪɨɩɧɟ ɟɮɟɤɬɟ ɢ ɧɟ ɞɟɥɭʁɟ ɤɚɨ ɞɪɭɝɢ ɜɢɬɚɦɢɧɢ ɫɚɦɨ ɧɚ ɛɢɨɯɟɦɢʁɫɤɟ ɩɪɨɰɟɫɟ, ɜɟʄ ɪɟɝɭɥɢɲɭ ɬɪɚɧɫɤɪɢɩɰɢʁɭ ɜɟɥɢɤɨɝ ɛɪɨʁɚ ɝɟɧɚ ɢ ɫɢɧɬɟɡɭ ʄɟɥɢʁɫɤɢɯ ɩɪɨɬɟɢɧɚ (Reichrath, 2007). ȼɢɲɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɛɢɥɨ ɞɚ ɩɨɬɢɱɟ ɢɡ ɤɨɠɟ, ɢɥɢ ʁɟ ɚɥɢɦɟɧɬɚɪɧɨɝ ɩɨɪɟɤɥɚ, ɫɟ ɨɞɥɚɠɟ ɭ ʁɟɬɪɭ, ɦɚɫɧɨ ɬɤɢɜɨ, ɫɤɟɥɟɬ ɢ ɦɢɲɢʄɟ. ɑɚɤ ɫɟ ɢ ɭ ɮɟɬɭɫɭ ɫɬɜɚɪɚʁɭ ɢɡɜɟɫɧɟ ɪɟɡɟɪɜɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɚɥɢ ɫɭ ɨɧɟ ʁɚɤɨ ɦɚɥɟ ɢ ɢɲɱɟɡɚɜɚʁɭ ɭ ɩɪɜɢɦ ɧɟɞɟʂɚɦɚ ɩɨ ɪɨђɟʃɭ (Wagner and Greer, 2008). ɍɥɨɝɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ 1) Оɞɪɠɚɜɚʃɟ ɯɨɦɟɨɫɬɚɡɟ ɤɚɥɰɢјɭɦɚ ɢ ɮɨɫɮɨɪɚ ɇɚʁɜɚɠɧɢʁɚ ɭɥɨɝɚ ɜɢɬɚɦɢɧɚ Ⱦ ɡɚʁɟɞɧɨ ɫɚ ɩɚɪɚɬɯɨɪɦɨɧɨɦ (ɉɌɏ) ʁɟ ɭ ɨɞɪɠɚɜɚʃɭ ɯɨɦɟɨɫɬɚɡɟ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɭ ɨɪɝɚɧɢɡɦɭ. ɍ ɰɪɟɜɢɦɚ ɤɨɦɩɥɟɤɫ ɜɢɬɚɦɢɧ Ⱦ-ȼȾɊ ɩɨɜɟʄɚɜɚ ɪɟɫɨɪɩɰɰɢʁɭ Cɚ2+ ɬɚɤɨ ɲɬɨ ɫɬɢɦɭɥɢɲɟ ɫɢɧɬɟɡɭ ɢ ɚɤɬɢɜɧɨɫɬ CК2+ ɜɟɡɭʁɭʄɟɝ ɩɪɨɬɟɢɧɚ ɧɚ ɥɭɦɢɧɚɥɧɨʁ ɦɟɦɛɪɚɧɢ ɢ CК2+ ɩɭɦɩɟ ɧɚ ɛɚɡɨɥɚɬɟɪɚɥɧɨʁ ɦɟɦɛɪɚɧɢ ʄɟɥɢʁɚ ɰɪɟɜɧɨɝ ɡɢɞɚ. ȼɢɬɚɦɢɧ Ⱦ ɭ ɛɭɛɪɟɡɢɦɚ ɩɨɜɟʄɚɜɚ ɪɟɚɩɫɨɪɩɰɢʁɭ CК2+. Ɉɫɬɟɨɛɥɚɫɬɢ ɭ ɤɨɫɬɢɦɚ ɫɚɞɪɠɟ ɪɟɰɟɩɬɨɪɟ ɡɚ ɜɢɬɚɦɢɧ Ⱦ (ȼȾɊ). 10 2) Дɟɥɨɜɚʃɟ ɧɚ ɝɪɚђɭ ɢ ɮɭɧɤɰɢјɭ ɦɢшɢʄɚ ɉɨɡɧɚɬɨ ʁɟ ɢ ɞɟʁɫɬɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɫɜɟ ɬɪɢ ɜɪɫɬɟ ɦɢɲɢʄɚ ɭ ɨɪɝɚɧɢɡɦɭ: ɤɚɪɞɢɨɦɢɨɰɢɬɟ, ɫɤɟɥɟɬɧɟ ɢ ɝɥɚɬɤɟ ɦɢɲɢʄɧɟ ʄɟɥɢʁɟ. ɍ ɫɥɭɱɚʁɟɜɢɦɚ ɫɥɚɛɢʁɟɝ ɢɡɥɚɝɚʃɚ ɫɭɧɰɭ, ɧɟɞɨɜɨʂɧɨɝ ɭɧɨɫɚ ɯɪɚɧɨɦ, ɫɦɚʃɟɧɟ ɞɟɛʂɢɧɟ ɤɨɠɟ, ɫɦɚʃɟɧɟ ɪɟɫɨɪɩɰɢʁɟ ɧɚ ɧɢɜɨɭ ɰɪɟɜɚ ɢ ɨɫɥɚɛʂɟɧɨɝ ɦɟɬɚɛɨɥɢɡɦɚ ɭ ɫɢɧɬɟɡɢ ɨɜɨɝ ɜɢɬɚɦɢɧɚ, ɱɟɫɬɨ, ɧɚɪɨɱɢɬɨ ɭ ɫɬɚɪɢʁɢɯ ɨɫɨɛɚ, ɦɨɠɟ ɞɚ ɞɨɜɟɞɟ ɞɨ ɫɦɚʃɟʃɚ ɦɢɲɢʄɧɟ ɫɧɚɝɟ ɢ ɦɚɫɟ (Samson, et al. 2000; Janssen, et al. 2002). ɍ ɩɥɚɡɦɢ ɫɟ ɧɚɥɚɡɢ 1000 ɩɭɬɚ ɜɟʄɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(OH)D, ɧɟɝɨ 1,25(OH)2D, ɬɚɤɨ ɞɚ ʁɟ ɩɪɢɫɭɬɧɚ ɤɨɦɩɟɬɢɰɢʁɚ ɜɟɡɢɜɚʃɚ ɡɚ ȼȾɊ (Janssen, et al. 2002; Bischoff, et al. 2001). Ʉɨɦɩɥɟɤɫ Ⱦ3-ȼȾɊ ɭɬɢɱɟ ɧɚ ɦɟɬɚɛɨɥɢɡɚɦ ɦɢɲɢʄɧɟ ʄɟɥɢʁɟ: ɩɨɤɪɟʄɟ ɧɟɤɨɥɢɤɨ ɩɭɬɟɜɚ ɞɪɭɝɢɯ ɝɥɚɫɧɢɤɚ ɢ ɭ ʁɟɞɪɭ ɞɨɜɨɞɢ ɞɨ ɫɢɧɬɟɡɟ ȾɇɄ, ɬɪɚɧɫɤɪɢɩɰɢʁɟ ɝɟɧɚ ɢ ɫɢɧɬɟɡɭ ɪɚɡɥɢɱɢɬɢɯ ȼȾɊ (Bischoff, et al. 2001). ɇɚ ɬɚʁ ɧɚɱɢɧ ɞɨɥɚɡɢ ɞɨ ɩɪɨɥɢɮɟɪɚɰɢʁɟ ɢ ɞɢɮɟɪɟɧɰɢʁɚɰɢʁɟ ɡɪɟɥɟ ɦɢɲɢʄɧɟ ʄɟɥɢʁɟ. ɍɫɥɟɞ ɬɨɝɚ ɫɟ ɩɨɜɟʄɚɜɚ ɦɚɫɚ ɢ ɫɧɚɝɚ ɦɢɲɢʄɚ (Samson and Verhaar, 2002; Zehnder, et al. 2001). 3) Дɟɥɨɜɚʃɟ ɧɚ ɦɚɫɧɨ ɬɤɢɜɨ ɢ ɦɟɬɚɛɨɥɢɡɚɦ Ʉɨɦɩɥɟɤɫ ɜɢɬɚɦɢɧ Ⱦ-ȼȾɊ ɭ ɦɚɫɧɨɦ ɬɤɢɜɭ ɢɧɯɢɛɢɲɟ ɫɬɜɚɪɚʃɟ ɮɚɤɬɨɪɚ ɚɞɢɩɨɝɟɧɟɡɟ. Јɟɞɚɧ ɨɞ ɬɢɯ ɮɚɤɬɨɪɚ ʁɟ ɚɤɬɢɜɚɬɨɪ ɩɟɪɨɤɫɢɡɨɦɚ. Ɂɚɬɨ, ɭɫɥɟɞ ʃɟɝɨɜɨɝ ɞɟɮɢɰɢɬɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚɧɟ ɞɢɮɟɪɟɧɰɢʁɚɰɢʁɟ ɩɪɟɚɞɢɩɨɰɢɬɚ ɭ ɚɞɢɩɨɰɢɬɟ. ɇɚ ɬɚʁ ɧɚɱɢɧ ɫɟ ɫɬɜɚɪɚ ɧɨɜɨ ɦɚɫɧɨ ɬɤɢɜɨ (ɧɚɪɨɱɢɬɨ ɜɢɫɰɟɪɚɥɧɨ ɢ ɫɭɛɤɭɬɚɧɨ) (Alvarez and Ashraf, 2010). 4) Дɟɥɨɜɚʃɟ ɧɚ ɫɪɰɟ Ɂɚ ɮɢɡɢɨɥɨɲɤɨ ɮɭɧɤɰɢɨɧɢɫɚʃɟ ɤɚɪɞɢɨɦɢɨɰɢɬɚ, ɤɚɨ ɢ ɩɪɨɰɟɫɟ ɪɟɩɚɪɚɰɢʁɟ ɧɚɤɨɧ ɢɫɯɟɦɢʁɟ, ɧɟɨɩɯɨɞɧɚ ʁɟ ɯɨɦɟɨɫɬɚɡɚ ɤɚɥɰɢʁɭɦɚ. Ɉɧɚ ʁɟ ɧɟɨɩɯɨɞɧɚ ɢ ɡɚ ɢɧɨɬɪɨɩɧɨ, ɞɪɨɦɨɬɪɨɩɧɨ, ɛɚɬɦɨɬɪɨɩɧɨ ɢ ɥɭɡɢɬɪɨɩɧɨ ɫɜɨʁɫɬɜɨ ɦɢɨɤɚɪɞɚ (ĐuФКЧШvТć, Т Нr. 2009). ȼɢɬɚɦɢɧ Ⱦ, ɬɚɤɨђɟ, ɞɨɜɨɞɢ ɞɨ ɧɟɝɚɬɢɜɧɟ ɪɟɝɭɥɚɰɢʁɟ ɝɟɧɚ ɡɚ ɪɟɧɢɧ, ɩɚ ɬɚɤɨ ɫɦɚʃɭʁɟ ɤɪɜɧɢ ɩɪɢɬɢɫɚɤ, ɨɞɧɨɫɧɨ ɪɢɡɢɤ ɨɞ ɯɢɩɟɪɬɟɧɡɢʁɟ, ɩɚ ɫɚɦɢɦ ɬɢɦ ɢ ɨɞ ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɢ ɰɟɪɟɛɪɨɜɚɫɤɭɥɚɪɧɢɯ ɨɛɨʂɟʃɚ (Reichrath, et al. 2007; Holick, 2004). Ɍɪɟɛɚ ɢɫɬɚʄɢ ɞɟʁɫɬɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɫɚɡɪɟɜɚʃɟ, ɞɢɮɟɪɟɧɰɢɪɚʃɟ ɢ ɦɢɝɪɚɰɢʁɭ ɞɟɧɞɪɢɬɢɱɤɢɯ ʄɟɥɢʁɚ ɤɨʁɟ ɫɭ ɜɚɠɧɟ ɤɨɦɩɨɧɟɧɬɟ ɢɦɭɧɨɥɨɲɤɨɝ ɫɢɫɬɟɦɚ, ʁɟɪ ɩɪɟɡɟɧɬɭʁɭ ɚɧɬɢɝɟɧɟ ɥɢɦɮɨɰɢɬɢɦɚ, ɭɡ ɫɬɜɚɪɚʃɟ ɰɢɬɨɤɢɧɚ, ɤɨʁɢ ɡɚɩɨɱɢʃɭ ɢɦɭɧɨɥɨɲɤɢ ɨɞɝɨɜɨɪ Ɍ- ɥɢɦɮɨɰɢɬɚ (PОtrШЧТУОvТć, 2009; HШХТМФ, 2004; ArЧsШЧ, Оt КХ. 2007). 11 6) Вɢɬɚɦɢɧ Д ɢ ɤɪɜɧɢ ɫɭɞɨɜɢ ɉɨɫɬɨʁɟ ɞɨɤɚɡɢ ɞɚ 1,25(Ɉɇ)2D3 ɞɟɥɭʁɟ ɢ ɚɧɬɢɚɬɟɪɨɫɤɥɟɪɨɬɢɱɧɨ ɬɚɤɨ ɲɬɨ ɫɦɚʃɭʁɟ ɩɪɨɥɢɮɟɪɚɰɢʁɭ ɝɥɚɬɤɢɯ ɦɢɲɢʄɧɢɯ ʄɟɥɢʁɚ ɭ ɡɢɞɭ ɤɪɜɧɢɯ ɫɭɞɨɜɚ ɢ ɞɟɥɭʁɟ ɧɚ ɫɚɦ ɟɧɞɨɬɟɥ ɤɪɜɧɢɯ ɫɭɞɨɜɚ. 7) Дɟɥɨɜɚʃɟ ɧɚ ɢɧɫɭɥɢɧ ɢ ɝɥɭɤɨɡɭ ɭ ɤɪɜɢ ȼɢɬɚɦɢɧ Ⱦ ɩɨɜɟʄɚɜɚ ɫɟɤɪɟɰɢʁɭ ɢ ɫɟɧɡɢɬɢɜɧɨɫɬ ɢɧɫɭɥɢɧɚ ɬɚɤɨ ɲɬɨ ɭɱɟɫɬɜɭʁɟ ɭ ɫɢɧɬɟɡɢ ɟɧɡɢɦɚ ɡɧɚɱɚʁɧɢɯ ɡɚ ɩɪɟɭɡɢɦɚʃɟ ɝɥɭɤɨɡɟ ɢɡ ɤɪɜɢ. Ɂɚɬɨ ɩɪɢ ɞɟɮɢɰɢɬɭ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɫɬɨʁɢ ɩɨɜɟʄɚɧɚ ɢɧɰɢɞɟɧɰɚ ɞɢʁɚɛɟɬɟɫɚ ɦɟɥɢɬɭɫɚ ɬɢɩ 2 (Alvarez and Ashraf, 2010; Miller, 2003). 8) Дɟɥɨɜɚʃɟ ɧɚ ɦɨɡɚɤ ɂɫɬɪɚɠɢɜɚʃɚ ɫɭ ɞɨɤɚɡɚɥɚ ɡɧɚɱɚʁɧɭ ɭɥɨɝɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɟɜɟɧɰɢʁɢ ɦɟɧɬɚɥɧɢɯ ɨɛɨʂɟʃɚ. Ⱦɨɤɚɡɚɧɨ ʁɟ ɞɚ ɭɫɥɟɞ ɞɟɮɢɰɢɬɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚɫɬɚʁɭ ɤɨɝɧɢɬɢɜɧɢ ɩɨɪɟɦɟʄɚʁɢ ɢ ɞɟɩɪɟɫɢɜɧɚ ɪɚɫɩɨɥɨɠɟʃɚ (Garicion, et al. 2002). Ɋɟɰɟɩɬɨɪɢ ɜɢɬɚɦɢɧ Ⱦ (ȼȾɊ) ɫɟ ɧɚɥɚɡɟ ɢ ɭ ɧɟɭɪɨɧɢɦɚ ɢ ɝɥɢʁɚ ʄɟɥɢʁɚɦɚ. Ʉɚɞɚ ɫɟ ɚɤɬɢɜɢɲɭ, ɭɬɢɱɭ ɧɚ ɝɟɧɟ ɤɨʁɢ ɤɨɧɬɪɨɥɢɲɭ ɛɢɨɫɢɧɬɟɡɭ ɚɡɨɬ-ɦɨɧɨɤɫɢɞɚ, ɟɧɡɢɦɚ ɤɨʁɢ ɫɭ ɭɤʂɭɱɟɧɢ ɭ ɫɢɧɬɟɡɢ ɝɥɭɬɚɬɢɨɧɚ ɤɨʁɢ ɢɦɚ ɞɟɬɨɤɫɢɤɭʁɭʄɟ ɢ ɧɟɭɪɨɩɪɨɬɟɤɬɢɜɧɨ ɞɟʁɫɬɜɨ. ɍɬɢɱɟ ɢ ɧɚ ɫɢɧɬɟɡɭ ɬɢɪɨɡɢɧ-ɯɢɞɪɨɤɫɢɥɚɡɟ, ɟɧɡɢɦɚ ɤɨʁɢ ɪɟɝɭɥɢɲɟ ɛɢɨɫɢɧɬɟɡɭ ɦɨɠɞɚɧɢɯ ɦɨɧɨɚɦɢɧɚ; ɫɬɜɚɪɚʃɟ ɧɟɭɪɨɬɪɚɧɫɦɢɬɟɪɚ ɫɟɪɨɬɨɧɢɧɚ; ɫɢɧɬɟɡɭ ɮɚɤɬɨɪɚ ɪɚɫɬɚ ɧɟɪɚɜɚ. ɇɚ ɬɚʁ ɧɚɱɢɧ ɞɟɥɭʁɟ ɧɚ ɫɚɦ ɪɚɡɜɨʁ ɦɨɡɝɚ, ɫɦɚʃɭʁɟ ɦɢɬɨɡɭ ʄɟɥɢʁɚ ɢ ɩɨɜɟʄɚɜɚ ʃɢɯɨɜɭ ɞɢɮɟɪɟɧɰɢʁɚɰɢʁɭ (Garicion,et al. 2002; Lambert, et al. 2002). 9) Аɧɬɢɤɚɧɰɟɪɨɝɟɧɨ ɞɟɥɨɜɚʃɟ Ⱥɧɬɢɩɪɨɥɢɮɟɪɚɬɢɜɧɢ ɢ ɩɪɨɞɢɮɟɪɟɧɰɢɪɚʁɭʄɢ ɟɮɟɤɚɬ ɜɢɬɚɦɢɧɚ Ⱦ ɡɧɚɱɚʁɚɧ ʁɟ ɭ ɩɪɟɜɟɧɰɢʁɢ ɤɚɪɰɢɧɨɦɚ. ɇɚɪɨɱɢɬɨ ʁɟ ɞɨɤɚɡɚɧɨ ɚɧɬɢɤɚɧɰɟɪɨɝɟɧɨ ɞɟɥɨɜɚʃɟ ɨɜɨɝ ɜɢɬɚɦɢɧɚ ɤɨɞ ɨɛɨɥɟɥɢɯ ɨɞ ɤɚɪɰɢɧɨɦɚ ɦɨɤɪɚʄɧɟ ɛɟɲɢɤɟ, ɞɟɛɟɥɨɝ ɰɪɟɜɚ (ɤɨɥɨɧɚ ɢ ɪɟɤɬɭɦɚ), ɞɨʁɤɟ, ɨɜɚɪɢʁɭɦɚ ɢ ɩɪɨɫɬɚɬɟ (Thorne and Campbell, 2008; National Cancer Institute, 2009). ɂɧɫɭɮɢɰɢјɟɧɰɢјɚ ɢ ɞɟɮɢɰɢјɟɧɰɢјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɂɫɯɪɚɧɚ ɢ ɩɨɪɟɦɟʄɚʁɢ ɢɫɯɪɚʃɟɧɨɫɬɢ ɢ ʃɢɯɨɜɟ ɩɨɫɥɟɞɢɰɟ ɫɭ ɫɬɚɥɧɨ ɭ ɠɢɠɢ ɢɧɬɟɪɟɫɨɜɚʃɚ ɩɟɞɢʁɚɬɚɪɚ. ɉɨɫɥɟɞʃɢɯ ɝɨɞɢɧɚ ɲɢɪɨɦ ɫɜɟɬɚ ʁɟ ɭ ɥɢɬɟɪɚɬɭɪɢ ɩɪɢɫɭɬɚɧ ɜɟɥɢɤɢ ɛɪɨʁ ɩɭɛɥɢɤɚɰɢʁɚ ɭ ɤɨʁɢɦɚ ɚɭɬɨɪɢ ɢɡɜɟɲɬɚɜɚʁɭ ɨ ɫɜɟ ɜɟʄɨʁ ɭɱɟɫɬɚɥɨɫɬɢ ɞɟɮɢɰɢɬɚ 12 ɜɢɬɚɦɢɧɚ Ⱦ. ȼɢɬɚɦɢɧ Ⱦ ʁɟ ɩɪɟɞɦɟɬ ɛɪɨʁɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ ɫɚ ɧɚɫɬɨʁɚʃɟɦ ɞɚ ɫɟ ɨɬɤɪɢʁɟ ʃɟɝɨɜɚ ɩɨɬɟɧɰɢʁɚɥɧɚ ɭɥɨɝɚ ɭ ɡɞɪɚɜʂɭ ɢ ɛɨɥɟɫɬɢ ɞɟɰɟ ɫɜɢɯ ɭɡɪɚɫɬɚ. ɑɚɤ ɢ ɛɥɚɝɚ ɞɟɮɢɰɢɰɢʁɟɧɰɢʁɚ, ɨɞɧɨɫɧɨ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɪɟɦɚ ɫɚɜɪɟɦɟɧɢɦ ɢɫɬɪɚɠɢɜɚʃɢɦɚ, ɢɦɚʁɭ ɛɪɨʁɧɟ ɟɮɟɤɬɟ ɧɚ ɨɪɝɚɧɢɡɚɦ, ɧɚ ɫɜɟ ɨɪɝɚɧɟ ɢ ɫɜɟ ɫɢɫɬɟɦɟ, ɤɚɨ ɢ ɲɬɟɬɧɢ ɟɮɟɤɚɬ ɧɚ ɫɬɜɚɪɚʃɟ ɤɨɫɬɢʁɭ. Ⱥɦɟɪɢɱɤɚ ɚɤɚɞɟɦɢʁɚ ɡɚ ɩɟɞɢʁɚɬɪɢʁɭ (ȺȺɊ) ʁɟ 2003. ɝɨɞɢɧɟ ɞɚɥɚ ɫɦɟɪɧɢɰɟ, ɧɚɤɨɧ ɩɪɟɩɨɪɭɤɚ ɞɚ ʄɟ 200 ʁɟɞɢɧɢɰɚ ɜɢɬɚɦɢɧɚ Ⱦ ɛɢɬɢ ɞɨɜɨʂɧɨ ɞɚ ɫɟ ɫɩɪɟɱɢ ɪɚɯɢɬɢɫ, ʁɟɪ ɨɜɚ ɤɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ, ɞɨɩɪɢɧɨɫɢ ɩɨɜɟʄɚʃɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɧɚ ɜɪɟɞɧɨɫɬɢ >11 ЧР/ЦХ, ɲɬɨ ɫɩɪɟɱɚɜɚ ɩɨʁɚɜɭ ɪɚɯɢɬɢɫɚ. Ɍɚɞɚ ʁɟ ɜɢɲɟ ɫɬɭɞɢʁɚ ɞɨɤɚɡɚɥɨ ɫɥɭɱɚʁɟɜɟ ɪɚɯɢɬɢɫɚ ɭ ɧɟɤɟ ɞɟɰɟ ɤɨʁɚ ɫɭ ɢɦɚɥɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɤɚɥɰɢɞɢɨɥɚ ɞɨ 20 ЧР/ЦХ (Kreiter, et al. 2000; Spence and Serwint, 2004). ɍ ɩɪɨɲɥɨɫɬɢ, ɞɟɰɚ ɤɨʁɚ ɫɭ ɤɨɪɢɫɬɢɥɚ ɭʂɟ ʁɟɬɪɟ ɛɚɤɚɥɚɪɚ ɤɨʁɟ ɫɚɞɪɠɢ 400 ʁɟɞɢɧɢɰɚ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ, ɩɨɫɬɢɡɚɥɚ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ 25(OH)D>20 ЧР/ЦХ ɛɟɡ ɢɤɚɤɜɢɯ ɧɟɠɟʂɟɧɢɯ ɟɮɟɤɚɬɚ (Park, 1940; Rajakumar and Thomas, 2005). Ʉɥɢɧɢɱɤɚ ɢɫɩɢɬɢɜɚʃɚ ɫɭ ɭɜɟɤ ɩɨɬɪɟɛɧɚ, ɤɚɤɨ ɛɢ ɫɟ ɬɚɱɧɨ ɨɞɪɟɞɢɥɚ ɞɨɡɚ ɜɢɬɚɦɢɧɚ Ⱦ ɡɚ ɩɨɫɬɢɡɚʃɟ ɨɩɬɢɦɚɥɧɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɢ ɫɩɪɟɱɢɥɚ ɞɟɦɢɧɟɪɚɥɢɡɚɰɢʁɚ ɢ ɪɚɯɢɬɢɫ ɭ ɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɩɨɩɭɥɚɰɢʁɢ. Ɍɚɛɟɥɚ ɛɪ. 2 ɋɚɞɪɠɚј ɜɢɬɚɦɢɧɚ Д ɭ ɯɪɚɧɢ (IJ/100Р) ɏɭɦɚɧɨ ɦɥɟɤɨ 2.5-3.0 ɋɬɚɧɞɚɪɞɧɟ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ 40-60 Ʉɨɤɨɲʁɟ ɠɭɦɚɧɰɟ 125 ɉɢɥɟʄɚ џɢɝɟɪɢɰɚ 50 ɉɟɱɭɪɤɟ (ɲɚɦɩɢʃɨɧɢ) 75 ɒɤɨʂɤɟ (ɨɫɬɪɢɝɚ) 320 Ɇɨɪɫɤɚ ɪɢɛɚ 200-650 Ɋɢɛʂɟ ɭʂɟ (ɛɚɤɚɥɚɪ) 8400 Ɋɚɯɢɬɢɫ ʁɟ ɩɪɜɢ ɩɭɬ ɨɩɢɫɚɧ ɭ 17. ɜɟɤɭ ɨɞ ɫɬɪɚɧɟ ɞɪ Ⱦɚɧɢɟɥɚ ȼɢɫɬɥɟɪɚ ɢ ɩɪɨɮɟɫɨɪɚ Ɏɪɚɧɫɢɫ Ƚɥɢɫɨɧɚ. Ɇɟђɭɬɢɦ, ɫɜɟ ɞɨ ɪɚɧɢɯ ɝɨɞɢɧɚ 20. ɜɟɤɚ ɧɢʁɟ ɩɪɟɩɨɡɧɚɬɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɚɨ ɨɫɧɨɜɧɢ ɭɡɪɨɤ, ɞɨɤ ɫɟ ɡɚ ɫɭɧɱɟɜɭ ɫɜɟɬɥɨɫɬ ɫɦɚɬɪɚɥɨ ɞɚ ʁɟ ɨɞɝɨɜɨɪɧɚ ɡɚ ɨɞɪɠɚɜɚʃɟ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ. Ɍɚɞɚ ʁɟ ɩɨɤɭɲɚɧɨ ɞɚ ɫɟ ɭɧɨɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɯɪɚɧɭ ɪɟɲɢ ɨɜɚʁ ɜɟɨɦɚ ɪɚɫɩɪɨɬɪɚʃɟɧ ɧɟɞɨɫɬɚɬɚɤ. ɍ Ʉɚɧɚɞɢ ʁɟ 1950. ɝɨɞɢɧɟ ɡɚɩɨɱɟɬɨ ɫɚ ɮɨɪɬɢɮɢɤɚɰɢʁɨɦ ɦɥɟɤɚ ɭ ɩɪɚɯɭ, ɞɨɤ ɫɭ 1965. ɝɨɞɢɧɟ ɩɪɨɩɢɫɢ ɡɚ ɮɨɪɬɢɮɢɤɚɰɢʁɭ ɜɢɬɚɦɢɧɨɦ Ⱦ ɭɤʂɭɱɢɥɢ ɬɟɱɧɚ ɦɥɟɤɚ (Suskind DL, 2009) 13 ɂɡɜɟɲɬɚʁɢ ɨ ɧɟɞɨɫɬɚɬɤɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡ ɪɚɡɧɢɯ ɡɟɦɚʂɚ, ɤɚɨ ɲɬɨ ɫɭ ȼɟɥɢɤɚ Ȼɪɢɬɚɧɢʁɚ (Hyppönen and Power, 2007), Ⱥɭɫɬɪɢʁɚ (Koenig and Elmadfa, 2000), ɇɟɦɚɱɤɚ (Hintzpeter, et al. 2008), Ɏɢɧɫɤɚ (Lamberg-Allardt, et al. 2001), ɇɨɜɢ Ɂɟɥɚɧɞ (Rockell, et al. 2006) ɢ ɂɧɞɢʁɚ (Sachan, et al. 2005), ɭɤɚɡɭʁɭ ɧɚ ɨɛɢɦ ɩɚɧɞɟɦɢʁɟ. ɑɚɤ ɢ ɭ ɫɭɧɱɚɧɨʁ Ⱥɭɫɬɪɚɥɢʁɢ, 30-50% ɞɟɰɟ ɢ ɨɞɪɚɫɥɢɯ ɢɦɚʁɭ ɞɟɮɢɰɢɬ ɭ ɜɢɬɚɦɢɧɭ Ⱦ. ɍɬɜɪђɟɧɚ ʁɟ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ 70% ɚɦɟɪɢɱɤɟ ɞɟɰɟ. Ɉɧɢ ɤɨʁɢ ɫɭ ɩɢɥɢ ɦɥɟɤɨ ɪɟђɟ ɨɞ ʁɟɞɧɨɦ ɧɟɞɟʂɧɨ ɫɭ ɛɢɥɢ ɦɟђɭ ɧɚʁɪɢɡɢɱɧɢʁɢɦɚ ɡɚ ɧɚɫɬɚɧɚɤ ɞɟɮɢɰɢɬɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (25(Ɉɇ)D < 20ЧР/ЦХ ʁɟ ɛɢɨ ɱɟɲʄɢ ɭ ɫɬɚɪɢʁɟ ɞɟɰɟ, ɞɟɰɟ ɠɟɧɫɤɨɝ ɩɨɥɚ, ɝɨʁɚɡɧɟ ɢ ɞɟɰɟ ɤɨʁɚ ɜɢɲɟ ɨɞ 4 ɫɚɬɚ ɩɪɨɜɨɞɟ ɩɪɟɞ ɬɟɥɟɜɢɡɨɪɨɦ ɢɥɢ ɡɚ ɤɨɦɩʁɭɬɟɪɨɦ. Ⱦɟɰɚ ɬɚɦɧɢʁɟ ɩɭɬɢ ɫɭ ɛɢɥɚ ɫɤɥɨɧɢʁɚ ɞɟɮɢɰɢʁɟɧɰɢʁɢ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ, ʁɟɪ ʁɚɱɚ ɩɢɝɦɟɧɬɚɰɢʁɚ ɩɨɞɪɚɡɭɦɟɜɚ ɜɟʄɟ ɩɪɢɫɭɫɬɜɨ ɦɟɥɚɧɢɧɚ ɭ ɤɨɠɢ. Ɇɟɥɚɧɢɧ ʁɟ ɩɢɝɦɟɧɬ ɤɨʁɢ ɫɩɪɟɱɚɜɚ ɫɭɧɱɟɜɟ ɡɪɚɤɟ ɞɚ ɩɪɨɞɪɭ ɭ ɤɨɠɭ ɢ ɬɚɤɨ ɦɨɠɟ ɨɧɟɦɨɝɭʄɢɬɢ ɫɬɜɚɪɚʃɟ ɜɢɬɚɦɢɧɚ Ⱦ. Ɋɚɫɩɪɨɫɬɪɚʃɟɧɨɫɬ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ ʁɟ ɢ ɭ ɞɪɭɝɢɦ ɡɟɦʂɚɦɚ, ɭɤʂɭɱɭʁɭʄɢ ȿɧɝɥɟɫɤɭ (Callaghan, et al. 2006), Ƚɪɱɤɭ (Nicolaidou, et al. 2006) ɢ Ʉɚɧɚɞɭ (Binet and Kooh, 1996; Ward, et al. 2007). Јɟɞɧɚ ɫɬɭɞɢʁɚ ɢɡ Ʉɢɧɟ ɨɬɤɪɢɥɚ ʁɟ 65,3% ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 12 ɞɨ 24 ɦɟɫɟɰɚ ɠɢɜɨɬɚ ɫɚ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɤ ɫɭ ɤɨɞ 3,7% ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɧɚђɟɧɢ ɤɥɢɧɢɱɤɢ ɡɧɚɰɢ ɪɚɯɢɬɢɫɚ ɢ ɪɚɞɢɨɝɪɚɮɫɤɟ ɩɪɨɦɟɧɟ ɧɚ ɤɨɫɬɢɦɚ ɭ ɫɦɢɫɥɭ ɨɜɨɝ ɨɛɨʂɟʃɚ (Strand, et al. 2007). ɉɪɟɬɯɨɞɧɟ ɫɬɭɞɢʁɟ ɭɤɚɡɭʁɭ ɧɚ ɮɚɤɬɨɪɟ ɪɢɡɢɤɚ, ɤɚɨ ɲɬɨ ɫɭ, ɛɨʁɚ ɤɨɠɟ (ɩɢɝɦɟɧɬɚɰɢʁɚ) (Gessner, et al. 1997; Ziegler, et al. 2006; Binet and Kooh, 1996), ɢ ɞɨʁɟʃɟ ɭɡ ɨɞɫɭɫɬɜɨ ɩɪɢɦɟɧɟ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ (Gessner, et al. 1997; Shah, et al. 2000; Weisberg, et al. 2004; Binet and Kooh, 1996; Ward, et al. 2007). Ⱦɨ ɫɚɞɚ ʁɟ ɦɚʃɟ ɢɫɩɢɬɢɜɚɧɚ ɝɪɭɩɚ ɦɚɥɟ ɞɟɰɟ, ɤɨʁɚ ɞɨɛɢʁɚʁɭ ɧɟɦɥɟɱɧɭ ɯɪɚɧɭ, ɢ ɪɚɡɧɟ ɜɪɫɬɟ ɦɥɟɤɚ ɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ. ɉɪɟɬɟɠɧɨ ʁɟ ɢɫɩɢɬɢɜɚɧɚ ɝɪɭɩɚ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɞɨ 24 ɦɟɫɟɰК ɠɢɜɨɬɚ. ȼɢɫɨɤ ɩɪɨɰɟɧɚɬ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɝɞɟ ʁɟ ɧɢɜɨ 25 (OH)D < 20 ЧР/ЦХ, ɧɚђɟɧ ʁɟ ɢ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɢɯ ɚɞɨɥɟɫɰɟɧɚɬɚ (42%) (Gordon, et al. 2008). ɉɪɟɜɚɥɟɧɰɚ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɛɥɢɤɭ ɯɢɩɨɤɚɥɰɟɦɢʁɫɤɢɯ ɧɚɩɚɞɚ ɢɥɢ ɪɚɯɢɬɢɫɚ ɭ ɞɟɰɟ ɭ ɫɜɟɬɭ ʁɟ ɭ ɩɨɪɚɫɬɭ, ɡɛɨɝ ɧɟɞɨɜɨʂɧɨɝ ɭɧɨɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɫɦɚʃɟɧɨɝ ɢɡɥɚɝɚʃɚ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ. Ɇɨɝɭʄɟ ʁɟ ɞɚ ɝɟɧɟɬɫɤɢ ɮɚɤɬɨɪɢ ɩɪɟɞɢɫɩɨɧɢɪɚʁɭ ɨɫɨɛɟ ɫɚ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (Kitanaka, et al. 2012). ɍɩɪɤɨɫ ɞɭɝɨʁ ɢɫɬɨɪɢʁɢ ɩɨɡɧɚɜɚʃɚ ɨɜɨɝ ɩɪɨɛɥɟɦɚ, ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɞɚʂɟ ɨɫɬɚʁɟ ɡɧɚɱɚʁɧɢ ɡɞɪɚɜɫɬɜɟɧɢ ɩɪɨɛɥɟɦ. ɑɚɤ 25-30% ɞɟɰɟ ɢ ɝɨɬɨɜɨ 1/2 ɨɞɪɚɫɥɢɯ ɢɦɚ ɞɟɮɢɰɢʁɟɧɰɢʁɭ, ɨɞɧɨɫɧɨ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨʁК ɛɢɬɧɨ ɭɬɢɱɟ ɧɚ ɩɪɨɰɟɫɟ ɧɚ ɨɪɝɚɧɢɦɚ. ɉɨɞɚɰɢ ɭɤɚɡɭʁɭ 14 ɞɚ ɨɞɪɚɫɥɢ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɢɦɚʁɭ ɜɟʄɟ ɲɚɧɫɟ ɡɚ ɞɢʁɚɛɟɬɟɫ, ɩɨɜɟʄɚɧ ɤɪɜɧɢ ɩɪɢɬɢɫɚɤ, ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɚ ɨɛɨʂɟʃɚ, ɩɚ ɱɚɤ ɢ ɤɚɪɰɢɧɨɦ, ɚ ɚɤɨ ɞɟɰɚ ɨɞ ɞɟɬɢʃɫɬɜɚ ɧɟɦɚʁɭ ɞɨɜɨʂɧɨ ɜɢɬɚɦɢɧɚ Ⱦ, ɨɧɞɚ ɫɟ ɨɜɚʁ ɪɢɡɢɤ ʁɨɲ ɩɨɜɟʄɚɜɚ. ȼɢɬɚɦɢɧ Ⱦ ʁɟ ɜɚɠɚɧ ɢ ɡɚ ɧɨɪɦɚɥɧɨ ɫɬɜɚɪɚʃɟ ɢ ɮɭɧɤɰɢʁɭ ɢɧɫɭɥɢɧɚ ɭ ɩɚɧɤɪɟɚɫɭ. ȼɢɲɟ ɢɫɬɪɚɠɢɜɚʃɚ (e.g. Robert Koch Institute, Berlin; School of Earth Atmospheric and Environmental Sciences, University of Manchester, U.K.) ʁɟ ɩɨɤɚɡɚɥɨ ɞɚ 50-80% ɩɨɩɭɥɚɰɢʁɟ ɟɜɪɨɩɫɤɢɯ ɡɟɦɚʂɚ ɢɦɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɬɨɤɨɦ ɡɢɦɟ. ɑɚɤ ɢ ɬɨɤɨɦ ɥɟɬʃɢɯ ɦɟɫɟɰɢ ɜɟʄɢɧɚ ɩɨɩɭɥɚɰɢʁɚ ɩɪɟɬɟɧɞɭʁɟ ɞɚ ɢɦɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ȼɢɬɚɦɢɧ Ⱦ ɤɨʁɢ ɫɟ ɧɚɤɭɩʂɚ ɬɨɤɨɦ ɥɟɬʃɢɯ ɦɟɫɟɰɢ ɫɟ ɛɪɡɨ ɬɪɨɲɢ, ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɍȼȻ ɡɪɚɤɚ ɬɨɤɨɦ ɡɢɦɫɤɢɯ ɦɟɫɟɰɢ (ɨɞ ɨɤɬɨɛɪɚ ɞɨ ɦɚɪɬɚ ɭ ȿɜɪɨɩɢ) ɧɢʁɟ ɞɨɜɨʂɧɚ ɡɚ ɩɪɨɢɡɜɨɞʃɭ ɜɢɬɚɦɢɧɚ Ⱦ (ɫɥɢɤɚ ɛɪ. 3). ȼɨɞɟʄɢ ɟɤɫɩɟɪɬɢ ɩɪɟɩɨɪɭɱɭʁɭ ɫɭɧɱɚʃɟ ɞɜɚ ɩɭɬɚ ɧɟɞɟʂɧɨ. Ȼɢɬɧɨ ʁɟ ɞɚ ɩɨɜɪɲɢɧɫɤɢ ɫɥɨʁ ɤɨɠɟ ɛɭɞɟ ɲɬɨ ɜɢɲɟ ɢɡɥɨɠɟɧ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ, ʁɟɪ ɫɟ ɜɢɬɚɦɢɧ Ⱦ ɩɪɨɢɡɜɨɞɢ ɭ ɤɨɠɢ. ɋɥɢɤɚ ɛɪ. 3 ɋɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɩɟɪɢɨɞ ɭ ɝɨɞɢɧɢ ɉɪɟɝɥɟɞ ɭ ɱɚɫɨɩɢɫɭ AЦОrТМКЧ JШurЧКХ ШП PuЛХТМ HОКХtС (Entin, 2008) ɩɪɨɰɟʃɭʁɟ ɞɚ ʁɟ ɞɧɟɜɧɨ ɩɨɬɪɟɛɧɨ ɫɚɦɨ 15 ɦɢɧɭɬɚ ɢɡɥɚɝɚʃɚ ɤɨɠɟ ɫɭɧɰɭ ɤɚɤɨ ɛɢ ɫɟ ɨɞɪɠɚɨ ɧɨɪɦɚɥɚɧ 15 ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɥɟɬɨ, ɢ 20 ɦɢɧɭɬɚ ɭ ɬɨɤɭ ɪɚɧɟ ʁɟɫɟɧɢ ɢɥɢ ɤɪɚʁɟɦ ɩɪɨɥɟʄɚ ɭ ɋȺȾ-ɭ ɢɥɢ ɭ ɡɟɦʂɚɦɚ ɫɚ ɩɪɢɛɥɢɠɧɨɦ ɝɟɨɝɪɚɮɫɤɨɦ ɲɢɪɢɧɨɦ. ɉɪɟɩɨɪɭɱɭʁɟ ɫɟ ɞɭɠɢɧɚ ɟɤɫɩɨɡɢɰɢʁɟ ɞɜɚ ɩɭɬɚ ɞɭɠɟ ɡɚ Ⱥɮɪɨɚɦɟɪɢɤɚɧɰɟ (Entin, 2008). ɂɫɬɪɚɠɢɜɚʃɟ ɢɡ ȼɟɥɢɤɟ Ȼɪɢɬɚɧɢʁɟ ɭɬɜɪɞɢɥɨ ʁɟ ɞɚ ɨɤɨ 1 ɭ 100 ɞɟɰɟ ɤɨʁɚ ɧɢɫɭ ɛɟɥɟ ɪɚɫɟ ɢɦɚ ɪɚɯɢɬɢɫ (Ashraf and Mughal, 2002). Ɋɚɯɢɬɢɫ ʁɟ ɱɟɲʄɢ ɤɨɞ ɞɟɰɟ ɤɨʁɚ ɢɦɚʁɭ ɬɚɦɧɢʁɭ ɤɨɠɭ ɢ ɤɨɞ ɞɟɰɟ ɤɨʁɢ ɫɭ ɧɚ ɩɨɞɨʁɭ ɧɟɝɨ ɞɟɰɚ ɯɪɚʃɟɧɚ ɧɚ ɮɥɚɲɢɰɭ (Ashraf and Mughal, 2002). ɉɪɟɦɚ ɫɚɜɪɟɦɟɧɢɦ ɫɬɚɜɨɜɢɦɚ, ɩɪɟɩɨɪɭɱɟɧɢ ɞɧɟɜɧɢ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ, ɬʁ. ɤɨɥɢɱɢɧɚ ɤɨʁɚ ɩɨɤɪɢɜɚ ɫɜɟ ʃɟɝɨɜɟ ɮɢɡɢɨɥɨɲɤɟ ɭɥɨɝɟ, ɢɡɧɨɫɢ 400 IJ ɡɚ ɭɡɪɚɫɬ ɨɞ ɪɨђɟʃɚ ɞɨ 18 ɝɨɞɢɧɚ (Garicon, et al. 2002), 600IJ ɨɞ 19-70 ɝɨɞɢɧɚ, ɚ ɩɨɫɥɟ 70 ɝɨɞɢɧɚ 800 IJ. ɉɨɬɪɟɛɟ ɭ ɜɢɬɚɦɢɧɭ Ⱦ ɩɪɟɜɪɟɦɟɧɨ ɪɨђɟɧɨɝ ɨɞɨʁɱɟɬɚ, ɤɚɨ ɢ ɨɧɨɝ ɫɚ ɦɚɥɨɦ ɩɨɪɨђɚʁɧɨɦ ɬɟɠɢɧɨɦ ɡɚ ɝɟɫɬɚɰɢɨɧɭ ɞɨɛ, ɬɚɤɨђɟ ɢɡɧɨɫɟ 400 IJ ɞɧɟɜɧɨ. ɍɧɨɫ ɯɪɚɧɟ ɫɢɪɨɦɚɲɧɟ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɧɟɞɨɜɨʂɧɨ ɢɡɥɚɝɚʃɟ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ ɭ ɞɟɰɟ ɢ ɨɞɪɚɫɥɢɯ ɡɚɯɬɟɜɚ ɩɨɜɟʄɚɧ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ (800-1000 IJ/ɞɚɧ). ɉɨɫɬɨʁɟ ɪɚɡɥɢɱɢɬɢ ɫɬɚɜɨɜɢ ɨ ɩɨɬɪɟɛɧɢɦ ɞɨɡɚɦɚ ɫɭɩɥɟɦɟɧɬɚ Ⱦ3. ɉɨ ɞɪɭɝɢɦ ɢɡɜɨɪɢɦɚ, ɞɟɰɢ ɢɫɩɨɞ ɝɨɞɢɧɭ ɞɚɧɚ ɬɪɟɛɚ ɞɚ ɫɟ ɞɚʁɟ 1000-2000 IJ/ɞɚɧ, ɚ ɚɞɨɥɟɫɰɟɧɬɢɦɚ ɢ ɨɞɪɚɫɥɢɦɚ 600-800 IJ/ɞɚɧ (Lambert, et al. 2002). Ȼɨɥɟɫɧɢɰɢɦɚ ɤɨʁɢ ɢɦɚʁɭ ɧɟɤɨ ɨɛɨʂɟʃɟ ɭ ɤɨʁɟɦ ɜɢɬɚɦɢɧ Ⱦ ɦɨɠɟ ɞɚ ɞɨɜɟɞɟ ɞɨ ɩɨɛɨʂɲɚʃɚ ɞɚʁɭ ɫɟ ɢ ɜɟʄɟ ɞɨɡɟ, ɧɚ ɩɪɢɦɟɪ 5000 IJ/ɞɚɧ (Lambert, et al. 2002). Ⱦɚ ɛɢ ɫɟ ɨɞɪɟɞɢɨ ɫɭɛɤɥɢɧɢɱɤɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ʃɟɝɨɜɚ ɤɨɪɟɥɚɰɢʁɚ ɫɚ ɞɨʁɟʃɟɦ, ɭ ɨɞɨʁɱɚɞɢ ɭɡɪɚɫɬɚ ɨɞ 1-6 ɦɟɫɟɰɢ, ɪɚђɟɧɚ ʁɟ ɫɬɭɞɢʁɚ ɭ ȼɚɥɟɧɫɢʁɢ (ɒɩɚɧɢʁɚ) ɤɨʁɚ ʁɟ ɧɚ ɝɟɨɝɪɚɮɫɤɨʁ ɲɢɪɢɧɢ 39,50 ɇ. ɂɫɩɢɬɢɜɚɧɨ ʁɟ 60 ɪɨɱɧɟ ɨɞɨʁɱɚɞɢ ɱɢʁɚ ʁɟ ɩɪɨɫɟɱɧɚ ɫɬɚɪɨɫɬ ɢɡɧɨɫɢɥɚ 3,9 ɦɟɫɟɰɚ. Ⱦɟɰɚ ɫɭ ɛɢɥɚ ɡɞɪɚɜɚ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɨɞɨʁɱɚɞɢ, 33 ʁɟ ɛɢɥɨ ɢɫɤʂɭɱɢɜɨ ɧɚ ɩɨɞɨʁɭ, ɚ 27 ɨɞɨʁɱɚɞɢ ʁɟ ɞɨɛɢʁɚɥɨ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ. ɋɜɚ ɞɟɰɚ ɫɭ ɢɦɚɥɚ ɧɨɪɦɚɥɚɧ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ ɤɚɥɰɢʁɭɦɚ (ɋɚ), ɮɨɫɮɚɬɚ ɢ ɊɌɇ. ɉɟɬɨɪɨ ɨɞɨʁɱɚɞɢ ʁɟ ɢɦɚɥɨ ɧɢɜɨ 25(OH)D<10 ЧР/ЦХ, ɢ ɫɜɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ (15,1% ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ). ɇɢʁɟɞɧɨ ɨɞ ɨɜɢɯ 5 ɨɞɨʁɱɚɞɢ ɧɢʁɟ ɞɨɛɢʁɚɥɨ ɫɭɩɥɟɦɟɧɬɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɍ ɨɞɨʁɱɚɞɢ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ, ɜɪɟɞɧɨɫɬɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɫɭ ɛɢɥɟ ɥɚɤɨ ɩɨɜɢɲɟɧɟ. ɋɚɦɨ 48% ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ʁɟ ɞɨɛɢʁɚɥɨ ɫɭɩɥɟɦɟɧɬɟ ɜɢɬɚɦɢɧɚ Ⱦ. Ɂɚɤʂɭɱɟɧɨ ʁɟ ɞɚ ɱɚɤ ɢ ɭ ɪɟɝɢɨɧɢɦɚ ɫɚ ɭɦɟɪɟɧɨɦ ɤɥɢɦɨɦ, ɞɟɰɚ ɧɚ ɢɫɤʂɭɱɢɜɨɦ ɩɨɞɨʁɭ, ɛɟɡ ɚɞɟɤɜɚɬɧɟ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɤɨʁɚ ɫɭ ɫɥɚɛɢʁɟ ɢɡɥɚɝɚɧɚ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ ɢɦɚʁɭ ɫɭɛɤɥɢɧɢɱɤɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (Cabezuelo, et al. 2007). ɋɬɚɬɭɫ ɜɢɬɚɦɢɧ Ⱦ ɢ ɮɚɤɬɨɪɢ ɤɨʁɢ ɭɡɪɨɤɭʁɭ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ 1077 ʁɨɪɞɚɧɫɤɟ ɦɚɥɟ ɞɟɰɟ (ɭɡɪɚɫɬɚ ɨɞ 12-59 ɦɟɫɟɰɢ) ɨɞɪɟђɢɜɚɧ ʁɟ ɭ ɩɪɨɥɟʄɟ 2010. ɝɨɞɢɧɟ. 16 Ɋɟɡɭɥɬɚɬɢ ɫɭ ɩɨɤɚɡɚɥɢ ɞɚ ʁɟ 19,8% ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ ɢɦɚɥɨ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (<12 ЧР/ЦХ) ɢ 56,5% ɧɟɞɨɜɨʂɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ (<20 ЧР/ЦХ). ɍɱɟɫɬɚɥɨɫɬ ɧɟɞɨɫɬɚɬɤɚ ɛɢɨ ʁɟ ɜɟʄɢ ɭ ɠɟɧɫɤɟ ɞɟɰɟ, ɭ ɩɨɪɟђɟʃɭ ɫɚ ɦɭɲɤɨɦ (ɪ = 0.002), ɢ ɦɚʃɚ ɡɚ ɞɟɰɭ ɭɡɪɚɫɬɚ 24-35 ɦɟɫɟɰɢ (ɪ = 0.018), ɭ ɩɨɪɟђɟʃɭ ɫɚ ɞɟɰɨɦ ɭɡɪɚɫɬɚ ɨɞ 12-23 ɦɟɫɟɰɢ ɠɢɜɨɬɚ. ɍ ɪɭɪɚɥɧɢɦ ɨɛɥɚɫɬɢɦɚ, ɧɢʁɟ ɛɢɥɨ ɪɚɡɥɢɤɟ ɭ ɩɪɟɜɚɥɟɧɰɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɨɧɢɯ ɱɢʁɟ ɦɚʁɤɟ ɫɭ ɢɦɚɥɟ / ɧɟɦɚɥɟ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (ɪ = 0,312). Ɇɟђɭɬɢɦ, ɭ ɭɪɛɚɧɢɦ ɫɪɟɞɢɧɚɦɚ, ɭɱɟɫɬɚɥɨɫɬ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɛɢɨ 3,18 ɩɭɬɚ ɜɟʄɢ ɭ ɞɟɰɟ ɱɢʁɟ ɫɭ ɦɚʁɤɟ ɛɢɥɟ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɬɧɟ ɭ ɩɨɪɟђɟʃɭ ɫɚ ɞɟɰɨɦ ɱɢʁɟ ɦɚʁɤɟ ɧɢɫɭ ɢɦɚɥɟ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ (ɪ = 0,000). Ɉɜɨ ɫɟ ɨɛʁɚɲʃɚɜɚ ɱɢʃɟɧɢɰɚɦɚ ɞɚ ɫɭ ɦɚʁɤɟ ɭ ɭɪɛɚɧɢɦ ɫɪɟɞɢɧɚɦɚ ɦɚʃɟ ɢɡɥɚɝɚɥɟ ɫɜɨʁɭ ɞɟɰɭ ɫɭɧɰɭ (Nichols, et al. 2015). ɂɫɬɪɚɠɢɜɚʃɟ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ 133 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 6-23 ɦɟɫɟɰɢ ɧɚ Ⱥʂɚɫɰɢ ɬɨɤɨɦ 2001. ɢ 2002. ɝɨɞɢɧɟ ɩɨɤɚɡɚɥɨ ʁɟ, ɞɚ ʁɟ, 15 (11%) ɢ 26 (20%) ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɢɦɚɥɨ ɚɛɧɨɪɦɚɥɧɨ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ (<15 ЧР/ЦХ) ɢ 15 ɜɪɟɞɧɨɫɬɢ 25(OH)D<25 ЧР/ЦХ (ɫɪɟɞʃɟ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ). ȼɟʄɟ ɲɚɧɫɟ ɡɚ ɚɛɧɨɪɦɚɥɧɨ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɢ ɫɪɟɞʃɟ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ, ɢɦɚɥɚ ɫɭ ɞɟɰɚ ɤɨʁɚ ɫɭ ɛɢɥɚ ʁɨɲ ɭɜɟɤ ɧɚ ɩɨɞɨʁɭ. Ɉɞ 41 ɞɟɬɟɬɚ ɤɨʁɟ ʁɟ ʁɨɲ ɭɜɟɤ ɛɢɥɨ ɧɚ ɩɨɞɨʁɭ, 14 (34%) ɫɭ ɞɨɛɢʁɚɥɚ ɜɢɬɚɦɢɧɟ, ɚ 6 (18%) ɫɭ ɧɚɜɟɥɢ ɞɚ ɫɭ ɫɜɚɤɢ ɞɚɧ ɞɨɛɢʁɚɥɚ ɜɢɬɚɦɢɧɟ (Gessner, et al. 2003). Ʉɥɢɧɢɱɤɟ ɩɨɫɥɟɞɢɰɟ ɤɨјɟ ɭɤɚɡɭјɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ Ʉɥɢɧɢɱɤɟ ɩɨɫɥɟɞɢɰɟ ɛɥɚɝɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɱɟɫɬɨ ɦɚʃɟ ɩɪɟɩɨɡɧɚɬʂɢɜɟ ɢɥɢ ɭɨɩɲɬɟ ɧɢɫɭ ɢɫɩɨʂɟɧɟ. Ɇɟђɭɬɢɦ, ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɯɪɨɧɢɱɧɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɥɚɡɢ ɞɨ ɫɦɚʃɟʃɚ ɝɭɫɬɢɧɟ ɤɨɫɬɢʁɭ, ɱɚɤ ɢ ɭ ɨɞɫɭɫɬɜɭ ɪɚɯɢɬɢɫɚ. Ɋɚɯɢɬɢɫ ɧɚɫɬɚʁɟ ɭɫɥɟɞ ɢɡɪɚɠɟɧɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɫɚ ɧɚʁɜɟʄɨɦ ɭɱɟɫɬɚɥɨɲʄɭ ɢɡɦɟђɭ 3 ɢ 18 ɦɟɫɟɰɢ ɠɢɜɨɬɚ ɭ ɞɟɰɟ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɩɪɢɫɭɬɚɧ ɜɢɲɟ ɦɟɫɟɰɢ ɩɪɟ ɩɨʁɚɜɟ ɫɢɦɩɬɨɦɚ ɢ ɡɧɚɤɨɜɚ ɪɚɯɢɬɢɫɚ, ɱɟɫɬɨ ɭ ɜɢɞɭ ɯɢɩɨɤɚɥɰɟɦɢʁɫɤɢɯ ɤɨɧɜɭɥɡɢʁɚ, ɧɟɞɨɜɨʂɧɨɝ ɪɚɫɬɚ, ɥɟɬɚɪɝɢʁɟ, ɪɚɡɞɪɚɠʂɢɜɨɫɬɢ, ɛɥɟɞɢɥɚ, ɭɦɨɪɚ, ɩɨɪɟɦɟʄɚʁɚ ɜɚɪɟʃɚ, ɧɟɫɚɧɢɰɟ ɢ ɨɛɢɥɧɨɝ ɡɧɨʁɟʃɚ. ɑɟɫɬɟ ɫɭ ɩɪɟɞɢɫɩɨɡɢɰɢʁɟ ɡɚ ɭɱɟɫɬɚɥɟ ɪɟɫɩɢɪɚɬɨɪɧɟ ɛɨɥɟɫɬɢ ɬɨɤɨɦ ɪɚɧɨɝ ɞɟɬɢʃɫɬɜɚ. Ɉɜɢ ɪɚɧɢ ɫɢɦɩɬɨɦɢ ɛɨɥɟɫɬɢ ɫɭ ɧɟɫɩɟɰɢɮɢɱɧɢ, ɬɟɲɤɨ ɫɟ ɨɬɤɪɢɜɚʁɭ ɢ ɪɟɬɤɨ ɩɪɢɩɢɫɢʁɭ ɪɚɯɢɬɢɫɭ. Ɉɛɢɥɧɨ ɡɧɨʁɟʃɟ ʁɟ ɫɜɚɤɚɤɨ ʁɟɞɚɧ ɨɞ ɧɚʁɜɚɠɧɢʁɢɯ ɡɧɚɤɨɜɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ. Ɉɧɨ ʁɟ ɧɚɪɨɱɢɬɨ ɢɫɩɨʂɟɧɨ ɧɚ ɩɨɬɢʂɤɭ. Ɋɨɞɢɬɟʂɢ ɞɚʁɭ ɩɨɞɚɬɚɤ ɞɚ ʁɟ ɡɧɨʁɟʃɟ ɬɚɤɨ ɨɛɢɥɧɨ, ɞɚ ʁɟ ɢɡʁɭɬɪɚ, ʁɚɫɬɭɤ ɢɫɩɨɞ ɝɥɚɜɟ, ɦɨɤɚɪ. Ⱦɟɬɟ ʁɟ ɡɥɨɜɨʂɧɨ, ɧɟɪɚɫɩɨɥɨɠɟɧɨ, ɢ ɫɜɟ ɜɪɟɦɟ ɨɞɚʁɟ ɭɬɢɫɚɤ "ɞɚ ɦɭ ɧɟɲɬɨ ɧɟɞɨɫɬɚʁɟ". ɋɥɚɛɨ ɫɩɚɜɚ ɢ ɥɚɤɨ ɫɟ ɛɭɞɢ. 17 Ʉɨɞ ɞɪɭɝɟ ɝɪɭɩɟ ɞɟɰɟ ɫɭ ɛɢɥɟ ɢɫɩɨʂɟɧɟ ɯɪɨɧɢɱɧɟ ɛɨɥɟɫɬɢ ɫɚ ɢɡɪɚɠɟɧɢɦ ɫɢɦɩɬɨɦɢɦɚ ɢ ɡɧɚɰɢɦɚ ɪɚɯɢɬɢɫɚ, ɢɥɢ ɫɚɦɨ ɨɫɬɟɨɩɟɧɢʁɟ, ɞɨɤ ʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɭ ɫɟɪɭɦɭ ɛɢɥɚ ɧɨɪɦɚɥɧɚ ɢɥɢ ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɚɫɢɦɩɬɨɦɚɬɫɤɚ ɯɢɩɨɤɚɥɰɢɟɦɢʁɚ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɦɨɠɟ ɭɡɪɨɤɨɜɚɬɢ ɛɨɥ ɭ ɦɢɲɢʄɢɦɚ, ɦɢɲɢʄɧɭ ɫɥɚɛɨɫɬ ɢ ɛɨɥ ɭ ɤɨɫɬɢɦɚ ɭ ɛɢɥɨ ɤɨʁɨʁ ɠɢɜɨɬɧɨʁ ɞɨɛɢ. Ɍɪɭɞɧɢɰɟ ɤɨʁɟ ɢɦɚʁɭ ɦɚʃɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ɭɡɪɨɤɭʁɭ ɦɚʃɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɭ ɮɟɬɭɫɚ. ɉɨɧɟɤɚɞ, ɭ ɦɚʁɤɢ ɫɚ ɨɫɬɟɨɦɚɥɚɰɢʁɨɦ ɫɟ ɭ ɧɨɜɨɪɨђɟɧɱɚɞ ʁɚɜʂɚ ɪɚɯɢɬɢɫ ɫɚ ɩɪɨɦɟɧɚɦɚ ɧɚ ɦɟɬɚɮɢɡɚɦɚ. ɉɨɧɟɤɚɞ ɫɟ ɧɚ ɫɩɨʁɭ ɤɨɫɬɢʁɭ ɝɥɚɜɟ ɩɨɡɚɞɢ ɩɚɥɩɢɪɚ ɤɪɚɧɢɨɬɚɛɟɫ, ɪɚɡɦɟɤɲɚʃɟ ɭ ɜɢɞɭ ɮɟɧɨɦɟɧɚ "ɩɢɧɝ ɩɨɧɝ ɥɨɩɬɢɰɟ". ɍ ɫɬɚɪɢʁɟ ɨɞɨʁɱɚɞɢ ɱɟɫɬɨ ɞɟɰɚ ɤɚɫɧɢʁɟ ɩɨɱɢʃɭ ɞɚ ɫɚɦɨɫɬɚɥɧɨ ɫɟɞɟ ɢ ɩɭɡɟ. ȼɟɥɢɤɚ ɮɨɧɬɚɧɟɥɚ ɫɟ ɤɚɫɧɢʁɟ ɡɚɬɜɚɪɚ, ɝɥɚɜɚ ʁɟ ɱɟɫɬɨ ɭ ɨɛɥɢɤɭ ɤɜɚɞɪɚɬɚ ɡɛɨɝ ɤɨɫɬɟɨɯɨɧɞɪɚɥɧɢɯ ɡɚɞɟɛʂɚʃɚ, ɤɨʁɚ ɫɟ ɧɚ ɫɩɨʁɟɜɢɦɚ ɯɪɫɤɚɜɢɰɟ ɢ ɤɨɫɬɢʁɭ ɪɟɛɚɪɚ ɨɱɢɬɚɜɚʁɭ ɤɚɨ ɛɪɨʁɚɧɢɰɟ. Ʉɚɫɧɢʁɟ ɫɟ ʁɚɜʂɚʁɭ ɢ ɦɧɨɝɨɛɪɨʁɧɢ ɞɟɮɟɤɬɢ ɧɚ ɤɨɫɬɢɦɚ, ɢɡɛɨɱɟɧɟ ɝɪɭɞɢ (ɧɚ ɫɬɟɪɧɭɦɭ), ɩɪɨɦɟɧɟ ɧɚ ɟɤɫɬɪɟɦɢɬɟɬɢɦɚ, ɧɨɝɟ ɭ ɨɛɥɢɤɭ ɫɥɨɜɚ Ɉ ɢ ɏ, ɤɢɮɨɫɤɨɥɢɨɡɚ, ɞɟɰɚ ɤɚɫɧɢʁɟ ɩɪɨɯɨɞɚʁɭ. Ɋɚɯɢɬɢɱɧɚ ɬɟɬɚɧɢʁɚ ʁɟ ɭɡɪɨɤɨɜɚɧɚ ɯɢɩɨɤɚɥɰɢɟɦɢʁɨɦ, ɢ ɦɨɠɟ ɫɟ ʁɚɜɢɬɢ ɢ ɭ ɞɟɰɟ, ɢ ɭ ɨɞɪɚɫɥɢɯ. Јɚɜʂɚ ɫɟ ɭ ɨɛɥɢɤɭ ɩɚɪɟɫɬɟɡɢʁɚ ɭɫɧɢɰɚ, ʁɟɡɢɤɚ ɢ ɩɪɫɬɢʁɭ; ɤɚɪɩɨɩɟɞɚɥɧɢ ɫɩɚɡɚɦ ɢ ɫɩɚɡɚɦ ɥɢɰɚ. ɍ ɫɥɭɱɚʁɟɜɢɦɚ ɢɡɪɚɠɟɧɟ ɯɢɩɨɤɚɥɰɢɟɦɢʁɟ, ɦɨɝɭ ɫɟ ʁɚɜɢɬɢ ɯɢɩɨɤɚɥɰɟɦɢʁɫɤɟ ɤɨɧɜɭɥɡɢʁɟ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɤɢ, ɦɨɠɟ ɢɡɚɡɜɚɬɢ ɬɟɬɚɧɢʁɭ ɭ ɧɨɜɨɪɨђɟɧɱɟɬɚ. ɋɭɛɨɩɬɢɦɚɥɧɢ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɫɟ ɱɟɫɬɨ ʁɚɜʂɚ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ. Ʉɨɞ ɞɟɰɟ ɢ ɨɞɪɚɫɥɢɯ, ɫɢɦɩɬɨɦɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭɤʂɭɱɭʁɭ ɛɨɥ ɭ ɤɨɫɬɢɦɚ, ɞɟɮɨɪɦɢɬɟɬɟ ɢ ɧɚɫɥɚɝɟ ɧɚ ɡɭɛɢɦɚ, ɫɦɚʃɟɧɭ ɛɪɡɢɧɭ ɪɚɫɬɟʃɚ, ɱɟɲʄɟ ɩɪɟɥɨɦɟ ɤɨɫɬɢʁɭ, ɝɪɱɟɜɟ ɭ ɦɢɲɢʄɢɦɚ, ɧɢɡɚɤ ɪɚɫɬ, ɫɤɟɥɟɬɧɟ ɞɟɮɨɪɦɢɬɟɬɟ ɧɚ ɝɪɭɞɧɨʁ ɤɨɫɬɢ, ɤɨɫɬɢɦɚ ɝɥɚɜɟ, ɤɚɪɥɢɰɟ ɢ ɟɤɫɬɪɟɦɢɬɟɬɚ, ɤɚɨ ɢ ɭ ɪɚɯɢɬɢɫɭ. ɇɚɭɱɧɢ ɢɫɬɪɚɠɢɜɚɱɢ JШСЧs HШpФТЧs CСТХНrОЧ,s CОЧtОr ɫɭ ɭ ɫɜɨɦ ɧɚʁɧɨɜɢʁɟɦ ɢɫɬɪɚɠɢɜɚʃɭ ɞɨɤɚɡɚɥɢ ɞɚ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ɞɟɬɟɬɚ ɩɨɜɟʄɚɜɚʁɭ ɪɢɡɢɤ ɨɞ ɚɧɟɦɢʁɟ. ɋɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɨɛʁɚɜʂɟɧɚ ɨɤɬɨɛɪɚ 2013. ɝɨɞɢɧɟ ɭ ɉɟɞɢʁɚɬɪɢʁɫɤɨɦ ɠɭɪɧɚɥɭ, ɫɦɚɬɪɚ, ɞɚ ʁɟ ɨɜɚʁ ɰɟɧɬɚɪ, ɩɪɜɢ, ɤɨʁɢ ʁɟ ɢɧɬɟɧɡɢɜɧɨ ɢɫɬɪɚɠɢɜɚɨ ɜɟɡɭ ɢɡɦɟђɭ ɨɜɚ ɞɜɚ ɞɟɮɢɰɢɬɚ ɭ ɨɪɝɚɧɢɡɦɭ ɞɟɰɟ. Ⱥɧɟɦɢʁɚ ɭ ɞɟɬɢʃɫɬɜɭ ʁɟ ɞɟɮɢɧɢɫɚɧɚ ɤɚɨ ɫɦɚʃɟʃɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɯɟɦɨɝɥɨɛɢɧɚ ɢɫɩɨɞ ɞɜɟ ɫɬɚɧɞɚɪɞɧɟ ɞɟɜɢʁɚɰɢʁɟ ɨɞ ɫɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɡɚ ɭɡɪɚɫɬ ɡɞɪɚɜɟ ɞɟɰɟ (JКЧТć, 2002). ɂɚɤɨ ʁɟ ɚɧɟɦɢʁɚ ɢɡɚɡɜɚɧɚ ɧɟɞɨɫɬɚɬɤɨɦ ɝɜɨɠђɚ ɞɨɛɪɨ ɩɪɨɭɱɟɧ ɩɨɪɟɦɟʄɚʁ, ɧɟ ɩɨɫɬɨʁɟ ʁɚɫɧɨ ɞɟɮɢɧɢɫɚɧɟ ɧɭɦɟɪɢɱɤɟ ɜɪɟɞɧɨɫɬɢ ɬɟɫɬɨɜɚ ɤɨʁɢ ɝɚ ɞɟɮɢɧɢɲɭ, ɢɡɭɡɟɜ ɜɪɟɞɧɨɫɬɢ ɯɟɦɨɝɥɨɛɢɧɚ ɢ ɯɟɦɚɬɨɤɪɢɬɚ. 18 ɇɟɞɨɫɬɚɬɚɤ ɝɜɨɠђɚ ɬɚɤɨђɟ ɩɪɟɨɜɥɚɞɚɜɚ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ ɢ ɪɚɫɥɚ ɭ ɥɨɲɢɦ ɫɨɰɢɨɟɤɨɧɨɦɫɤɢɦ ɭɫɥɨɜɢɦɚ, ɧɚɪɨɱɢɬɨ ɭ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ (Monterrosa, et al. 2008). Ɏɚɤɬɨɪɢ ɪɢɡɢɤɚ ɡɚ ɚɧɟɦɢʁɭ ɭɤʂɭɱɭʁɭ: ɭɧɨɫ ɯɪɚɧɟ ɫɢɪɨɦɚɲɧɟ ɭ ɝɜɨɠђɭ ɢ ɮɨɥɚɬɢɦɚ, ɨɡɛɢʂɧɟ ɛɨɥɟɫɬɢ, ɭɤʂɭɱɭʁɭʄɢ ɭɧɭɬɪɚɲʃɟ ɤɪɜɚɪɟʃɟ, ɛɨɥɟɫɬɢ ɛɭɛɪɟɝɚ, ɪɚɤ, ɞɢʁɚɛɟɬɟɫ, ɏɂȼ/ȺɂȾɋ, ɛɨɥɟɫɬɢ ʁɟɬɪɟ ɢ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɟɥɟɱɟɧɚ, ɯɪɨɧɢɱɧɚ ɚɧɟɦɢʁɚ ɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɦɨɝɭ ɢɦɚɬɢ ɞɚɥɟɤɨɫɟɠɧɟ ɩɨɫɥɟɞɢɰɟ ɩɨ ɡɞɪɚɜʂɟ, ɭɤʂɭɱɭʁɭʄɢ, ɨɲɬɟʄɟʃɟ ɨɪɝɚɧɚ, ɞɟɮɨɪɦɢɬɟɬɟ ɫɤɟɥɟɬɚ ɢ ɱɟɫɬɟ ɩɪɟɥɨɦɟ, ɤɚɨ ɢ ɞɚ ɞɨɜɟɞɭ ɞɨ ɩɪɟɜɪɟɦɟɧɟ ɨɫɬɟɨɩɨɪɨɡɟ ɭ ɤɚɫɧɢʁɟɦ ɠɢɜɨɬɭ. Jeffrey Fadrowski, M.D., M.H.S., ɞɟɱʁɢ ɧɟɮɪɨɥɨɝ ɭ JШСns Hopkins Children,s Centru ɧɚɲɚɨ ʁɟ ɞɚ ʁɟ ɭ ɞɟɰɟ ɫɚ ɫɭɛɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D<30 ЧР/ЦХ ɩɨɫɬɨʁɚɥɚ ʁɟ ɡɧɚɱɚʁɧɚ ɩɨɜɟɡɚɧɨɫɬ ɫɚ ɜɟʄɨɦ ɭɱɟɫɬɚɥɨɲʄɭ ɚɧɟɦɢʁɟ ɤɨɞ ɡɞɪɚɜɟ ɞɟɰɟ ɭ ɋȺȾ-ɭ, ɪ=0,006, ɤɨɞ ɞɟɰɟ ɫɚ 25(OH)D<20 ЧР/ЦХ ɪ=0,004. ȼɟʄɚ ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɢ ɧɢɠɟ ɜɪɟɞɧɨɫɬɢ HЛ ɫɭ ɧɚђɟɧɟ ɭ ɰɪɧɟ ɞɟɰɟ, ɭ ɩɨɪɟђɟʃɭ ɫɚ ɢɫɩɢɬɢɜɚɧɨɦ ɛɟɥɨɦ ɞɟɰɨɦ (Atkinson, et al. 2013). ɇɟɦɚ ɩɪɢʁɚɜʂɟɧɢɯ ɫɬɭɞɢʁɚ ɞɚ ɜɢɬɚɦɢɧ Ⱦ ɫɩɪɟɱɚɜɚ ɚɧɟɦɢʁɭ. Ɇɟђɭɬɢɦ, ɧɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɡɚ ɞɪɭɝɟ ɛɨɥɟɫɬɢ, ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɧɚɞ 30-40 ng/ml (75-100 nmol/L) ɦɨɠɟ ɩɨɜɟʄɚɬɢ ɛɪɨʁ ɟɪɢɬɪɨɰɢɬɚ ɭ ɫɟɪɭɦɭ ɢ ɨɤɫɢɝɟɧɚɰɢʁɭ ɤɪɜɢ (William, at al.2007). Atkinson ɢ ɫɚɪɚɞɧɢɰɢ (Atkinson MA et al, 2013) ɫɭ ɭ ɫɬɭɞɢʁɢ ɤɨɞ 10410 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 1-21 ɝɨɞɢɧɟ ɫɬɚɪɨɫɬɢ ɨɞ 2001. - 2006. ɝɨɞɢɧɟ ɢɫɩɢɬɢɜɚɥɢ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ 25- ɯɢɞɪɨɤɫɢɜɢɬɚɦɢɧɚ Ⱦ (25(OH)D) ɞɟɮɢɰɢɬɚ ɢ ɚɧɟɦɢʁɟ ɭ ɧɚɨɤɨ ɡɞɪɚɜɟ ɞɟɰɟ ɤɚɤɨ ɛɢ ɭɬɜɪɞɢɥɢ ɞɚ ɥɢ ɩɨɫɬɨʁɢ ɩɨɜɟɡɚɧɨɫɬ. ɇɚɲɥɢ ɫɭ, ɞɚ ɫɭ ɢɫɩɢɬɚɧɢɰɢ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D ɧɢɠɢɦ ɨɞ 30 ЧР/ЦХ ɢɦɚɥɢ ɩɨɜɟʄɚɧɢ ɪɢɡɢɤ ɡɚ ɚɧɟɦɢʁɭ, ɞɨɤ ʁɟ ɪɢɡɢɤ ɡɚ ɚɧɟɦɢʁɭ ɭ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D ɧɢɠɢɦ ɨɞ 20 ЧР/ЦХ ɛɢɨ ɡɧɚɱɚʁɧɨ ɜɟʄɢ. ɇɚɲɥɢ ɫɭ ɞɚ ɫɭ ɜɪɟɞɧɨɫɬɢ 25(OH)D ɛɢɥɟ ɡɧɚɱɚʁɧɨ ɧɢɠɟ ɭ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɰɪɧɟ ɪɚɫɟ, ɱɟɫɬɨ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D < 12 ng/ml (Meredith, et al. 2011). ɍ ɩɨɩɪɟɱɧɨɦ ɩɪɟɫɟɤɭ ɫɬɭɞɢʁɟ (Sim,et al. 2010). ɧɚ ɯɟɦɚɬɨɥɨɲɤɨɦ ɨɞɟʂɟʃɭ Ⱦɟɱʁɟɝ ɨɞɟʂɟʃɚ ʁɟ ɭɩɨɪɟђɢɜɚɧɚ ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɭ ɩɨɩɭɥɚɰɢʁɢ ɞɟɰɟ ɫɚ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɨɪɟђɟʃɭ ɫɚ ɞɟɰɨɦ ɤɨʁɚ ɢɦɚʁɭ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ɍ ɩɟɪɢɨɞɭ ɨɞ 01.01.2004. ɞɨ 31.12.2006. ɝɨɞɢɧɟ, ɨɞ ɭɤɭɩɧɨ 554 ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ, ɚɧɟɦɢʁɚ (HЛ<110 Р/L) ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɭ 49% ɞɟɰɟ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D<30 ЧР/ЦХ, ɭ ɩɨɪɟђɟʃɭ ɫɚ 36% ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɤɨʁɚ ɫɭ ɢɦɚɥɚ ɧɢɜɨ 25(OH)D>30 ЧР/ЦХ (ɪ<0,01). Ȼɭɞɭʄɟ ɪɚɧɞɨɦɢɡɨɜɚɧɟ ɫɬɭɞɢʁɟ ɬɪɟɛɚ ɞɚ ɢɫɩɢɬɚʁɭ ɞɚ ɥɢ ɜɢɬɚɦɢɧ Ⱦ ɞɢɪɟɤɬɧɨ ɭɬɢɱɟ ɟɪɢɬɪɨɩɨɟɡɭ (Sim,et al. 2010). 19 ɋɬɭɞɢʁɚ ɚɡɢʁɫɤɢɯ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɢɫɩɨɞ 2 ɝɨɞɢɧɟ ɩɨɤɚɡɚɥɚ ʁɟ ɡɧɚɱɚʁɧɭ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ ȽȾ (ɞɟɮɢɰɢɬɚ ɝɜɨɠђɚ) ɢ ȼȾȾ (ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɚ) (Grindulis, et al. 1986). Ʉɚɥɰɢјɭɦ ɭ ɢɫɯɪɚɧɢ Ʉɨɧɰɟɧɬɪɚɰɢʁɚ ʁɨɧɢɡɨɜɚɧɨɝ ɤɚɥɰɢʁɭɦɚ ʁɟ ɩɨɞ ɞɢɪɟɤɬɧɢɦ ɭɬɢɰɚʁɟɦ ɊɌɇ, ɤɚɥɰɢɬɨɧɢɧɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ. Ɂɚ ɭɪɚɜɧɨɬɟɠɟɧ ɛɢɥɚɧɫ ɤɚɥɰɢʁɭɦɚ, ɩɨɬɪɟɛɚɧ ʁɟ ɚɞɟɤɜɚɬɚɧ ɭɧɨɫ ɤɚɥɰɢʁɭɦɚ ɯɪɚɧɨɦ, ɧɨɪɦɚɥɧɚ ɚɩɫɨɪɩɰɢʁɚ ɭ ɰɪɟɜɢɦɚ ɢ ɟɥɢɦɢɧɚɰɢʁɚ ɩɭɬɟɦ ɰɪɟɜɚ ɢ ɛɭɛɪɟɝɚ. Ⱥɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɫɦɚʃɭʁɭ ɨɤɫɚɥɚɬɢ ɢ ɤɚɪɛɨɧɚɬɢ, ɤɚɨ ɢ ɜɟɥɢɤɟ ɤɨɥɢɱɢɧɟ ɮɨɫɮɚɬɚ ɢ ɦɚɫɧɢɯ ɤɢɫɟɥɢɧɚ ɭ ɰɪɟɜɢɦɚ. ɇɚʁɩɨɡɧɚɬɢʁɢ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ ɭ ɢɫɯɪɚɧɢ ɫɭ ɦɥɟɤɨ ɢ ɦɥɟɱɧɢ ɩɪɨɢɡɜɨɞɢ. Ȼɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (ɫɩɟɰɢɮɢɱɧɢ ɛɢɨɦɚɪɤɟɪɢ ɦɟɬɚɛɨɥɢɡɦɚ ɤɨɫɬɢјɭ) ɍɤɭɩɚɧ ɤɚɥɰɢјɭɦ Ʉɚɥɰɢʁɭɦ ʁɟ ʁɟɞɚɧ ɨɞ ɩɟɬ ɧɚʁɡɧɚɱɚʁɧɢʁɢɯ ɟɥɟɦɟɧɚɬɚ, ɤɚɨ ɢ ɧɚʁɪɚɫɩɪɨɫɬɪɚʃɟɧɢʁɢ ɤɚɬʁɨɧ ɭ ʂɭɞɫɤɨɦ ɨɪɝɚɧɢɡɦɭ (MКУФТć-Singh, 2006). ɇɚɥɚɡɢ ɫɟ ɪɚɫɩɨɪɟђɟɧ ɭ ɬɪɢ ɬɟɥɟɫɧɚ ɩɪɨɫɬɨɪɚ: ɫɤɟɥɟɬɭ, ɦɟɤɢɦ ɬɤɢɜɢɦɚ ɢ ɟɤɫɬɪɚʄɟɥɢʁɫɤɨʁ ɬɟɱɧɨɫɬɢ. Ʉɚɥɰɢʁɭɦ ɫɟ ɭ ɟɤɫɬɪɚʄɟɥɢʁɫɤɨʁ ɬɟɱɧɨɫɬɢ ɧɚɥɚɡɢ ɫɤɨɪɨ ɭɜɟɤ ɭ ɩɪɢɛɥɢɠɧɨ ɢɫɬɢɦ ɤɨɧɰɟɧɬɪɚɰɢʁɚɦɚ, ɨɤɨ 2,4 ЦЦШХ/L (ɨɞ 2,2-2,7 mmol/L) ɭ ɞɟɰɟ. ɍ ɩɥɚɡɦɢ ɫɟ ɤɚɥɰɢʁɭɦ ɧɚɥɚɡɢ ɭ ɬɪɢ ɨɛɥɢɤɚ. Ɉɤɨ 41% ɤɚɥɰɢʁɭɦɚ (1 ЦЦШХ/L) ɜɟɡɚɧɨ ʁɟ ɡɚ ɩɪɨɬɟɢɧɟ ɩɥɚɡɦɟ ɢ ɭ ɨɜɨɦ ɨɛɥɢɤɭ ɧɟ ɞɢɮɭɧɞɭʁɟ ɤɪɨɡ ɤɚɩɢɥɚɪɧɭ ɦɟɦɛɪɚɧɭ. Ɉɤɨ 9% ɤɚɥɰɢʁɭɦɚ (0,2 ЦЦШХ/L) ɦɨɠɟ ɞɚ ɞɢɮɭɧɞɭʁɟ ɤɪɨɡ ɤɚɩɢɥɚɪɧɭ ɦɟɦɛɪɚɧɭ, ɚɥɢ ʁɟ ɜɟɡɚɧɨ ɡɚ ɚɧʁɨɧɫɤɟ ɫɭɩɫɬɚɧɰɟ ɩɥɚɡɦɟ ɢ ɢɧɬɟɪɫɬɢɰɢʁɭɦɫɤɟ ɬɟɱɧɨɫɬɢ (ɰɢɬɪɚɬɟ, ɮɨɫɮɚɬɟ) ɢ ɤɚɨ ɬɚɤɚɜ ʁɟ ɧɟʁɨɧɢɡɨɜɚɧ. ɉɪɟɨɫɬɚɥɢɯ 50% ɤɚɥɰɢʁɭɦɚ ɭ ɩɥɚɡɦɢ (1,2 ЦЦШХ/L) УО ʁɨɧɢɡɨɜɚɧɨ ɢ ɞɢɮɭɡɢɛɢɥɧɨ ɤɪɨɡ ɤɚɩɢɥɚɪɧɭ ɦɟɦɛɪɚɧɭ. ɇɨɪɦɚɥɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɤɚɥɰɢʁɭɦɚ ɭ ɩɥɚɡɦɢ ɢ ɢɧɬɟɪɫɬɢɰɢʁɭɦɫɤɨʁ ɬɟɱɧɨɫɬɢ ɢɡɧɨɫɢ ɨɤɨ 1,2 ЦЦШХ/L, ɲɬɨ ɩɪɟɞɫɬɚɜʂɚ ɫɚɦɨ ɩɨɥɨɜɢɧɭ ɭɤɭɩɧɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɤɚɥɰɢʁɭɦɚ ɭ ɩɥɚɡɦɢ. Ʉɚɥɰɢʁɭɦ ɭ ʁɨɧɫɤɨɦ ɨɛɥɢɤɭ ʁɟ ɜɚɠɚɧ ɡɚ ɜɟʄɢɧɭ ɮɭɧɤɰɢʁɚ ɤɚɥɰɢʁɭɦɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɤɚɨ ɲɬɨ ɫɭ ɭɬɢɰɚʁ ɧɚ ɫɪɰɟ, ɛɪɨʁɧɟ ɦɟɬɚɛɨɥɢɱɤɟ ɮɭɧɤɰɢʁɟ, ɧɟɪɜɧɢ ɫɢɫɬɟɦ (ɧɟɭɪɨɦɢɲɢʄɧɭ ɬɪɚɧɫɦɢɫɢʁɭ) ɢ ɦɢɧɟɪɚɥɢɡɚɜɢʁɭ ɫɤɟɥɟɬɚ ɢ ɡɭɛɚ (American Academy of Pediatrics, 2009). 20 ɇɢɡɚɤ ɧɢɜɨ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ (ɯɢɩɨɤɚɥɰɟɦɢʁɚ), ɋɚ<1,9 mmol/L,ʁɟ ɧɚʁɱɟɲʄɟ ɩɨɫɥɟɞɢɰɚ ɫɦɚʃɟʃɚ ɤɚɥɰɢʁɭɦɚ ɤɨʁɢ ʁɟ ɜɟɡɚɧ ɡɚ ɚɥɛɭɦɢɧ ɢɥɢ ɫɦɚʃɟʃɚ ɫɥɨɛɨɞɧɨɝ ɤɚɥɰɢʁɭɦɚ (Baldwin and Chernow, 1987). ɍɨɛɢɱɚʁɟɧ ɞɧɟɜɧɢ ɭɧɨɫ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ ɞɧɟɜɧɨ ɢɡɧɨɫɢ ɨɤɨ 1000 ЦР/ɞɚɧ, ɲɬɨ ɨɬɩɪɢɥɢɤɟ ɨɞɝɨɜɚɪɚ ɤɨɥɢɱɢɧɚɦɚ ɤɨʁɟ ɫɟ ɧɚɥɚɡɟ ɭ 1 ɥɢɬɪɭ ɦɥɟɤɚ. ɂɦɚ ɝɚ ɢ ɭ ɜɨʄɭ, ɢ ɩɨɜɪʄɭ. ȼɢɬɚɦɢɧ Ⱦ, ɨɞɧɨɫɧɨ ʃɟɝɨɜ ɦɟɬɚɛɨɥɢɬ 1,25(Ɉɇ)2D ɩɨɞɫɬɢɱɟ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɭ ɰɪɟɜɢɦɚ ɨɤɨ 35% ɞɧɟɜɧɨ (ɨɤɨ 350 ЦР/ɞɚɧ). ɉɪɟɨɫɬɚɥɢ ɤɚɥɰɢʁɭɦ ɫɟ ɟɤɫɤɪɟɬɭʁɟ ɮɟɰɟɫɨɦ. ɉɭɬɟɦ ɫɟɤɪɟɬɨɜɚɧɢɯ ɝɚɫɬɪɨɢɧɬɟɫɬɢɧɚɥɧɢɯ ɫɨɤɨɜɚ ɢ ɫʂɭɲɬɟɧɢɯ ɢɜɢɱɧɢɯ ɦɭɤɨɡɧɢɯ ʄɟɥɢʁɚ, ɭ ɥɭɦɟɧ ɰɪɟɜɚ ɞɨɥɚɡɢ ʁɨɲ 250 ЦР ɤɚɥɰɢʁɭɦɚ ɧɚ ɞɚɧ. Ⱦɧɟɜɧɨ ɫɟ, ɡɧɚɱɢ, ɩɭɬɟɦ ɮɟɰɟɫɚ ɢɡɥɭɱɢ ɨɤɨ 90% (900 ЦР/ɞɚɧ) ɤɚɥɰɢʁɭɦɚ. Ɉɤɨ 10% (100 ЦР) ɧɚ ɞɚɧ ɭɧɟɬɨɝ ɤɚɥɰɢʁɭɦɚ ɫɟ ɟɤɫɤɪɟɬɭʁɟ ɭɪɢɧɨɦ. ɉɪɢɛɥɢɠɧɨ 90% ɤɚɥɰɢʁɭɦɚ ɫɟ ɪɟɫɨɪɛɭʁɟ ɭ ɩɪɨɤɫɢɦɚɥɧɢɦ ɬɭɛɭɥɢɦɚ, ɯɟɧɥɟʁɨɜɨʁ ɩɟɬʂɢ ɢ ɩɨɱɟɬɧɨɦ ɞɟɥɭ ɞɢɫɬɚɥɧɢɯ ɬɭɛɭɥɚ. Ɋɟɚɩɫɨɪɩɰɢʁɚ ɩɪɟɨɫɬɚɥɢɯ 10% ɫɟ ɨɞɜɢʁɚ ɭ ɡɚɜɪɲɧɨɦ ɞɟɥɭ ɞɢɫɬɚɥɧɢɯ ɬɭɛɭɥɚ ɢ ɭ ɩɨɱɟɬɧɨɦ ɞɟɥɭ ɫɚɛɢɪɧɢɯ ɰɟɜɱɢɰɚ ɢ ɡɚɜɢɫɢ ɨɞ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ʁɨɧɚ ɤɚɥɰɢʁɭɦɚ ɭ ɤɪɜɢ. Ʉɚɞɚ ʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɤɚɥɰɢʁɭɦɚ ɦɚɥɚ, ɨɜɚ ɪɟɚɩɫɨɪɩɰɢʁɚ ʁɟ ɜɟɥɢɤɚ, ɩɚ ɫɟ ɫɤɨɪɨ ɧɢɦɚɥɨ ɤɚɥɰɢʁɭɦɚ ɧɟ ɝɭɛɢ ɭɪɢɧɨɦ. ɑɚɤ ɢ ɧɟɡɧɚɬɧɨ ɩɨɜɟʄɚʃɟ ɤɚɥɰɢʁɭɦɚ ɭ ɤɪɜɢ, ɢɡɪɚɡɢɬɨ ɩɨɜɟʄɚɜɚ ʃɟɝɨɜɨ ɢɡɥɭɱɢɜɚʃɟ ɭɪɢɧɨɦ. ɇɚ ʃɟɝɨɜɭ ɚɩɫɨɪɩɰɢʁɭ ɭɬɢɱɭ ɰɟɥɭɥɨɡɚ ɯɪɚɧɟ, ɦɚɫɬ, ɲɟʄɟɪ, ɠɭɱɧɟ ɫɨɥɢ ɢ ɨɤɫɚɥɚɬɢ. Ⱦɢʁɟɬɚ ɛɨɝɚɬɚ ɰɟɥɭɥɨɡɨɦ ɫɦɚʃɭʁɟ ɚɩɫɨɪɩɰɢʁɭ. ɉɚɪɚɬɯɨɪɦɨɧ (ɊɌɇ) ʁɟ ɧɚʁɜɚɠɧɢʁɢ ɮɚɤɬɨɪ ɤɨʁɢ ɤɨɧɬɪɨɥɢɲɟ ɪɟɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɭ ɞɢɫɬɚɥɧɢɦ ɞɟɥɨɜɢɦɚ ɧɟɮɪɨɧɚ, ɩɚ ɫɚɦɢɦ ɬɢɦ ɢ ʃɟɝɨɜɭ ɟɤɫɤɪɟɰɢʁɭ (Weaver, et al. 1991). Ʉɨɫɬɢ ɫɭ ɫɚɱɢʃɟɧɟ ɨɞ ɬɜɪɞɨɝ ɨɪɝɚɧɫɤɨɝ ɦɚɬɪɢɤɫɚ ɤɨʁɢ ʁɟ ɢɡɪɚɡɢɬɨ ɨʁɚɱɚɧ ɧɚɫɥɚɝɚɦɚ ɤɚɥɰɢʁɭɦɨɜɢɯ ɫɨɥɢ. Ʉɪɢɫɬɚɥɢ ɫɨɥɢ ɤɨʁɟ ɫɟ ɬɚɥɨɠɟ ɭ ɨɪɝɚɧɫɤɨɦ ɦɚɬɪɢɤɫɭ ɤɨɫɬɢ ɫɚɫɬɨʁɟ ɫɟ ɭɝɥɚɜɧɨɦ ɨɞ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ. Ⱦɚ ɛɢ ɫɟ ɭ ɞɟɬɢʃɫɬɜɭ ɩɨɫɬɢɝɥɚ ɨɩɬɢɦɚɥɧɚ ɝɭɫɬɢɧɚ ɤɨɫɬɢʁɭ, ɧɟɨɩɯɨɞɧɨ ʁɟ ɞɚ ɩɨɫɬɨʁɢ ɤɨɧɬɢɧɭɢɪɚɧɨ ɩɨɡɢɬɢɜɚɧ ɛɢɥɚɧɫ ɤɚɥɰɢʁɭɦɚ. Ʉɚɥɰɢʁɭɦ ʁɟ ɧɚʁɜɚɠɧɢʁɢ ɧɭɬɪɢʁɟɧɬ ɡɚ ɩɨɫɬɢɡɚʃɟ ɤɜɚɥɢɬɟɬɧɟ ɤɨɲɬɚɧɟ ɦɚɫɟ. ȼɟɥɢɤɢ ɛɪɨʁ ɫɬɭɞɢʁɚ ɩɨɬɜɪђɭʁɟ ɩɨɡɢɬɢɜɧɭ ɤɨɪɟɥɚɰɢʁɭ ɢɡɦɟђɭ ɢɫɯɪɚɧɟ ɛɨɝɚɬɟ ɤɚɥɰɢʁɭɦɨɦ ɢ ɫɤɟɥɟɬɧɟ ɦɚɫɟ, ɢ ɭɝɥɚɜɧɨɦ ʁɟ ɜɟʄɢɧɚ ɢɫɬɪɚɠɢɜɚɱɚ ɫɚɝɥɚɫɧɚ ɞɚ ʁɟ ɟɮɟɤɚɬ ɤɚɥɰɢʁɭɦɚ ɡɧɚɱɚʁɧɢʁɢ ɭ ɞɨɛɚ ɩɪɟ ɩɭɛɟɪɬɟɬɚ. Ɂɚɬɨ ɫɭ ɤɚɦɩɚʃɟ ɭ ɫɜɟɬɭ ɞɚɧɚɫ ɮɨɤɭɫɢɪɚɧɟ ɧɚ ɚɞɟɤɜɚɬɧɭ ɢɫɯɪɚɧɭ ɛɨɝɚɬɭ ɤɚɥɰɢʁɭɦɨɦ ɞɟɰɟ ɢ ɚɞɨɥɟɫɰɟɧɚɬɚ, ɧɚɪɨɱɢɬɨ ɞɟɜɨʁɱɢɰɚ ɭ ɪɚɧɨɦ ɭɡɪɚɫɬɭ (Ⱥɦɟɪɢɱɤɚ ɧɚɰɢɨɧɚɥɧɚ Ɏɨɧɞɚɰɢʁɚ ɡɚ ɨɫɬɟɨɩɨɪɨɡɭ, 2001), ɢ Ʉɨɦɢɫɢʁɚ ɡɚ ɥɟɤɨɜɟ ɢ ɯɪɚɧɭ (1996). 21 ɉɪɟɩɨɪɭɱɟɧɟ ɞɧɟɜɧɟ ɩɨɬɪɟɛɟ ɭ ɤɚɥɰɢʁɭɦɭ ɡɚɜɢɫɟ ɨɞ ɭɡɪɚɫɬɚ ɢ ɮɢɡɢɨɥɨɲɤɨɝ ɫɬɚʃɚ ɨɫɨɛɟ (ɬɪɭɞɧɨʄɚ ɢ ɞɨʁɟʃɟ ɡɚɯɬɟɜɚʁɭ ɞɨɞɚɬɧɟ ɤɨɥɢɱɢɧɟ). Ⱦɚ ɛɢ ɫɟ ɫɚɱɭɜɚɥɨ ɡɞɪɚɜʂɟ ɤɨɫɬɢʁɭ ɞɧɟɜɧɟ ɩɨɬɪɟɛɟ ɭ ɤɚɥɰɢʁɭɦɭ ɫɟ ɦɨɝɭ ɨɛɟɡɛɟɞɢɬɢ ɫɚ ɞɜɟ ɞɨ ɱɟɬɢɪɢ ɩɨɪɰɢʁɟ ɦɥɟɤɚ ɢɥɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ, ɤɚɨ ɢ ɯɪɚɧɨɦ ɨɛɨɝɚʄɟɧɨɦ ɤɚɥɰɢʁɭɦɨɦ. Ɂɚɬɨ ʁɟ ɧɟɨɩɯɨɞɧɨ ɩɪɟɜɟɧɰɢʁɭ ɨɫɬɟɨɩɨɪɨɡɟ ɤɨʁɚ ʁɟ ɱɟɫɬɚ ɭ ɫɬɚɪɢʁɢɯ ɨɫɨɛɚ ɡɚɩɨɱɟɬɢ ɜɟʄ ɭ ɩɟɪɢɨɞɭ ɧɚʁɢɧɬɟɧɡɢɜɧɢʁɟɝ ɪɚɡɜɨʁɚ ɫɤɟɥɟɬɚ, ɞɚ ɛɢ ɫɟ ɞɨɫɬɢɝɚɨ ɲɬɨ ɜɢɲɢ ɤɨɲɬɚɧɢ ɦɚɤɫɢɦɭɦ ɤɨʁɢ ɩɪɟɞɫɬɚɜʂɚ "ɪɟɡɟɪɜɭ ɡɚ ɛɭɞɭʄɧɨɫɬ". ȼɢɲɟ ɨɞ 99% ɤɚɥɰɢʁɭɦɚ ɢ 80-85% ɮɨɫɮɨɪɚ ʂɭɞɫɤɨɝ ɨɪɝɚɧɢɡɦɚ ɡɚɫɬɭɩʂɟɧɨ ʁɟ ɭ ɤɨɫɬɢɦɚ, ɚɥɢ ɨɜɢ ɟɥɟɦɟɧɬɢ ɢɦɚʁɭ ɢ ɞɪɭɝɟ ɜɚɠɧɟ ɮɭɧɤɰɢʁɟ ɭ ɨɪɝɚɧɢɡɦɭ. ɇɚʁɜɟʄɢ ɞɟɨ ɩɪɟɨɫɬɚɥɟ ɤɨɥɢɱɢɧɟ ɤɚɥɰɢʁɭɦɚ ɧɚɥɚɡɢ ɫɟ ɭ ɩɥɚɡɦɢ. ɂɚɤɨ ʁɟ ɤɨɥɢɱɢɧɚ ɤɚɥɰɢʁɭɦɚ ɭ ɩɥɚɡɦɢ ɪɟɥɚɬɢɜɧɨ ɦɚɥɚ ɭ ɨɞɧɨɫɭ ɧɚ ʃɟɝɨɜɭ ɤɨɥɢɱɢɧɭ ɭ ɤɨɫɬɢɦɚ, ɢɩɚɤ ʁɟ ʁɚɤɨ ɜɚɠɧɚ ɡɚ ɪɟɝɭɥɚɰɢʁɭ ɜɟɥɢɤɨɝ ɛɪɨʁɚ ɚɤɬɢɜɧɨɫɬɢ. ɫɬɪɭɤɬɭɪɧɚ (ɫɚɫɬɚɜɧɢ ʁɟ ɞɟɨ ɤɨɫɬɢ, ɯɪɫɤɚɜɢɰɟ, ɡɭɛɧɟ ɝɥɟђɢ), ɟɧɡɢɦɫɤɚ (ɤɨɟɧɡɢɦ-ɮɚɤɬɨɪɚ ɤɨɚɝɭɥɚɰɢʁɟ ɤɪɜɢ), ɧɟɭɪɨɦɭɫɤɭɥɚɪɧɚ (ɤɨɧɬɪɨɥɢɲɟ ɟɤɫɰɢɬɚɛɢɥɧɨɫɬ, ɢɧɢɰɢɪɚ ɤɨɬɪɚɤɰɢʁɟ, ɨɫɥɨɛɚђɚ ɧɟɭɪɨɬɪɚɧɫɦɢɬɟɪɟ), ɯɨɪɦɨɧɫɤɚ (ɮɭɧɤɰɢʁɚ ɢɧɬɪɚɰɟɥɭɥɚɪɧɨɝ ɫɟɤɭɧɞɚɪɧɨɝ ɝɥɚɫɧɢɤɚ). ɇɟɨɪɝɚɧɫɤɢ ɮɨɫɮɚɬ (ɊɈ4-) Ɏɨɫɮɨɪ ʁɟ ɭɡ ɤɚɥɰɢʁɭɦ ɜɚɠɚɧ ɡɚ ɢɡɝɪɚɞʃɭ ɤɨɫɬɢʁɭ, ɤɚɨ ɢ ɭ ɚɤɬɢɜɚɰɢʁɢ ɦɧɨɝɢɯ ɦɟɬɚɛɨɥɢɱɤɢɯ ɩɭɬɟɜɚ. Њɟɝɨɜɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɭ ɫɟɪɭɦɭ ʁɟ ɩɨɞ ɞɢɪɟɤɬɧɢɦ ɭɬɢɰɚʁɟɦ ɩɚɪɚɬɢɪɟɨɢɞɧɢɯ ɠɥɟɡɞɚ, ɢɫɯɪɚɧɟ, ɚɩɫɨɪɩɰɢʁɟ ɭ ɨɪɝɚɧɢɦɚ ɡɚ ɜɚɪɟʃɟ, ɮɭɧɤɰɢʁɟ ɛɭɛɪɟɝɚ ɢ ɦɟɬɚɛɨɥɢɡɦɚ ɤɨɫɬɢʁɭ. Ɏɨɫɮɨɪ ɫɟ, ɨɫɢɦ ɭ ɤɨɲɬɚɧɨɦ ɬɤɢɜɭ, ɧɚɥɚɡɢ ɢ ɭ ɩɥɚɡɦɢ, ɭ ɨɛɥɢɤɭ ɨɪɝɚɧɫɤɨɝ ɢ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ, ɭ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 1,4-2,1 mmol/L ɭ ɞɟɰɟ. ɂɦɚ ɝɚ ɢ ɭ ʄɟɥɢʁɚɦɚ. ɍ ʄɟɥɢʁɚɦɚ ɫɟ ɮɨɫɮɨɪ ɧɚɥɚɡɢ ɭ ɨɛɥɢɤɭ ɫɥɨɛɨɞɧɨɝ ɮɨɫɮɚɬɧɨɝ ʁɨɧɚ ɢ ɭ ɫɚɫɬɚɜɭ ɧɭɤɥɟɢɧɫɤɢɯ ɤɢɫɟɥɢɧɚ, ɧɭɤɥɟɨɬɢɞɚ, ɮɨɫɮɨɥɢɩɢɞɚ ɢ ɞɪɭɝɢɯ ʁɟɞɢʃɟʃɚ. Ɏɨɫɮɨɪ ɢɦɚ ɡɧɚɱɚʁɧɭ ɭɥɨɝɭ ɭ ɩɪɨɰɟɫɭ ɨɤɨɲɬɚɜɚʃɚ, ɫɚɫɬɚɜɧɢ ʁɟ ɞɟɨ ɧɭɤɥɟɢɧɫɤɢɯ ɤɢɫɟɥɢɧɚ, ɧɭɤɥɟɨɬɢɞɚ, ɦɚɤɪɨɟɧɟɪɝɟɬɫɤɢɯ ʁɟɞɢʃɟʃɚ (ɚɞɟɧɨɡɢɧ ɬɪɢɮɨɫɮɚɬ - ȺɌɊ, ɝɭɚɧɨɡɢɧ ɬɪɢɮɨɫɮɚɬ - GTP), ɤɨʁɚ ɭɱɟɫɬɜɭʁɭ ɭ ɞɟɩɨɧɨɜɚʃɭ ɢ ɩɪɟɧɨɫɭ ɟɧɟɪɝɢʁɟ, ɭɱɟɫɬɜɭʁɟ ɭ ɪɟɚɤɰɢʁɚɦɚ ɮɨɫɮɨɪɢɥɚɰɢʁɟ. ɋɚɫɬɚɜɧɢ ʁɟ ɞɟɨ ɤɨɟɧɡɢɦɚ ɜɢɬɚɦɢɧɫɤɟ ɩɪɢɪɨɞɟ, ɝɥɚɜɧɢ ɚɧʁɨɧ ɢɧɬɪɚɰɟɥɭɥɚɪɧɟ ɬɟɱɧɨɫɬɢ, ɭɥɚɡɢ ɭ ɫɚɫɬɚɜ ɮɨɫɮɚɬɧɨɝ ɩɭɮɟɪɚ. Ɉɞɪɟђɢɜɚʃɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɚɧɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ ʁɟ ɜɚɠɚɧ ɩɨɤɚɡɚɬɟʂ ɤɨɲɬɚɧɟ ɢɡɝɪɚɞʃɟ, ɨɞɧɨɫɧɨ ɪɚɡɝɪɚɞʃɟ. ɉɨɪɟɦɟʄɚʁ ɦɟɬɚɛɨɥɢɡɦɚ ɮɨɫɮɚɬɚ ɫɟ ɨɝɥɟɞɚ ɭ ɫɦɚʃɟʃɭ ɢɥɢ ɩɨɜɟʄɚʃɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɮɨɫɮɚɬɚ, ɲɬɨ ɞɨɜɨɞɢ ɞɨ ɯɢɩɨɮɨɫɮɚɬɟɦɢʁɟ ɢɥɢ ɯɢɩɟɪɮɨɫɮɚɬɟɦɢʁɟ. 22 ɏɢɩɨɮɨɫɮɚɬɟɦɢʁɚ ɩɪɟɞɫɬɚɜʂɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ ɢɫɩɨɞ ɞɨʃɟ ɝɪɚɧɢɰɟ ɪɟɮɟɪɟɧɬɧɨɝ ɢɧɬɟɪɜɚɥɚ ɤɨʁɢ ʁɟ ɨɛɢɱɧɨ < 0,81 ЦЦШХ/L, К ʁɚɜʂɚ ɫɟ ɧɚʁɱɟɲʄɟ ɭ ɯɨɫɩɢɬɚɥɢɡɨɜɚɧɢɯ ɛɨɥɟɫɧɢɤɚ (ШФШ 2%) (Brunelli and Goldfarb, 2007). Ʉɨɞ ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɩɪɢɦɚɪɧɢɦ ɢɥɢ ɫɟɤɭɧɞɚɪɧɢɦ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɨɦ, ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɫɟɤɪɟɰɢʁɟ PTH, ɲɬɨ ɫɦɚʃɭʁɟ ɫɩɨɫɨɛɧɨɫɬ ɛɭɛɪɟɝɚ ɞɚ ɡɚɞɪɠɚɜɚ ɮɨɫɮɚɬɟ ɢ ɪɟɡɭɥɬɭʁɟ ɝɭɛɢɬɤɨɦ ɮɨɫɮɚɬɚ (Moe, 2008). ɉɨɜɢɲɟɧɟ ɜɪɟɞɧɨɫɬɢ ɮɨɫɮɨɪɚ ɭ ɫɟɪɭɦɭ ɧɚɥɚɡɢɦɨ ɤɨɞ ɉɟџɟɬɨɜɟ ɛɨɥɟɫɬɢ, ɧɟɤɢɯ ɦɚɥɢɝɧɢɯ ɨɛɨʂɟʃɚ ɢ ɤɨɞ ɩɚɰɢʁɟɧɚɬɚ ɤɨɞ ɤɨʁɢɯ ɡɚɪɚɫɬɚʁɭ ɤɨɫɬɢ. ɉɨɜɢɲɟɧɟ ɜɪɟɞɧɨɫɬɢ ɫɟ ʁɚɜʂɚʁɭ ɢ ɤɨɞ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɛɭɛɪɟɝɚ, ɯɢɩɨɩɚɪɚɬɢɪɟɨɡɟ ɢ ɯɢɩɟɪɜɢɬɚɦɢɧɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɤɚɨ ɢ ɭɫɥɟɞ ɭɡɢɦɚʃɚ ɯɪɚɧɟ ɫɚ ɦɧɨɝɨ ɤɚɥɰɢʁɭɦɚ ɭ ɞɟɬɢʃɫɬɜɭ (Moe, 2008). Ⱥɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ (ȺLЈ) Ⱥɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ (ȺLP) ʁɟ ɧɟɫɩɢɰɢɮɢɱɧɚ ɮɨɫɮɨɦɨɧɨɟɫɬɟɪɚɡɚ ɤɨʁɚ ɭ ɛɚɡɧɨʁ ɫɪɟɞɢɧɢ ɭɡ ɭɱɟɲʄɟ ɦɨɥɟɤɭɥɚ ɜɨɞɟ ɪɚɡɥɚɠɟ ɦɨɧɨɟɫɬɪɟ ɮɨɫɮɨɪɧɟ ɤɢɫɟɥɢɧɟ, ɭɡ ɨɫɥɨɛɚђɚʃɟ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ. ɋɟɪɭɦ, ɨɞɧɨɫɧɨ ɤɪɜɧɚ ɩɥɚɡɦɚ ɡɞɪɚɜɢɯ ɨɫɨɛɚ ɭɝɥɚɜɧɨɦ ɫɚɞɪɠɢ ȺLP ɤɨʁɚ ɩɪɢɩɚɞɚ ɬɤɢɜɧɨ ɧɟɫɩɟɰɢɮɢɱɧɨɦ L/K/B (LТvОr/ФТНЧОв/ЛШЧО) ɬɢɩɭ, ɚ ɩɨɬɢɱɟ ɢɡ ʁɟɬɪɟ ɢ ɤɨɫɬɢ. ȿɧɡɢɦ ɢɡ ʁɟɬɪɟ ɱɢɧɢ 60% ɚɤɬɢɜɧɨɫɬɢ ALP ɭ ɫɟɪɭɦɭ ɡɞɪɚɜɢɯ ɨɫɨɛɚ (KШrКćОvТć, 2000). Ⱥɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ ɭ ɫɟɪɭɦɭ ɡɞɪɚɜɢɯ ɨɞɪɚɫɥɢɯ ɨɫɨɛɚ ɭɝɥɚɜɧɨɦ ɩɨɬɢɱɟ ɢɡ ʁɟɬɪɟ, ɚ ɭ ɫɟɪɭɦɭ ɞɟɰɟ ɢ ɢɡ ɤɨɫɬɢʁɭ. Ɍɨɤɨɦ ɪɚɫɬɚ ɢ ɪɚɡɜɨʁɚ, ɞɨɥɚɡɢ ɞɨ ɢɧɬɟɧɡɢɜɧɢɯ ɩɪɨɦɟɧɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɤɨʁɟ ɫɭ ɩɨɫɥɟɞɢɰɚ ɡɧɚɱɚʁɧɢɯ ɯɨɪɦɨɧɫɤɢɯ ɩɪɨɦɟɧɚ ɜɟʄɟɝ ɛɪɨʁɚ ɯɨɪɦɨɧɚ, ɤɨʁɢ ɫɜɨʁɢɦ ɞɟɥɨɜɚʃɟɦ ɧɚ ɰɢʂɧɚ ɬɤɢɜɚ ɢ ɨɪɝɚɧɟ ɢ ɦɟђɭɫɨɛɧɢɦ ɢɧɬɟɪɚɤɰɢʁɚɦɚ ɭɫɥɨɜʂɚɜɚʁɭ ɦɧɨɲɬɜɨ ɛɢɨɯɭɦɨɪɚɥɧɢɯ ɢɡɦɟɧɚ, ɫɬɜɚɪɚʁɭʄɢ ɫɜɨʁɟɜɪɫɬɚɧ ɩɪɨɛɥɟɦ ɭ ɢɧɬɟɪɩɪɟɬɚɰɢʁɢ ɛɢɨɯɟɦɢʁɫɤɢɯ ɪɟɡɭɥɬɚɬɚ ɭ ɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɩɨɩɭɥɚɰɢʁɢ. Ʉɨɞ ɞɟɰɟ ɭ ɪɚɡɜɨʁɭ, ɜɪɟɞɧɨɫɬ ɨɜɨɝ ɩɚɪɚɦɟɬɪɚ ʁɟ ɩɨɜɢɲɟɧɚ. ɇɚʁɡɧɚɱɚʁɧɢʁɟ ɩɪɨɦɟɧɟ ɫɭ ɢɧɬɟɧɡɢɜɚɧ ɦɟɬɚɛɨɥɢɱɤɢ ɨɛɪɬ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɨɪɚ ɭ ɫɦɢɫɥɭ ʃɢɯɨɜɟ ɦɨɛɢɥɢɡɚɰɢʁɟ ɢ ɞɟɩɨɧɨɜɚʃɚ ɭ ɤɨɲɬɚɧɨɦ ɬɤɢɜɭ, ɭɡ ɢɡɦɟɧɟ ɚɤɬɢɜɧɨɫɬɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɤɚɨ ɩɨɫɥɟɞɢɰɟ ɢɡɪɚɠɟɧɟ ɨɫɬɟɨɛɥɚɫɬɧɟ ɚɤɬɢɜɧɨɫɬɢ (De Kievet, et al. 1986). ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ɨɛɟɡɛɟђɭʁɟ ɤɨɧɬɪɨɥɭ ɟɤɫɬɪɚɰɟɥɭɥɚɪɧɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ʁɨɧɚ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ, ɬɚɤɨ ɲɬɨ ɪɟɝɭɥɢɲɟ ɪɟɚɩɫɨɪɩɰɢʁɭ ɧɚ ɧɢɜɨɭ 23 ɰɪɟɜɚ, ɟɤɫɤɪɟɰɢʁɭ ɩɭɬɟɦ ɛɭɛɪɟɝɚ ɢ ɪɚɡɦɟɧɭ ɨɜɢɯ ʁɨɧɚ ɢɡɦɟђɭ ɟɤɫɬɪɚɰɟɥɭɥɚɪɧɟ ɬɟɱɧɨɫɬɢ ɢ ɤɨɫɬɢ. Ⱦɟɥɨɜɚʃɟ ɊɌɇ ɧɚ ɤɨɫɬɢ ɫɟ ɨɞɜɢʁɚ ɧɚ ɞɜɚ ɧɚɱɢɧɚ. ɉɪɜɢ ɧɚɱɢɧ ʁɟ ʁɚɤɨ ɛɪɡ, ɨɞɜɢʁɚ ɫɟ ɡɚ ɧɟɤɨɥɢɤɨ ɦɢɧɭɬɚ ɢ ɩɨɜɟʄɚɜɚ ɫɟ ɩɪɨɝɪɟɫɢɜɧɨ ɡɚ ɧɟɤɨɥɢɤɨ ɫɚɬɢ, ɚ ɩɨɫɥɟɞɢɰɚ ʁɟ ɚɤɬɢɜɚɰɢʁɟ ɜɟʄ ɩɪɢɫɭɬɧɢɯ ɨɫɬɟɨɰɢɬɚ ɤɨʁɢ ɢɡɚɡɢɜɚʁɭ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ. Ⱦɪɭɝɚ ɮɚɡɚ ʁɟ ɦɧɨɝɨ ɫɩɨɪɢʁɚ. Ɍɚɞɚ ɞɨɥɚɡɢ ɞɨ ɩɪɨɥɢɮɟɪɚɰɢʁɟ ɨɫɬɟɨɤɥɚɫɬɚ, ɩɪɢ ɱɟɦɭ ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚɧɟ ɨɫɬɟɨɤɥɚɫɬɧɟ ɪɟɫɨɪɩɰɢʁɟ ɫɚɦɟ ɤɨɫɬɢ, ɚ ɧɟ ɫɚɦɨ ɚɩɫɨɪɩɰɢʁɚ ɫɨɥɢ ɤɚɥɰɢʁɭɦ-ɮɨɫɮɚɬɚ. ȿɮɟɤɚɬ ɫɟ ɩɨɫɬɢɠɟ ɬɟɤ ɧɚɤɨɧ ɧɟɤɨɥɢɤɨ ɞɚɧɚ, ɱɚɤ ɢ ɧɟɞɟʂɚ. ɑɚɤ ɢ ɧɚʁɦɚʃɟ ɫɧɢɠɟʃɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ʁɨɧɚ ɤɚɥɰɢʁɭɦɚ ɭ ɟɤɫɬɪɚʄɟɥɢʁɫɤɨʁ ɬɟɱɧɨɫɬɢ, ɭ ɬɨɤɭ ɧɟɤɨɥɢɤɨ ɦɢɧɭɬɚ, ɞɨɜɨɞɟ ɞɨ ɩɨɜɟʄɚɧɟ ɫɟɤɪɟɰɢʁɟ ɩɚɪɚɬɢɪɟɨɢɞɧɢɯ ɠɥɟɡɞɚ. ɍ ɫɥɭɱɚʁɟɜɢɦɚ ɤɚɞɚ ʁɟ ɧɢɫɤɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɤɚɥɰɢʁɭɦɚ ɞɭɠɟ ɢɫɩɨʂɟɧɚ, ɠɥɟɡɞɟ ɯɢɩɟɪɬɪɨɮɢɲɭ, ɧɟɤɚɞ ɢ ɩɟɬɨɫɬɪɭɤɨ, ɢ ɜɢɲɟ. Ɍɨ ʁɟ ɫɥɭɱɚʁ ɤɨɞ ɪɚɯɢɬɢɫɚ, ɢɚɤɨ ʁɟ ɧɢɜɨ ɤɚɥɰɢʁɭɦɚ ɦɚɥɨ ɫɧɢɠɟɧ. Ⱦɨ ɯɢɩɟɪɬɪɨɮɢʁɟ ɠɥɟɡɞɚ ɞɨɥɚɡɢ ɢ ɭ ɩɟɪɢɨɞɭ ɬɪɭɞɧɨʄɟ, ɚ ɭ ɬɨɤɭ ɥɚɤɬɚɰɢʁɟ ɫɟ ɩɚɪɚɬɢɪɟɨɢɞɧɟ ɠɥɟɡɞɟ ʁɚɤɨ ɩɨɜɟʄɚɜɚʁɭ (ɯɢɩɟɪɬɪɨɮɢɲɭ), ʁɟɪ ɫɟ ɭ ɨɜɨɦ ɫɬɚɞɢʁɭɦɭ ɤɚɥɰɢʁɭɦ ɤɨɪɢɫɬɢ ɡɚ ɫɬɜɚɪɚʃɟ ɦɥɟɤɚ. ȼɟɥɢɱɢɧɚ ɩɚɪɚɬɢɪɟɨɢɞɧɢɯ ɠɥɟɡɞɚ ɫɟ ɫɦɚʃɭʁɟ ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɤɚɞɚ ɫɟ ɢɫɯɪɚɧɨɦ ɭɧɨɫɢ ɩɪɟɜɢɲɟ ɤɚɥɰɢʁɭɦɚ, ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɤɚɞɚ ʁɟ ɚɩɫɨɪɩɰɢʁɚ ɤɨɫɬɢʁɭ ɢɡɚɡɜɚɧɚ ɧɟɤɢɦ ɞɪɭɝɢɦ ɮɚɤɬɨɪɢɦɚ, ɚ ɧɟ ɊɌɇ (ɤɚɨ ɲɬɨ ɫɭ ɨɛɨʂɟʃɚ ɤɨɫɬɢʁɭ). ɂɚɤɨ ʁɟ ɞɨʃɚ ɝɪɚɧɢɰɚ 25(OH)D ɭ ɫɟɪɭɦɭ ɤɨʁɚ ɭɤɚɡɭʁɟ ɧɚ ɞɟɮɢɰɢɬ (ɧɟɞɨɫɬɚɬɚɤ) ɜɢɬɚɦɢɧɚ Ⱦ 10 ЧР/ЦХ, ɤɚɨ ɲɬɨ ʁɟ ɞɨɤɚɡɚɧɨ ɨɞ ɦɧɨɝɨɛɪɨʁɧɢɯ ɚɭɬɨɪК (Holick, AAP, IOM, SZO), ɩɨɫɬɨʁɟ ʁɚɤɢ ɞɨɤɚɡɢ ɞɚ ɭɫɥɟɞ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɭ ɫɟɪɭɦɭ ɢɫɩɨɞ 20 ЧР/ЦХ ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ ɭ ɫɟɪɭɦɭ, ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ (Holick, 2002; Malabanan, et al. 1998). ɋɚɦɢɦ ɬɢɦ ɫɟ ɞɨɧɨɫɢ ɡɚɤʂɭɱɚɤ ɞɚ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ɭ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25(OH)D<20 ЧР/ЦХ ɧɟɞɨɜɨʂɚɧ, ɨɞɧɨɫɧɨ ɩɨɤɚɡɭʁɟ ɦɚʃɚɤ ɭ ɨɪɝɚɧɢɡɦɭ. ɍ ɨɜɢɦ ɫɥɭɱɚʁɟɜɢɦɚ ɤɥɢɧɢɱɤɢ ɡɧɚɰɢ ɫɭ ɢɡɭɡɟɬɧɨ ɫɭɩɬɢɥɧɢ ɢɥɢ ɧɟɫɩɟɰɢɮɢɱɧɢ. Ʉɚɞɚ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɫɦɚʃɟɧɟ, ɞɨɥɚɡɢ ɞɨ ɫɦɚʃɟɧɟ ɟɮɢɤɚɫɧɨɫɬɢ ɢɧɬɟɫɬɢɧɚɥɧɟ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ, ɢ ɩɨɫɥɟɞɢɱɧɨɝ ɩɨɜɟʄɚɧɨɝ ɥɭɱɟʃɚ ɊɌɇ. ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ɩɨɞɫɬɢɱɟ ɛɭɛɪɟɝɟ ɞɚ ɩɨʁɚɱɚɧɨ ɩɪɨɢɡɜɨɞɟ 1,25(Ɉɇ)2D ɢ ɧɚ ɬɚʁ ɧɚɱɢɧ ɫɟ ɩɨɜɟʄɚɜɚ ɪɟɚɩɫɨɪɩɰɢʁɚ ɤɚɥɰɢʁɭɦɚ ɢɡ ɤɨɫɬɢʁɭ. ɉɨɜɟʄɚʃɟ ɛɪɨʁɚ ɨɫɬɟɨɤɥɚɫɬɚ ɢ ʃɢɯɨɜɟ ɚɤɬɢɜɧɨɫɬɢ ɦɨɝɭ ɭ ɞɟɰɟ ɞɚ ɞɨɜɨɞɟ ɞɨ ɩɨɝɨɪɲɚʃɚ ɨɫɬɟɨɦɚɥɚɰɢʁɟ ɢ ɨɫɬɟɨɩɨɪɨɡɟ. Ⱦɚɜɚʃɟ ɦɚɥɢɯ ɤɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɦɚɠɟ ɭ ɤɚɥɰɢɮɢɤɚɰɢʁɢ ɤɨɫɬɢ. Ɉɧ ɩɨɜɟʄɚɜɚ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɢɡ ɰɪɟɜɚ. ɂ ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɤɚɞ ɨɜɚɤɜɨɝ ɩɨɜɟʄɚʃɚ ɚɩɫɨɪɩɰɢʁɟ ɧɟɦɚ, ɨɧ ɭɛɪɡɚɜɚ ɦɢɧɟɪɚɥɢɡɚɰɢʁɭ ɤɨɫɬɢ. ȼɟɪɨɜɚɬɧɨ ɢ ɨɜɞɟ 24 ɡɧɚɱɚʁɧɭ ɭɥɨɝɭ ɢɦɚ 1,25(Ɉɇ)2D ɩɨɞɫɬɢɱɭʄɢ ɬɪɚɧɫɩɨɪɬ ɤɚɥɰɢʁɭɦɨɜɢɯ ʁɨɧɚ ɤɪɨɡ ʄɟɥɢʁɫɤɟ ɦɟɦɛɪɚɧɟ. ɋɚɞɚ ɫɟ ɨɜɚʁ ɩɪɨɰɟɫ ɨɞɜɢʁɚ ɭ ɫɭɩɪɨɬɧɨɦ ɫɦɟɪɭ, ɤɪɨɡ ɦɟɦɛɪɚɧɟ ɨɫɬɟɨɛɥɚɫɬɚ ɢ ɨɫɬɟɨɰɢɬɚ. Ɍɪɟɧɭɬɧɟ ɫɦɟɪɧɢɰɟ ɤɨɪɢɫɬɟ ɪɚɡɥɢɱɢɬɟ ɞɟɮɢɧɢɰɢʁɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɨɫɧɨɜɭ ɫɟɪɭɦɫɤɨɝ 25(OH)D, ɲɬɨ ɡɧɚɬɧɨ ɤɨɦɩɥɢɤɭʁɟ ɤɥɢɧɢɱɤɭ ɨɞɥɭɤɭ ɨ ɞɨɡɚɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɟɜɟɧɰɢʁɢ ɢ ɥɟɱɟʃɭ. ɋɬɭɞɢʁɚ ɭ ɚɩɪɢɥɭ 2013. (Atapattu, et al. 2013) ɢɫɩɢɬɢɜɚɥɚ ʁɟ ɩɪɢɪɨɞɧɢ ɨɞɧɨɫ ɢɡɦɟђɭ ɫɟɪɭɦɫɤɨɝ 25(OH)D, ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ), ɤɚɥɰɢʁɭɦɚ, ɮɨɫɮɚɬɚ ɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɤɨɞ ɞɟɰɟ. ɂɫɩɢɬɢɜɚɧɨ ʁɟ 214 ɞɟɰɟ, ɚ ɤɨɞ 17 ɞɟɰɟ ʁɟ ɪɚɞɢɨɥɨɲɤɢ ɩɨɬɜɪђɟɧ ɪɚɯɢɬɢɫ ɭɫɥɟɞ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɍɩɨɪɟђɢɜɚɧɚ ʁɟ ɜɪɟɞɧɨɫɬ 25(OH)D ɭ ɫɟɪɭɦɭ ɭ ɞɟɰɟ ɫɚ ɩɪɨɦɟɧɚɦɚ ɭ ɤɨɫɬɢɦɚ. ɇɚʁɛɨʂɚ ɦɢɧɟɪɚɥɢɡɚɰɢʁɚ ʁɟ ɭɬɜɪђɟɧɚ ɭ ɞɟɰɟ ɫɚ ɧɢɜɨɨɦ 25(OH)D ɜɟʄɢɦ ɨɞ 13 (12-17 ЧР/ЦХ). Ⱦɟɰɚ ɫɚ ɡɧɚɰɢɦɚ ɪɚɯɢɬɢɫɚ ɧɚ ɤɨɫɬɢɦɚ ɫɭ ɫɜɚ ɢɦɚɥɚ ɜɪɟɞɧɨɫɬ 25(OH)D<13 ЧР/ЦХ, ɚ ɜɟʄɢɧɚ ʁɟ ɢɦɚɥɚ ɜɪɟɞɧɨɫɬ ɊɌɇ>50 pР/ЦХ. ɂɡ ɨɜɟ ɫɬɭɞɢʁɟ ɡɚɤʂɭɱɟɧɨ ʁɟ ɞɚ ʁɟ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɛɚɡɢ ɊɌɇ ɧɚʁɛɨʂɟ ɞɟɮɢɧɢɫɚɧ ɧɢɜɨɨɦ 25(OH)D<13 ЧР/ЦХ. Ɂɚɬɨ, ɫɦɚʃɟɧɨ ɫɧɚɛɞɟɜɚʃɟ ɤɚɥɰɢʁɭɦɨɦ ɱɟɫɬɨ ɤɨɟɝɡɢɫɬɢɪɚ ɫɚ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɦɨɠɟ ɞɚ ɢɡɚɡɨɜɟ ɧɭɬɪɢɬɢɜɧɢ ɪɚɯɢɬɢɫ, ɩɪɚɝ ɡɚ ɟɮɟɤɚɬ ɧɚ ɫɤɟɥɟɬ ɜɢɬɚɦɢɧɚ Ⱦ ɧɟ ɬɪɟɛɚ ɞɚ ɫɟ ɡɚɫɧɢɜɚ ɢɫɤʂɭɱɢɜɨ ɧɚ ɧɢɜɨɭ 25(OH)D ɭ ɫɟɪɭɦɭ. Ʉɨɞ ɞɟɰɟ, ɧɟɤɨɥɢɤɨ ɫɬɭɞɢʁɚ ʁɟ ɬɚɤɨђɟ ɩɨɤɚɡɚɥɨ ɢɧɜɟɪɡɧɢ ɨɞɧɨɫ ɢɡɦɟђɭ 25(OH)D ɢ ɊɌɇ (Gordon, et al. 2004; Outila, et al. 2001; Guillemant, et al. 1995; Guillemant, et al. 1999; El-Hajj Fuleihan, et al. 2001; Hill, et al. 2010; Marwaha, et al. 2005; Hill, et al. 2010). Ɇɟђɭɬɢɦ, ɧɟɦɚ ʁɚɫɚɧ ɤɨɧɫɟɧɡɭɫ ɡɚ ɞɟɮɢɧɢɫɚʃɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɨɫɧɨɜɭ ɨɜɢɯ ɫɬɭɞɢʁɚ. Ɂɚɬɨ, ɡɚɞɚɬɚɤ ɫɥɟɞɟʄɢɯ ɢɫɬɪɚɠɢɜɚʃɚ ɬɪɟɛɚ ɞɚ ɭɬɜɪɞɢ ɧɢɜɨ 25(OH)D ɭ ɫɟɪɭɦɭ ɩɪɢ ɤɨʁɨʁ ɊɌɇ ɢ ɨɫɬɚɥɢ ɛɢɨɯɟɦɢʁɫɤɢ ɦɚɪɤɟɪɢ ɩɨɱɢʃɭ ɞɚ ɧɚɪɭɲɚɜɚʁɭ ɦɢɧɟɪɚɥɢɡɚɰɢʁɭ ɤɨɫɬɢʁɭ. ɇɢɜɨɢ ɤɚɥɰɢʁɭɦɚ <2,2 ЦЦШХ/L, ɛɢɥɢ ɫɭ ɩɨɜɟɡɚɧɢ ɫɚ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ 25(OH)D ɭ ɫɟɪɭɦɭ ɢ ɩɨɜɟʄɚɧɢɦ ɧɢɜɨɨɦ ɊɌɇ (ɪ<0.001). ɋɥɢɱɧɨ ɬɨɦɟ, ɧɢɜɨ ɮɨɫɮɚɬɚ <1,1 ЦЦШХ/L ɛɢɨ ʁɟ ɩɨɜɟɡɚɧ ɫɚ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɋɚ (ɪ<0.001), ɮɨɫɮɚɬɚ (ɪ=0,004), ɚ ɜɢɫɨɤɢ ɧɢɜɨɢ ȺLP (ɪ<0,001). ɍ ɧɚʁɜɟʄɨʁ ɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɫɬɭɞɢʁɢ ɞɨ ɞɚɧɚɫ (Marwaha, et al. 2005), ɜɪɟɞɧɨɫɬ ɊɌɇ ɭ ɫɟɪɭɦɭ ɩɨɱɟɥɚ ʁɟ ɞɚ ɪɚɫɬɟ ɩɪɢ ɧɢɜɨɭ 25(Ɉɇ)D <25 ЧЦШХ/L (<10 ЧР/ЦХ). Ⱦɨɛɪɨ ʁɟ ɩɨɡɧɚɬɨ ɞɚ ɭ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢɬɚɪɧɨɦ ɪɚɯɢɬɢɫɭ ɫɟ ɦɨɠɟ ɧɚʄɢ ɧɟɞɨɫɬɚɬɚɤ ɤɚɥɰɢʁɭɦɚ (ɋɚ) ɫɚ ɧɨɪɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɧɚ ʁɟɞɧɨɦ ɤɪɚʁɭ ɫɩɟɤɬɪɚ ɢ ɧɨɪɦɚɥɚɧ ɜɢɬɚɦɢɧ Ⱦ ɫɚ ɧɨɪɦɚɥɧɢɦ ɭɧɨɫɨɦ ɤɚɥɰɢʁɭɦɚ, ɧɚ ɞɪɭɝɨɦ ɤɪɚʁɭ (DeLucia, et al. 2003; Thacher, et al. 2006). ɋɚɦɢɦ ɬɢɦ ɫɟ ɡɚɤʂɭɱɭʁɟ ɞɚ ɩɪɚɝ ɡɚ ɪɚɯɢɬɢɫ ɧɟ ɦɨɠɟ ɞɚ ɫɟ ɡɚɫɧɢɜɚ ɧɚ ɢɡɨɥɨɜɚɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ. 25 Ɂɚ ɪɚɡɥɢɤɭ ɨɞ ɧɢɜɨɚ ɊɌɇ, ɧɢɜɨ ɋɚ, ɮɨɫɮɚɬɚ, ɚ ɧɚɪɨɱɢɬɨ ȺLP ɜɚɪɢɪɚʁɭ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɭɡɪɚɫɬɚ ɢ ɩɪɨɰɟɫɚ ɪɚɫɬɚ (Navoda, et al. 2013). Ɍɨɤɫɢɱɧɚ ɞɟјɫɬɜɚ ɩɪɢ ɩɪɟɤɨɦɟɪɧɨɦ ɭɧɨɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɉɪɢ ɫɭɩɥɟɦɟɧɬɚɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ, ɚ ɭ ɭɡɪɚɫɬɭ ɨɞɨʁɱɟɬɚ ɢ ɦɚɥɟ ɞɟɰɟ, ɩɪɨɮɢɥɚɤɬɢɱɤɟ ɞɨɡɟ, ɨɞɧɨɫɧɨ ɩɪɟɤɨɦɟɪɚɧ ɞɧɟɜɧɢ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ, ɦɨɠɟ ɞɚ ɞɟɥɭʁɟ ɬɨɤɫɢɱɧɨ ɢ ɞɚ ɩɪɨɭɡɪɨɤɭʁɟ ɯɢɩɟɪɤɚɥɰɢɟɦɢʁɭ, ɯɢɩɟɪɮɨɫɮɚɬɟɦɢʁɭ, ɩɪɟɤɨɦɟɪɧɭ ɫɭɩɪɟɫɢʁɭ ɥɭɱɟʃɚ ɉɌɏ, ɟɤɫɬɪɚɫɤɟɥɟɬɧɟ ɤɚɥɰɢɮɢɤɚɰɢʁɟ (ɛɭɛɪɟɡɢ, ɦɢɨɤɚɪɞ, ɡɚɥɢɫɰɢ, ɡɢɞ ɤɪɜɧɢɯ ɫɭɞɨɜɚ). ɍ ɬɢɦ ɫɥɭɱɚʁɟɜɢɦɚ ʁɚɜʂɚʁɭ ɫɟ ɫɢɦɩɬɨɦɢ, ɤɚɨ ɲɬɨ ɫɭ: ɦɭɤɚ, ɩɨɜɪɚʄɚʃɟ, ɝɭɛɢɬɚɤ ɚɩɟɬɢɬɚ, ɤɨɧɫɬɢɩɚɰɢʁɚ, ɨɩɲɬɚ ɫɥɚɛɨɫɬ ɢ ɝɭɛɢɬɚɤ ɬɟɥɟɫɧɟ ɬɟɠɢɧɟ, ɚɧɨɪɟɤɫɢʁɚ, ɦɟɧɬɚɥɧɢ ɩɨɪɟɦɟʄɚʁɢ, ɤɨɧɮɭɡɢʁɚ, ɫɪɱɚɧɚ ɚɪɢɬɦɢʁɚ. Ɂɧɚɰɢ ɢɧɬɨɤɫɢɤɚɰɢʁɟ ɫɟ ɢɫɩɨʂɚɜɚʁɭ ɩɨɫɥɟ ɧɟɤɨɥɢɤɨ ɦɟɫɟɰɢɢ (ɪɟђɟ ɧɟɤɨɥɢɤɨ ɧɟɞɟʂɚ) ɞɚɜɚʃɚ ɜɟɥɢɤɢɯ ɤɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɨɞ 40000 ɞɨ ɩɪɟɤɨ 300000 ʁɟɞɢɧɢɰɚ ɞɧɟɜɧɨ. ɇɟɤɚɞ ɫɟ ɢ ɩɨɫɥɟ ɦɚʃɟ ɞɨɡɟ ʁɚɜɟ ɡɧɚɰɢ ɢɧɬɨɤɫɢɤɚɰɢʁɟ. ɍ ɛɨɥɟɫɧɢɤɚ ɫɟ ʁɚɜʂɚʁɭ ɯɢɩɟɪɤɚɥɰɢɟɦɢʁɚ ɢ ɯɢɩɟɪɤɚɥɰɢɭɪɢʁɚ, ɡɚɬɢɦ ɩɨɥɢɭɪɢʁɚ, ɢ ɤɨɧɚɱɧɨ ɪɟɧɚɥɧɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ. Ɇɨɠɟ ɧɚɫɬɚɬɢ ɢ ɧɟɮɪɨɤɚɥɰɢɧɨɡɚ ɢ ɤɚɥɰɢɮɢɤɚɰɢʁɚ ɦɟɤɢɯ ɬɤɢɜɚ (Schwartz, 1989). ɒɬɟɬɧɟ ɩɨɫɥɟɞɢɰɟ ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɩɨɜɢɲɟɧɢɯ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɤɪɜɢ ɫɭ ɪɟɬɤɟ, ɨɫɢɦ ɤɚɞɚ ɜɪɟɞɧɨɫɬɢ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɩɨɫɬɚʁɭ ɜɟɨɦɚ ɩɨɜɢɲɟɧɟ (>100 ЧР/ЦХ) ɢ ɤɚɞɚ ɨɫɨɛɟ ɭɧɨɫɟ ɜɟɥɢɤɟ ɞɨɡɟ ɫɭɩɥɟɦɟɧɬɚ ɜɢɬɚɦɢɧɚ Ⱦ (Misra, et al. 2008). ɂɧɫɬɢɬɭɬ ɡɚ ɦɟɞɢɰɢɧɭ (IOM) ɫɦɚɬɪɚ ɞɚ ʁɟ ɩɨɞɧɨɲʂɢɜ ɧɚʁɜɢɲɢ ɞɧɟɜɧɢ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɨɞ 2500 IJ (63 µР) ɡɚ ɞɟɰɭ ɭɡɪɚɫɬɚ ɨɞ 1-3 ɝɨɞɢɧɟ, 3000 IJ (75 µР) ɞɟɰɭ ɭɡɪɚɫɬɚ ɨɞ 4-8 ɝɨɞɢɧɚ, ɚ 4000 IJ (100 µР) ɡɚ ɞɟɰɭ ɢɡɦɟђɭ 14 ɢ 18 ɝɨɞɢɧɚ (Ross, 2011). ȿɧɞɨɤɪɢɧɨ ɞɪɭɲɬɜɨ ɫɦɚɬɪɚ ɞɚ ʁɟ ɧɚʁɜɢɲɢ ɞɧɟɜɧɢ ɭɧɨɫ 4000 IJ (100 µР) ɭ ɫɜɢɦ ɫɬɚɪɨɫɧɢɦ ɝɪɭɩɚɦɚ ɭ ɞɟɬɢʃɫɬɜɭ (Holick, et al. 2011; Harel, et al. 2013). Ⱦɚ ɛɢ ɫɟ ɢɡɛɟɝɥɚ ɲɬɟɬɧɚ ɞɟʁɫɬɜɚ ɩɪɢ ɩɪɢɦɟɧɢ ɜɢɫɨɤɢɯ ɞɨɡɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɧɟɨɩɯɨɞɧɨ ʁɟ ɫɜɚɤɚ 2-3 ɦɟɫɟɰɚ ɩɪɚɬɢɬɢ ɧɢɜɨ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ. Ɍɟɪɚɩɢʁɭ ɬɪɟɛɚ ɩɪɟɤɢɧɭɬɢ ɚɤɨ ʁɟ ɧɢɜɨ ɤɚɥɰɢʁɭɦɚ > 2,54 ЦЦШХ/L, ɢ ɮɨɫɮɚɬɚ > 1,49 mmol/L (PОtrШЧТУОvТć, 2009; HШХТМФ, 2004; GКrТМТШЧ, Оt КХ. 2002; LКЦЛОrt, Оt КХ. 2002). Tɨɤɫɢɱɧɚ ɞɨɡɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɞɟɮɢɧɢɫɚɧɚ ʁɟ ɤɚɨ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ≥ 375 nmol/L, ɢɥɢ 150 ng/ml), ɤɨɞ ɞɟɰɟ ʁɟ ɪɟɬɤɚ. Ɇɟɪɟʃɟ ɧɢɜɨɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɞɨɜɨʂɧɨ ʁɟ ɪɚɞɢɬɢ ɧɚ ɲɟɫɬ ɦɟɫɟɰɢ (Vogiatzi, et al. 2014). 26 ɂɧɬɟɪɚɤɰɢјɟ ɫɚ ɥɟɤɨɜɢɦɚ Ɇɧɨɝɢ ɥɟɤɨɜɢ, ɤɚɨɲɬɨ ɫɭ: ɚɧɬɢɟɩɢɥɟɩɬɢɰɢ, ɚɧɬɚɰɢɞɢ, ɥɟɤɨɜɢ ɤɨʁɢ ɫɧɢɠɚɜɚʁɭ ɯɨɥɟɫɬɟɪɨɥ ɭ ɤɪɜɢ, ɤɨɪɬɢɤɨɫɬɟɪɨɢɞɢ ɢ ɚɧɬɢɤɨɚɝɭɥɚɧɫɢ ɦɨɝɭ ɞɚ ɭɦɚʃɟ ɚɩɫɨɪɩɰɢʁɭ, ɫɢɧɬɟɡɭ ɢ ɚɤɬɢɜɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɤ ɜɢɬɚɦɢɧ Ⱦ3 ɦɨɠɟ ɞɚ ɫɦɚʃɢ ɟɮɢɤɚɫɧɨɫɬ ɚɧɬɚɝɨɧɢɫɬɚ ɤɚɥɰɢʁɭɦɚ (Lips, 2006; Holick, 2005; Holick, 2004). ȼɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢјɟɧɰɢјɚ ɢ ɝɨјɚɡɧɨɫɬ ɭ ɞɟɰɟ Ƚɨʁɚɡɧɨɫɬ ɞɟɰɟ ʁɟ ʁɟɞɚɧ ɨɞ ɝɥɚɜɧɢɯ ɝɥɨɛɚɥɧɢɯ ɩɪɨɛɥɟɦɚ ɭ ɫɜɟɬɭ. ɋɢɫɬɟɦɚɬɫɤɚ ɚɧɚɥɢɡɚ 1769 ɢɡɜɟɲɬɚʁɚ, ɤɨʁɢ ɩɪɟɞɫɬɚɜʂɚʁɭ 188 ɡɟɦɚʂɚ, ɨɬɤɪɢɜɚ, ɞɚ ʁɟ ɭɱɟɫɬɚɥɨɫɬ ɞɟɰɟ ɫɚ ɩɪɟɤɨɦɟɪɧɨɦ ɬɟɠɢɧɨɦ ɢ ɝɨʁɚɡɧɟ ɞɟɰɟ ɩɨɪɚɫɬɚɨ ɡɚ ɨɤɨ 50% ɭ ɡɚɞʃɟ ɬɪɢ ɞɟɰɟɧɢʁɟ (Fleming, et al. 2014). ɉɪɨɰɟʃɭʁɟ ɫɟ ɞɚ ʁɟ ɨɤɨ 43 ɦɢɥɢɨɧɚ ɞɟɰɟ ɭ ɫɜɟɬɭ ɝɨʁɚɡɧɨ, ɚ 92 ɦɢɥɢɨɧɚ ɞɟɰɟ ɫɭ ɭ ɪɢɡɢɤɭ ɨɞ ɜɢɲɤɚ ɤɢɥɨɝɪɚɦɚ. Ⱥɤɨ ɫɟ ɨɜɚʁ ɬɪɟɧɞ ɧɚɫɬɚɜɢ, ɩɪɟɞɜɢђɚ ɫɟ ɞɚ ʄɟ ɭ ɫɜɟɬɭ ɛɢɬɢ ɞɨ 60 ɦɢɥɢɨɧɚ ɝɨʁɚɡɧɟ ɞɟɰɟ ɞɨ 2020. ɝɨɞɢɧɟ (Wang and Lim, 2012). Ƚɨʁɚɡɧɨɫɬ ɩɨɞɪɚɡɭɦɟɜɚ ɩɨɪɚɫɬ ɬɟɥɟɫɧɟ ɦɚɫɟ ɢɡɧɚɞ ɚɪɛɢɬɪɚɧɨ ɭɬɜɪђɟɧɟ ɜɪɟɞɧɨɫɬɢ ɤɨʁɚ ɭɡɢɦɚ ɭ ɨɛɡɢɪ ɩɨɥ, ɯɪɨɧɨɥɨɲɤɢ ɭɡɪɚɫɬ ɢ ɬɟɥɟɫɧɭ ɜɢɫɢɧɭ ɞɟɬɟɬɚ, ɚ ɤɨʁɢ ʁɟ ɭɫɥɨɜʂɟɧ ɩɪɟɤɨɦɟɪɧɢɦ ɧɚɤɭɩʂɚʃɟɦ ɦɚɫɧɨɝ ɬɤɢɜɚ ɭ ɨɪɝɚɧɢɡɦɭ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɝɨʁɚɡɧɨɫɬ ɭ ɞɟɬɢʃɫɬɜɭ ɫɭ ɤɥɚɫɢɮɢɤɨɜɚɧɢ ɤɚɨ ɟɩɢɞɟɦɢʁɚ ɲɢɪɨɦ ɫɜɟɬɚ. ɂ ʁɟɞɧɚ ɢ ɞɪɭɝɚ ɛɨɥɟɫɬ ɢɦɚʁɭ ɧɟɤɟ ɡɚʁɟɞɧɢɱɤɟ ɮɚɤɬɨɪɟ ɪɢɡɢɤɚ, ɭɤʂɭɱɭʁɭʄɢ ɥɨɲɭ ɢɫɯɪɚɧɭ ɢ ɧɟɚɤɬɢɜɧɨɫɬ. Ʉɥɢɧɢɱɤɟ ɫɬɭɞɢʁɟ ɩɨɤɚɡɭʁɭ ɞɚ ɫɭ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ɨɛɪɧɭɬɨ ɫɪɚɡɦɟɪɧɟ ɫɚ ɤɨɥɢɱɢɧɨɦ ɦɚɫɧɨɝ ɬɤɢɜɚ ɭ ɨɪɝɚɧɢɡɦɭ. Јɨɲ ɭɜɟɤ ɧɢʁɟ ɞɨɤɚɡɚɧɨ ɞɚ ɥɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɞɨɜɨɞɢ ɞɨ ɝɨʁɚɡɧɨɫɬɢ, ɢɥɢ ʁɟ ɩɨɫɥɟɞɢɰɚ ɝɨʁɚɡɧɨɫɬɢ. ɋɚɦɢɦ ɬɢɦ ʁɨɲ ɭɜɟɤ ɧɢʁɟ ʁɚɫɧɚ ɢɧɬɟɪɚɤɰɢʁɚ ɢɡɦɟђɭ ɜɢɲɤɚ ɦɚɫɧɨɝ ɬɤɢɜɚ ɢ ɚɤɬɢɜɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ. ȿɮɟɤɬɢ ɫɦɚʃɟɧɨɝ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɝɨʁɚɡɧɨɫɬɢ ɭ ɞɟɬɢʃɫɬɜɭ ɢɦɚʁɭ ɧɟɝɚɬɢɜɚɧ ɭɬɢɰɚʁ ɧɚ ɰɟɥɨɤɭɩɧɨ ɡɞɪɚɜʂɟ, ɭɤʂɭɱɭʁɭʄɢ ɢɧɫɭɥɢɧɫɤɭ ɪɟɡɢɫɬɟɧɰɢʁɭ, ɡɚɩɚʂɟʃɚ ɢ ɨɬɟɠɚɧɭ ɦɢɧɟɪɚɥɢɡɚɰɢʁɭ ɤɨɫɬɢ, ɤɚɨ ɢ ɩɨɜɟʄɚɧ ɪɢɡɢɤ ɨɞ ɤɚɫɧɢʁɟɝ ʁɚɜʂɚʃɚ ɞɢʁɚɛɟɬɟɫɚ ɬɢɩ 2, ɤɚɪɞɢɨɜɚɫɤɭɥɚɪɧɢɯ ɛɨɥɟɫɬɢ ɢ ɨɫɬɟɨɩɨɪɨɡɟ. ɍɱɟɫɬɚɥɨɫɬ ɯɢɩɨɜɢɬɚɦɢɧɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ ɢ ɚɞɨɥɟɫɰɟɧɚɬɚ ɭ ɫɜɟɬɭ ʁɟ ɜɟɥɢɤɚ, ɢ ɧɚʁɜɢɲɟ ɫɟ ɨɞɧɨɫɢ ɧɚ ɝɨʁɚɡɧɭ ɞɟɰɭ. Ʉɨɞ ɞɟɰɟ ɫɚ ɧɨɪɦɚɥɧɨɦ ɬɟɠɢɧɨɦ ɭɱɟɫɬɚɥɨɫɬ ʁɟ 21%, ɤɨɞ ɞɟɰɟ ɫɚ ɜɢɲɤɨɦ ɤɢɥɨɝɪɚɦɚ 29%, ɝɨʁɚɡɧɟ 34%, ɢ ɨɡɛɢʂɧɨ ɝɨʁɚɡɧɟ 49% (Turer, et al. 2013). 27 ɉɨɞɚɰɢ ɢɡ ɫɬɭɞɢʁɟ ɪɚђɟɧɟ ɬɨɤɨɦ ɞɟɫɟɬ ɝɨɞɢɧɚ ɧɚ 1226 ɢɫɩɢɬɚɧɢɤɚ ɩɨɤɚɡɚɥɚ ɫɭ ɞɚ ɫɭ ɲɚɧɫɟ ɡɚ ɞɨɛɢʁɚʃɟ ɜɢɲɟ ɨɞ 3,7 ɤɝ (ɧɚ 75. ɩɟɪɰɟɧɬɢɥɭ) ɢɡɦɟђɭ ɞɜɟ ɤɨɧɬɪɨɥɟ ɤɨɞ ɨɧɢɯ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚɦɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ <17 ЧР/ЦХ 2,37 ɩɭɬɚ ɜɟʄО ɨɞ ɨɧɢɯ ɫɚ ɜɟʄШɦ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ (Gonzales, et al. 2013). Ʌɨɧɝɢɬɭɞɭɧɚɥɧɨɦ ɫɬɭɞɢʁɨɦ ɞɟɰɟ ɭ ɛɪɚɡɢɥɫɤɨɦ Ⱥɦɚɡɨɧɭ ɧɚђɟɧ ʁɟ ɟɮɟɤɚɬ ɝɟɧɚ ɡɚ ɝɨʁɚɡɧɨɫɬ (FTO pМ9939609) ɤɨʁɢ ʁɟ ɢɡɪɚɠɟɧɢʁɢ ɤɨɞ ɞɟɰɟ ɫɚ ɧɟɞɨɜɨʂɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (Lourenco, et al. 2014). ɇɟɞɚɜɧɨ ɫɩɪɨɜɟɞɟɧɚ ɞɜɨɫɦɟɪɧɚ Ɇɟɧɞɟɥɢɚɧ ɪɚɧɞɨɦɢɡɚɰɢɨɧɚ ɚɧɚɥɢɡɚ ɜɢɲɟ ɫɤɭɩɢɧɚ, ɭ ɤɨʁɟ ʁɟ ɛɢɥɨ ɭɤʂɭɱɟɧɨ ɜɢɲɟ ɨɞ 42000 ɨɫɨɛɚ, ɞɚɥɚ ʁɟ ɞɨɤɚɡɟ ɨ ɝɨʁɚɡɧɨɫɬɢ ɤɚɨ ɮɚɤɬɨɪɭ ɤɨʁɢ ɭɡɪɨɤɭʁɟ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɚɥɢ ɧɟ ɢ ɨɛɪɧɭɬɨ (Vimaleswaran, et al. 2013). Ɉɜɚ ɚɧɚɥɢɡɚ ʁɟ ɩɨɤɚɡɚɥɚ, ɞɚ ʁɟ ɫɜɚɤɨ ɩɨɜɟʄɚʃɟ ɨɞ 10% ɢɧɞɟɤɫɚ ɬɟɥɟɫɧɟ ɦɚɫɟ (BMI), ɞɨɜɟɥɨ ɞɨ ɫɦɚʃɟʃɚ ɨɞ 4,2% ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ (Vimaleswaran, et al. 2013). ɍɤɭɩɧɚ ɦɚɫɚ ɬɟɥɟɫɧɟ ɦɚɫɬɢ ɤɨɞ ɝɨʁɚɡɧɟ ɞɟɰɟ ɤɨʁɚ ɫɟ ɧɚɥɚɡɟ ɧɚ (BMI ≥Ɋ85), ɢ ɭ ɝɪɭɩɚɦɚ ɢɫɬɨɝ ɭɡɪɚɫɬɚ, ʁɟ ɜɢɲɟ ɨɞ ɬɪɢ ɩɭɬɚ ɜɟʄɚ (Mei, et al. 2002). Mɚɫɧɨ ɬɤɢɜɨ, ɭ ɤɨɦɟ ɫɟ ɫɤɥɚɞɢɲɬɢ ɜɢɲɚɤ ɦɚɫɬɢ, ɧɟɤɚɞɚ ɫɟ ɫɦɚɬɪɚɥɨ ɢɧɟɪɬɧɢɦ, ɞɨɤ ɫɟ ɫɚɞɚ ɡɧɚ ɞɚ ɨɧɨ ɩɪɟɞɫɬɚɜʂɚ ɜɚɠɚɧ ɦɟɬɚɛɨɥɢɱɤɢ ɟɧɞɨɤɪɢɧɢ ɨɪɝɚɧ (Mutt, et al. 2014). Ɉɧɨ ɥɭɱɢ ɜɢɲɟ ɨɞ 260 ɪɚɡɥɢɱɢɬɢɯ ɩɪɨɬɟɢɧɚ/ɩɟɩɬɢɞɚ (ɚɞɢɩɨɤɢɧɢ, ɯɟɦɨɤɢɧɢ, ɰɢɬɨɤɢɧɢ) ɢ ɩɪɟɞɫɬɚɜʂɚ ɝɥɚɜɧɨɝ ɭɱɟɫɧɢɤɚ ɭ ɝɥɢɤɨɪɟɝɭɥɚɰɢʁɢ. ɂɩɚɤ, ɫɩɟɰɢɮɢɱɧɚ ɮɭɧɤɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɚɞɢɩɨɝɟɧɟɡɢ ɨɫɬɚʁɟ ɭ ɜɟɥɢɤɨʁ ɦɟɪɢ ɧɟʁɚɫɧɚ, ɱɟɫɬɨ ɤɨɧɬɪɚɞɢɤɬɨɪɧɚ ɫɚ ɫɬɭɞɢʁɚɦɚ ɤɨʁɟ ɨɛʁɚɲʃɚɜɚʁɭ ɤɚɤɨ ɫɬɢɦɭɥɚɰɢʁɭ, ɬɚɤɨ ɢ ɢɧɯɢɛɢɰɢʁɭ ɚɞɢɩɨɝɟɧɟɡɟ (Mutt, et al. 2014). 28 ɐɂȴȿȼɂ ɂɋɌɊȺɀɂȼȺȵȺ ɐɢʂɟɜɢ ɢɫɬɪɚɠɢɜɚʃɚ ɫɭ: 1. ɍɬɜɪɞɢɬɢ ɭɱɟɫɬɚɥɨɫɬ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. 2. ɂɫɩɢɬɚɬɢ ɤɨɪɟɥɚɰɢʁɭ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɢɡɦɟђɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 3. ɂɫɩɢɬɚɬɢ ɩɨɜɟɡɚɧɨɫɬ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɢ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ 4. ɍɬɜɪɞɢɬɢ ɞɚ ɥɢ ɩɨɫɬɨʁɢ ɤɨɪɟɥɚɰɢʁɚ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢ ɛɨʁɟ ɤɨɠɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 5. ɂɫɩɢɬɚɬɢ ɩɨɜɟɡɚɧɨɫɬ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)Dɭ ɫɟɪɭɦɭ ɢ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ 6. ɂɫɩɢɬɚɬɢ ɭɬɢɰɚʁ ɜɪɫɬɟ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɧɚ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ 7. ɂɫɩɢɬɚɬɢ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɚɧɟɦɢʁɟ, ɢ ɭɬɜɪɞɢɬɢ ɞɚ ɥɢ ɩɨɫɬɨʁɢ ɩɨɜɟɡɚɧɨɫɬ ɢɡɦɟђɭ 25(Ɉɇ)D ɫɬɚɬɭɫɚ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɯɟɦɨɝɥɨɛɢɧɚ (Hb) ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 8. ɂɫɩɢɬɚɬɢ ɤɨɪɟɥɚɰɢʁɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 9. ɂɫɩɢɬɚɬɢ ɤɨɪɟɥɚɰɢʁɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɢ ɜɪɟɞɧɨɫɬɢ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 10. ɂɫɩɢɬɚɬɢ ɤɨɪɟɥɚɰɢʁɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ25(Ɉɇ)D ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALP) ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 11. ɂɫɩɢɬɚɬɢ ɤɨɪɟɥɚɰɢʁɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ25(Ɉɇ)D ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 12. ɍɬɜɪɞɢɬɢ ɤɨʁɢ ɫɭ ɧɚʁɛɨʂɢ ɢɧɞɢɪɟɤɬɧɢ ɩɨɤɚɡɚɬɟʂɢ ɫɢɫɬɟɦɫɤɨɝ ɟɮɟɤɬɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) 29 ɆȺɌȿɊɂȳȺɅ ɂ METOȾɈɅɈȽɂȳȺ ɊȺȾȺ ɂɫɬɪɚɠɢɜɚʃɟ ɩɪɟɞɫɬɚɜʂɚ ɩɪɨɫɩɟɤɬɢɜɧɭ ɤɥɢɧɢɱɤɭ ɫɬɭɞɢʁɭ. Ɂɛɨɝ ɫɟɡɨɧɫɤɟ ɜɚɪɢʁɚɰɢʁɟ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɫɩɢɬɢɜɚʃɚ ɫɭ ɪɚђɟɧɚ ɬɨɤɨɦ ʁɟɫɟɧɢ, ɭ ɡɢɦɫɤɢɦ ɢ ɩɪɨɥɟʄɧɢɦ ɦɟɫɟɰɢɦɚ, ɤɨʁɢ ɫɭ ɞɟɮɢɧɢɫɚɧɢ, ɨɞ 1. ɫɟɩɬɟɦɛɪɚ ɞɨ 31. ɦɚʁɚ, ɭ ɩɟɪɢɨɞɭ ɨɞ 2013. - 2015. ɝɨɞɢɧɟ. ɂɫɩɢɬɢɜɚʃɟ ʁɟ ɨɛɚɜʂɟɧɨ ɧɚ ɩɟɞɢʁɚɬɪɢʁɫɤɨɦ ɨɞɟʂɟʃɭ ɛɨɥɧɢɰɟ „Ʉɪɚʂ Ɇɢɥɭɬɢɧ” ɭ Ʌɚɩʂɟɦ ɋɟɥɭ. ɋɬɭɞɢʁɨɦ ʁɟ ɨɛɭɯɜɚʄɟɧɨ 150 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ ɧɚɜɪɲɟɧɢɯ ɦɟɫɟɰ ɞɚɧɚ ɞɨ 36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ. ɂɫɩɢɬɚɧɢɰɢ ɫɭ ɩɨɞɟʂɟɧɢ ɧɚ ɢɫɩɢɬɢɜɚɧɭ ɝɪɭɩɭ ɨɞɨʁɱɚɞɢ, ɨɞ ʁɟɞɧɨɝ ɦɟɫɟɰɚ ɞɨ 12 ɦɟɫɟɰɢ ɠɢɜɨɬɚ, ɢ ɝɪɭɩɭ ɦɚɥɟ ɞɟɰɟ, ɭɡɪɚɫɬɚ ɨɞ 13 ɞɨ 36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ. ɍ ɬɨɤɭ ɢɫɩɢɬɢɜɚʃɚ ɤɨɪɢɫɬɢɥɢ ɫɦɨ ɚɧɤɟɬɧɢ ɥɢɫɬ, ɤɨʁɢ ʁɟ ɭ ɫɚɪɚɞʃɢ ɫɚ ɪɨɞɢɬɟʂɢɦɚ ɩɨɩɭʃɚɜɚɧ ɨɞ ɫɬɪɚɧɟ ɥɟɤɚɪɚ. ɍɡɢɦɚʃɟɦ ɚɧɚɦɧɟɫɬɢɱɤɢɯ ɩɨɞɚɬɚɤɚ ɨɞ ɪɨɞɢɬɟʂɚ ɞɟɰɟ, ɞɨɛɢɥɢ ɫɦɨ ɩɨɞɚɬɤɟ ɨ ɭɡɪɚɫɬɭ ɞɟɬɟɬɚ, ɩɨɪɨђɚʁɧɨʁ ɦɚɫɢ, ɢ ɫɟɡɨɧɢ (ɦɟɫɟɰɭ) ɤɚɞɚ ʁɟ ɞɟɬɟ ɪɨђɟɧɨ. ɉɪɢ ɩɪɟɝɥɟɞɭ ʁɟ ɦɟɪɟɧɚ ɬɟɥɟɫɧɚ ɦɚɫɚ ɢ ɬɟɥɟɫɧɚ ɜɢɫɢɧɚ, ɤɨʁɢ ɫɭ ɧɚɦ ɛɢɥɢ ɜɚɠɧɢ ɤɚɤɨ ɛɢ ɩɪɨɰɟɧɢɥɢ ɫɬɚʃɟ ɭɯɪɚʃɟɧɨɫɬɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɋɨɞɢɬɟʂɢɦɚ ʁɟ ɩɨɫɬɚɜʂɚɧɨ ɩɢɬɚʃɟ ɨ ɜɪɟɦɟɧɭ (ɢɡɪɚɠɟɧɨ ɭ ɦɢɧɭɬɢɦɚ) ɬɨɤɨɦ ɫɭɧɱɚɧɢɯ ɞɚɧɚ ɤɚɞɚ ʁɟ ɤɨɠɚ ɞɟɬɟɬɚ ɢɡɥɚɝɚɧɚ ɫɭɧɰɭ. ɍ ɚɧɤɟɬɢ ɫɭ ɡɚɫɬɭɩʂɟɧɚ ɢ ɩɢɬɚʃɚ ɨ ɜɪɫɬɢ ɦɥɟɱɧɟ (ɩɨɞɨʁ, ɫɬɚɧɞɚɪɞɧɟ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ, ɦɥɟɤɚ ɨɛɨɝɚʄɟɧɚ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɤɪɚɜʂɟ ɦɥɟɤɨ) ɢ ɧɟɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɞɭɠɢɧɢ ɞɨʁɟʃɚ, ɞɨɯɪɚɧɢ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ, ɚ ɧɚɪɨɱɢɬɨ ɨ ɭɧɨɫɭ ɯɪɚɧɟ ɛɨɝɚɬɟ ɜɢɬɚɦɢɧɨɦ Ⱦ. ɍɡɢɦɚʃɟɦ ɩɨɞɚɬɚɤɚ ɨ ɜɪɫɬɢ ɦɥɟɱɧɟ ɢ ɧɟɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɭ ɭɡɪɚɫɬɭ ɨɞ 13 ɞɨ 36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ (ɦɚɥɚ ɞɟɰɚ), ɢɧɬɟɪɟɫɨɜɚɥɨ ɧɚɫ ʁɟ, ɞɚ ɥɢ ɞɟɰɚ ɭɡɢɦɚʁɭ ɞɨɜɨʂɧɟ ɤɨɥɢɱɢɧɟ ɦɥɟɤɚ ɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ, ɤɚɨ ɢ ɯɪɚɧɭ ɛɨɝɚɬɭ ɤɚɥɰɢʁɭɦɨɦ. ɉɨɫɬɚɜʂɚɧɚ ɫɭ ɩɢɬɚʃɚ ɢ ɨ ɭɧɨɫɭ ɯɪɚɧɟ ɛɨɝɚɬɟ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɤɚɨ ɲɬɨ ɫɭ: ɪɢɛɚ (ɥɨɫɨɫ, ɬɭɧɚ, ɫɤɭɲɚ), ɦɟɫɨ, џɢɝɟɪɢɰɚ, ɠɭɦɚɧɚɰ. Ɂɧɚɱɚʁɧɢ ɩɨɞɚɬɚɤ ʁɟ ɫɦɨ ɞɨɛɢʁɚɥɢ ɩɨɫɬɚɜʂɚʃɟɦ ɩɢɬɚʃɚ ɞɚ ɥɢ ʁɟ ɞɟɬɟ ɭ ɬɨɤɭ ɨɞɨʁɚɱɤɨɝ ɩɟɪɢɨɞɚ ɞɨɛɢʁɚɥɨ ɜɢɬɚɦɢɧ Ⱦ ɤɚɨ ɫɭɩɥɟɦɟɧɬ, ɤɨʁɭ ɜɪɫɬɢ ɤɚɩɢ, ɭ ɤɨʁɨʁ ɤɨɥɢɱɢɧɢ, ɢ ɧɚ ɤɨʁɢ ɧɚɱɢɧ. ɇɚ ɬɚʁ ɧɚɱɢɧ ɫɦɨ ɨɞɪɟђɢɜɚɥɢ ɞɚ ɥɢ ʁɟ ɩɪɨɮɢɥɚɤɫɚ ɜɢɬɚɦɢɧɨɦ Ⱦ ɛɢɥɚ ɚɞɟɤɜɚɬɧɚ, ɨɞɧɨɫɧɨ ɧɟɚɞɟɤɜɚɬɧɚ. ɉɨɞ ɬɟɪɦɢɧɨɦ ɚɞɟɤɜɚɬɧɟ ɩɪɨɮɢɥɚɤɫɟ ɫɭɩɥɟɦɟɧɬɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɞɪɚɡɭɦɟɜɚɥɢ ɫɦɨ ɚɞɟɤɜɚɬɧɭ ɤɨɥɢɱɢɧɭ ɭɧɟɬɨɝ ɜɢɬɚɦɢɧɚ Ⱦ ɬɨɤɨɦ ɞɚɧɚ (400 IJ/ɞɚɧ), ɫɜɚɤɨɞɧɟɜɧɨ ɭɡɢɦɚʃɟ ɩɪɨɮɢɥɚɤɬɢɱɤɟ ɞɨɡɟ 30 ɜɢɬɚɦɢɧɚ Ⱦ ɞɨ ɤɪɚʁɚ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ, ɤɚɨ ɢ ɩɪɢɦɟɧɚ ɤɚɩɢ ɜɢɬɚɦɢɧɚ Ⱦ ɞɢɪɟɤɬɧɨ ɭ ɭɫɬɚ ɞɟɰɟ, ɢɥɢ ɤɚɲɢɱɢɰɨɦ ɫɚ ɦɚɥɨ ɬɟɱɧɨɫɬɢ. Ⱥɧɚɦɧɟɫɬɢɱɤɢɦ ɢɫɩɢɬɢɜɚʃɟɦ ɪɨɞɢɬɟʂɚ ɞɨɛɢʁɚɥɢ ɫɦɨ ɩɨɞɚɬɚɤ, ɞɚ ɥɢ ɫɭ ɞɟɰɚ ɪɨђɟɧɚ ɭ ɡɢɦɫɤɢɦ ɦɟɫɟɰɢɦɚ ɞɨɛɢʁɚɥɚ ɩɪɨɮɢɥɚɤɬɢɱɧɟ ɞɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɭ ɡɢɦɫɤɢɦ ɦɟɫɟɰɢɦɚ ɭ ɞɪɭɝɨʁ ɢ ɬɪɟʄɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ. ɍ ɬɨɤɭ ɢɫɩɢɬɢɜɚʃɚ ɜɚɠɧɨ ɧɚɦ ʁɟ ɛɢɥɨ ɞɚ ɥɢ ɞɟɰɚ ɛɨɥɭʁɭ ɨɞ ɧɟɤɟ ɩɪɢɞɪɭɠɟɧɟ ɛɨɥɟɫɬɢ ɤɨʁɚ ɛɢ ɭɬɢɰɚɥɚ ɧɚ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ (ɛɪɨɧɯɨɨɩɫɬɪɭɤɰɢʁɚ, ɚɬɨɩɢʁɫɤɢ ɞɟɪɦɚɬɢɬɢɫ, ɚɫɬɦɚ, ɨɛɨʂɟʃɚ ɛɭɛɪɟɝɚ (ɧɟɮɪɨɬɫɤɢ ɫɢɧɞɪɨɦ), ɢɧɬɨɥɟɪɚɧɰɢʁɚ ɧɚ ɩɪɨɬɟɢɧɟ ɤɪɚɜʂɟɝ ɦɥɟɤɚ ɢ ɞɪ. ȼɨɞɢɥɢ ɫɦɨ ɪɚɱɭɧɚ ɨ ɟɜɟɧɬɭɚɥɧɨɦ ɭɡɢɦɚʃɭ ɥɟɤɨɜɚ ɤɨʁɢ ɛɢ ɞɢɪɟɤɬɧɨ ɭɬɢɰɚɥɢ ɧɚ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ɍ ɬɨɤɭ ɢɫɩɢɬɢɜɚʃɚ ɨɛɪɚɬɢɥɢ ɫɦɨ ɩɚɠʃɭ ɧɚ ɛɨʁɭ ɤɨɠɟ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ. ɂɫɩɢɬɢɜɚʃɟɦ ɪɨɞɢɬɟʂɚ ɞɨɛɢɥɢ ɫɦɨ ɨɞɝɨɜɨɪ ɧɚ ɩɢɬɚʃɚ ɞɚ ɥɢ ɭ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɩɨɫɬɨʁɟ ɤɥɢɧɢɱɤɢ ɡɧɚɰɢ ɤɨʁɢ ɛɢ ɭɤɚɡɢɜɚɥɢ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɍʁɟɞɧɨ ʁɟ ɜɪɲɟɧ ɤɥɢɧɢɱɤɢ ɩɪɟɝɥɟɞ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ. ɋɬɚɧɞɚɪɞɧɢɦ ɚɧɬɪɨɩɨɦɟɬɪɢʁɫɤɢɦ ɦɟɪɟʃɟɦ ɞɨɛɢɥɢ ɫɦɨ ɩɨɞɚɬɤɟ ɨ ɬɟɥɟɫɧɨʁ ɬɟɠɢɧɢ ɢ ɞɭɠɢɧɢ/ɜɢɫɢɧɢ ɞɟɬɟɬɚ. Ⱦɨɛɢʁɟɧɟ ɜɪɟɞɧɨɫɬɢ ɫɦɨ ɭɩɨɪɟђɢɜɚɥɢ ɫɚ ɫɬɚɧɞɚɪɞɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɡɚ ɭɡɪɚɫɬ ɢ ɩɨɥ. Ɉɞɨʁɱɚɞ ɢ ɦɚɥɭ ɞɟɰɭ ɫɚ ɬɟɥɟɫɧɨɦ ɬɟɠɢɧɨɦ ɩɪɢ ɩɪɟɝɥɟɞɭ ≥ Ɋ95, ɫɜɪɫɬɚɥɢ ɫɦɨ ɭ ɝɪɭɩɭ ɝɨʁɚɡɧɟ ɞɟɰɟ, ɞɨɤ ɫɭ ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ ɫɚ ɬɟɥɟɫɧɨɦ ɬɟɠɢɧɨɦ <Ɋ3, ɫɜɪɫɬɚɜɚɧɚ ɭ ɝɪɭɩɭ ɩɨɬɯɪɚʃɟɧɟ (ɯɢɩɨɬɪɨɮɢɱɧɟ) ɞɟɰɟ. ɍ ɞɟɥɭ ɚɧɤɟɬɧɨɝ ɥɢɫɬɚ ɦɚʁɤɚɦɚ ɫɭ ɩɨɫɬɚɜʂɟɧɚ ɩɢɬɚʃɚ ɭ ɜɟɡɢ ɫɚ ɭɧɨɫɨɦ ɦɭɥɬɢɜɢɬɚɦɢɧɚ, ɤɚɨ ɢ ɨ ɤɨɥɢɱɢɧɢ ɭɧɟɬɨɝ ɦɥɟɤɚ ɢ/ɢɥɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ (ʁɨɝɭɪɬ, ɫɢɪ) ɬɨɤɨɦ ɬɪɭɞɧɨʄɟ. ɋɭɩɥɟɦɟɧɬɚɰɢʁɚ ɦɭɥɬɢɜɢɬɚɦɢɧɫɤɢɦ ɩɪɟɩɚɪɚɬɢɦɚ ɤɨʁɢ ɫɚɞɪɠɟ 100-200 IJ ɜɢɬɚɦɢɧɚ Ⱦ, ɫɦɚɬɪɚɧɚ ʁɟ ɦɢɧɢɦɚɥɧɨɦ ɫɬɚɧɞɚɪɞɧɨɦ ɞɨɡɨɦ. Ʉɨɧɡɭɦɢɪɚʃɟ 200 ЦХ ɦɥɟɤɚ ɢɥɢ ʃɟɝɨɜɨɝ ɟɤɜɢɜɚɥɟɧɬɚ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ ɬɨɤɨɦ ɞɚɧɚ, ɧɚʁɦɚʃɟ 4-5 ɞɚɧɚ ɭ ɧɟɞɟʂɢ, ɫɦɚɬɪɚɧ ʁɟ ɤɚɨ "ɞɨɜɨʂɚɧ", ɞɨɤ ʁɟ ɭɧɨɫ ɦɥɟɤɚ ɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ 3 ɩɭɬɚ ɧɟɞɟʂɧɨ ɢɥɢ ɪɟђɟ ɩɪɢɯɜɚʄɟɧ ɤɚɨ "ɧɟɞɨɜɨʂɚɧ". Ʌɚɛɨɪɚɬɨɪɢјɫɤɟ ɚɧɚɥɢɡɟ ɋɜɢɦ ɢɫɩɢɬɚɧɢɰɢɦɚ ɭɪɚђɟɧɚ ɫɭ ɯɟɦɚɬɨɥɨɲɤɚ ɢɫɩɢɬɢɜɚʃɚ - ɤɨɦɩɥɟɬɧɚ ɤɪɜɧɚ ɫɥɢɤɚ (ɄɄɋ), ɤɚɨ ɢ ɛɢɨɯɟɦɢʁɫɤɟ ɩɪɟɬɪɚɝɟ: ɭɪɟɚ, ɤɪɟɚɬɢɧɢɧ, ɭɤɭɩɧɢ ɩɪɨɬɟɢɧɢ, ɚɥɛɭɦɢɧɢ, ɤɚɥɰɢʁɭɦ, ɮɨɫɮɨɪ, ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ, ɩɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ ɢ 25- ɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (25(Ɉɇ)D). 31 ɏɟɦɚɬɨɥɨɲɤɚ ɢɫɩɢɬɢɜɚњɚ ȼɪɟɞɧɨɫɬɢ ɯɟɦɨɝɥɨɛɢɧɚ, ɯɟɦɚɬɨɤɪɢɬɚ ɢ ɟɪɢɬɪɨɰɢɬɚ ɨɞɪɟђɢɜɚɧɟ ɫɭ ɢɡ ɤɚɩɢɥɚɪɧɟ ɤɪɜɢ. Ɉɞɪɟђɢɜɚʃɟ ɛɪɨʁɚ ɟɪɢɬɪɨɰɢɬɚ ɜɪɲɟɧɨ ʁɟ ɭ ɇɟɭɛɚɭɟɪɨɜɨʁ ɤɨɦɨɪɢ. Ȼɪɨʁ ɟɪɢɬɪɨɰɢɬɚ ɫɦɨ ɢɡɪɚɠɚɜɚɥɢ ɛɪɨʁɟɦ ɟɪɢɬɪɨɰɢɬɚ ɭ ʁɟɞɧɨɦ ɥɢɬɪɭ (ɛɪ б 1012/L). ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ ɫɭ ɨɞ 3,7-5,8 ɯ 1012/L. ɏɟɦɨɝɥɨɛɢɧ ʁɟ ɨɞɪɟђɢɜɚɧ ɮɨɬɨɦɟɬɪɢʁɫɤɢ-ɤɨɥɨɪɢɦɟɬɪɢʁɫɤɢɦ ɬɟɫɬɨɦ, ɩɨ Hemoglobin Cianid MОtШНТ. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɯɟɦɨɝɥɨɛɢɧɚ ɭ ɨɞɨʁɱɚɞɢ ɫɭ ɨɞ 105 ɞɨ 150 Р/L, ɡɚ ɦɚɥɨ ɞɟɬɟ ɨɞ 110 ɞɨ 140 Р/L. ɏɟɦɚɬɨɤɪɢɬɧɚ ɜɪɟɞɧɨɫɬ = MCV (ПХ) б ɛɪɨʁ ɟɪɢɬɪɨɰɢɬɚ (1012/L). ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ ɫɭ ɨɞ 0,33-0,43 (33-43%). Ȼɢɨɯɟɦɢјɫɤɚ ɢɫɩɢɬɢɜɚњɚ Ɉɞ ɛɢɨɯɟɦɢʁɫɤɢɯ ɚɧɚɥɢɡɚ ɨɞɪɟђɢɜɚɧɢ ɫɭ: ɭɪɟɚ, ɤɪɟɚɬɢɧɢɧ, ɭɤɭɩɧɢ ɩɪɨɬɟɢɧɢ, ɚɥɛɭɦɢɧɢ, ɤɚɥɰɢʁɭɦ, ɮɨɫɮɨɪ, ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ, ɩɚɪɚɬɢɪɨɢɞɧɢ ɯɨɪɦɨɧ ɢ 25 ɯɢɞɪɨɤɫɢ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (25(OH)D) . ɋɟɪɭɦɫɤɚ ɭɪɟɚ ʁɟ ɨɞɪɟђɢɜɚɧɚ GLDH ɦɟɬɨɞɨɦ. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 1,7 - 8,3 mmol/L. ɋɟɪɭɦɫɤɢ ɤɪɟɚɬɢɧɢɧ ʁɟ ɨɞɪɟђɢɜɚɧ ɦɟɬɨɞɨɦ ɩɨ JКППОu. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 44 - 97 µmol/L. ɋɟɪɭɦɫɤɢ ɭɤɭɩɧɢ ɩɪɨɬɟɢɧɢ ɨɞɪɟђɢɜɚɧɢ ɫɭ ɮɨɬɨɦɟɬɪɢʁɫɤɢ - ɤɨɥɨɪɢʁɫɤɢɦ ɬɟɫɬɨɦ, ɛɢɭɪɟɬɫɤɨɦ ɦɟɬɨɞɨɦ. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 65 - 83 g/L. ɋɟɪɭɦɫɤɢ ɚɥɛɭɦɢɧɢ ɨɞɪɟђɢɜɚɧɢ ɫɭ ɮɨɬɨɤɨɥɨɪɢɦɟɬɪɢʁɫɤɢɦ ɬɟɫɬɨɦ BCG (BrШЦ - krezol - РrООЧ) ɦɟɬɨɞɨɦ. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 38 - 51 g/L. ɍɤɭɩɧɢ ɫɟɪɭɦɫɤɢ ɤɚɥɰɢʁɭɦ ʁɟ ɨɞɪɟђɢɜɚɧ ɩɨ ɦɟɬɨɞɢ ɬɚɥɨɠɟʃɚ ɩɨ VКЧ SХвФОu Т Sendroy -u. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 1,90 - 2,55 mmol/L. ɋɟɪɭɦɫɤɢ ɮɨɫɮɨɪ ʁɟ ɨɞɪɟђɢɜɚɧ ɮɨɬɨɦɟɬɪɢʁɫɤɢɦ UV ɬɟɫɬɨɦ. ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ: 1,30 - 2,26 mmol/L. ɋɟɪɭɦɫɤɚ ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ ɨɞɪɟђɢɜɚɧɚ ɤɨɥɨɪɢɦɟɬɪɢʁɫɤɢɦ ɬɟɫɬɨɦ (AMP BuППОr, IFCC - ЦОtШНК). ɇɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɭ ɞɟɰɟ ɫɭ ɞɨ 644 U/L. ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ ɭ ɫɟɪɭɦɭ ɨɞɪɟђɢɜɚɧ ʁɟ ɟɥɟɤɬɪɨɯɟɦɢɥɭɦɢɧɢɫɰɟɧɬɧɢɦ ɬɟɫɬɨɦ "ECLIA". ɉɪɨɫɟɱɚɧ ɧɢɜɨ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɡɧɨɫɢ ɨɞ 5-55 pР/ЦХ. ɉɪɟɦɚ ɭɩɭɬɫɬɜɭ ɩɪɨɢɡɜɨђɚɱɚ ɭɡɨɪɚɤ ɫɟɪɭɦɚ ʁɟ ɫɬɚɛɢɥɚɧ 8 ɫɚɬɢ ɧɚ 15-25њC, 2 ɞɚɧɚ ɧɚ 2– 8 њC ɢɥɢ 6 ɦɟɫɟɰɢ ɧɚ -20 њC,ɨ ɱɟɦɭ ɫɦɨ ɜɨɞɢɥɢ ɪɚɱɭɧɚ. 32 25-ɯɢɞɪɨɤɫɢɯɨɥɟɤɚɥɰɢɮɟɪɨɥ (25(Ɉɇ)D) ʁɟ ɨɞɪɟђɢɜɚɧ ɧɚ ɚɭɬɨɦɚɬɫɤɨɦ ɚɧɚɥɢɡɚɬɨɪɭ COBAS ɟɥɟɤɬɪɨɯɟɦɢɥɭɦɢɧɢɫɰɟɧɬɧɢɦ ɬɟɫɬɨɦ "ECLIA". ɉɪɟɩɨɪɭɱɟɧɟ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɡɧɨɫɟ ɢɡɧɚɞ 30 ЧР/ЦХ, ɨɞɧɨɫɧɨ ɢɡɧɚɞ 75 nmol/L. ɋɬɚɬɢɫɬɢɱɤɟ ɚɧɚɥɢɡɟ ɋɬɚɬɢɫɬɢɱɤɚ ɨɛɪɚɞɚ ɩɨɞɚɬɚɤɚ ɪɚђɟɧɚ ʁɟ ɧɚ ɩɟɪɫɨɧɚɥɧɨɦ ɪɚɱɭɧɚɪɭ ɭ ɫɨɮɬɜɟɪɫɤɨɦ ɨɤɪɭɠɟʃɭ “MОНCКХМ® VОrsТШЧ 9.2.0.1”. Ɉɞ ɩɚɪɚɦɟɬɚɪɚ ɞɟɫɤɪɢɩɬɢɜɧɟ ɫɬɚɬɢɫɬɢɤɟ ɨɞɪɟђɢɜɚɧɢ ɫɭ: ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ (X), ɫɬɚɧɞɚɪɞɧɚ ɝɪɟɲɤɚ (SE), ɦɢɧɢɦɚɥɧɚ ɢ ɦɚɤɫɢɦɚɥɧɚ ɜɪɟɞɧɨɫɬ.. ɍ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɩɪɢɪɨɞɟ ɢɫɩɢɬɢɜɚɧɢɯ ɜɚɪɢʁɚɛɥɢ, ɡɚ ɤɨɦɩɚɪɚɰɢʁɭ ɩɨɞɚɬɚɤɚ ɤɨɪɢɲʄɟɧɢ ɫɭ: Hi2-ɬɟɫɬ ɢ ɤɨɪɟɥɚɰɢʁɚ. ɉɨɞɚɰɢ ɫɭ ɩɪɢɤɚɡɚɧɢ ɬɚɛɟɥɚɪɧɨ ɢ ɝɪɚɮɢɱɤɢi. 33 ɊȿɁɍɅɌȺɌɂ ɂɋɌɊȺɀɂȼȺȵȺ ɂɫɬɪɚɠɢɜɚʃɟɦ ʁɟ ɨɛɭɯɜɚʄɟɧɨ ɭɤɭɩɧɨ 150 ɢɫɩɢɬɚɧɢɤɚ. ɂɫɩɢɬɚɧɢɰɢ ɫɭ ɩɨɞɟʂɟɧɢ ɭ ɞɜɟ ɝɪɭɩɟ. Ƚɪɭɩɭ ɨɞɨʁɱɚɞɢ, ɭɡɪɚɫɬɚ ɨɞ ɦɟɫɟɰ ɞɚɧɚ ɞɨ 12 ɦɟɫɟɰК, ɫɚɱɢʃɚɜɚɥɨ ʁɟ 73 (49%) ɢɫɩɢɬɚɧɢɤɚ. ɍ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 13 ɞɨ 36 ɦɟɫɟɰɢ ɛɢɥɨ ʁɟ 77 (51%) ɢɫɩɢɬɚɧɢɤɚ (ɝɪɚɮɢɤɨɧ ɛɪ.1). Ƚɪɚɮɢɤɨɧ ɛɪ. 1 ɋɬɪɭɤɬɭɪɚ ɢɫɩɢɬɚɧɤɚ ɩɪɟɦɚ ɭɡɪɚɫɬɭ Ƚɪɚɮɢɤɨɧ ɛɪ. 2 Ɋɚɫɩɨɞɟɥɚ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɩɨɥɭ Ƚɪɚɮɢɤɨɧ ɛɪ.2 ɩɨɤɚɡɭʁɟ ɞɢɫɬɪɢɛɭɰɢʁɭ ɫɜɢɯ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɩɨɥɭ. ɍ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ, 36 ɨɞɨʁɱɚɞɢ ʁɟ ɦɭɲɤɨɝ ɩɨɥɚ, ɞɨɤ ʁɟ 37 ɨɞɨʁɱɚɞɢ ɠɟɧɫɤɨɝ ɩɨɥɚ. ɍ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɭ ɭɡɪɚɫɬɭ ɦɚɥɨɝ ɞɟɬɟɬɚ, 37 ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɦɭɲɤɨɝ ɩɨɥɚ ɢ 40 ɢɫɩɢɬɚɧɢɤɚ ɠɟɧɫɤɨɝ ɩɨɥɚ. Одој̸ад 49% ʺала деца 51% 34 Ƚɪɚɮɢɤɨɧ ɛɪ. 3 Ɋɚɫɩɨɞɟɥɚ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 3 ɩɪɢɤɚɡɚɧɚ ʁɟ ɪɚɫɩɨɞɟɥɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25 (Ɉɇ)D ɭ ɫɟɪɭɦɭ. Ɉɞ ɭɤɭɩɧɨ 150 (100%) ɢɫɩɢɬɚɧɢɤɚ, 24 ʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ, 35 ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 29 ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ, ɞɨɤ ʁɟ 62 ɢɦɚɥɨ ɨɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. Ɍɚɛɟɥɚ ɛɪ. 3 ɋɬɪɭɤɬɭɪɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɇɚ ɬɚɛɟɥɢ ɛɪ. 3 ɩɪɢɤɚɡɚɧɚ ʁɟ ɫɬɪɭɤɬɭɪɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25 (Ɉɇ)D ɭ ɫɟɪɭɦɭ. Ɉɞ ɭɤɭɩɧɨɝ ɛɪɨʁɚ ɢɫɩɢɬɚɧɢɤɚ, 24 (16%) ɞɟɰɟ ʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D<10 ЧР/ЦХ), 35 (23%) ʁɟ ɢɦɚɥɨ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D<20 ЧР/ЦХ), 29 (19%) ʁɟ ʦ̛та̛̥̦ ʪ ̭тату̭ ˁ̛̏ ̛̭п̛та̛̦ц̛ N % Те̹ка деф̛ц̛је̦ц̛ја 24 16 ʪеф̛ц̛је̦ц̛ја 35 23 И̦̭уф̛ц̛је̦ц̛ја 29 19 ВДД 88 58 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 62 42 ˄К˄ʿʻО 150 100 35 ɢɦɚɥɨ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ (ɫɭɛɨɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ) (ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D<30 ЧР/ЦХ), ɞɨɤ ʁɟ 62 (42%) ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɢɦɚɥɨ ɨɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ (ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D>30 ЧР/ЦХ). ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ, ɭɬɜɪђɟɧɨ ʁɟ ɞɚ ʁɟ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ (ȼȾȾ) ɢɦɚɥɨ ɱɚɤ 58% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ƚɪɚɮɢɤɨɧ ɛɪ. 4 ɋɬɪɭɤɬɭɪɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 4 ʁɟ ɩɪɢɤɚɡɚɧɚ ɪɚɫɩɨɞɟɥɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɚ ɝɪɚɮɢɤɨɧɭ ʁɟ ʁɚɫɧɨ ɜɢɞʂɢɜɨ ɞɚ ʁɟ ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɛɢɥɚ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧɚ ɭ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ, ɞɨɤ ʁɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɛɢɥɚ ɡɚɫɬɭɩʂɟɧɚ ɧɟɲɬɨ ɜɢɲɟ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ. Ɉɩɬɢɦɚɥɧɚ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɛɢɥɚ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧɚ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ. ɇɚ ɬɚɛɟɥɢ ɛɪ. 7 ɭɨɱɚɜɚɦɨ ɞɚ ʁɟ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɦɚɥɨ 8%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ 17%, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ 23% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ. ȼȾȾ ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɭ 48% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ. Ɍɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɢɦɚɥɨ 23%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ 30%, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ 16% ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ. ȼȾȾ ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɭ 69% ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ (ɬɚɛɟɥɚ ɛɪ. 4). 6 12 17 38 18 23 12 24 0 5 10 15 20 25 30 35 40 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ Одој̸ад ʺала деца 36 Ɍɚɛɟɥɚ ɛɪ. 4 ɋɬɪɭɤɬɭɪɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɋɬɚɬɢɫɬɢɱɤɨɦ ɨɛɪɚɞɨɦ ɞɨɛɢʁɟɧɢɯ ɩɨɞɚɬɚɤɚ (FТsСОr-Шv tОst) ɭɬɜɪɞɢɥɢ ɫɦɨ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɝɪɭɩɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (ɪ=0,0039). ɇɚ ɬɚɛɟɥɢ ɛɪ. 5ɚ, 5ɛ ɢ 5ɰ ɩɪɢɤɚɡɚɧɟ ɫɭ ɫɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɢɫɩɢɬɢɜɚɧɢɯ ɯɟɦɚɬɨɥɨɲɤɢɯ ɢ ɛɢɨɯɟɦɢʁɫɤɢɯ ɩɚɪɚɦɟɬɚɪɚ ɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢɡɧɨɫɢɥɚ ʁɟ 33,072 ЧР/ЦХ, ɞɨɤ ʁɟ ɭ ɭɡɪɚɫɬɭ ɦɚɥɟ ɞɟɰɟ ɨɧɚ ɢɡɧɨɫɢɥɚ 22,1 ЧР/ЦХ. Ɍɚɛɟɥɚ ɛɪ. 5ɚ ɋɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ, ɫɬɚɧɞɚɪɞɧɚ ɝɪɟɲɤɚ, ɧɚјɦɚʃɚ ɢ ɧɚјɜɟʄɚ ɭɬɜɪђɟɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɚ ɯɟɦɚɬɨɥɢɲɤɢɯ ɢ ɛɢɨɯɟɦɢјɫɤɢɯ ɩɚɪɚɦɟɬɚɪɚ ɤɨɞ ɫɜɢɯ ɢɫɩɢɬɚɧɢɤɚ С̬ед. ̬̏ед̦о̭т Ст̦̌д. ̬̐ешк̌ М̛̛̦̥у̥ М̌к̛̭̥у̥ В̛т̛̥̦̌ Д 27,441 1,3647 3,000 70,000 П̬̌̌т̵о̬̥о̦ 30,954 2,1274 4,580 186,70 ˈе̥о̐ло̛̦̍ 110,687 0,9846 68,000 143,000 ˈе̥̌ток̛̬т 0,335 0,0026 0,240 0,410 К̌л̶̛ју̥ 2,241 0,0222 0,950 2,900 ˇо̴̭̌т̛ ;̦ео̬̦̭̐̌к̛Ϳ 1,679 0,0228 0,980 2,900 Алк̌л̦̌ ̴о̴̭̌т̌̌̚ 449,633 20,1939 198,000 2133,000 Укуп̛̦ п̬оте̛̛̦ 74,981 0,4979 41,000 88,000 Ал̍у̛̛̥̦ 46,100 0,3518 28,000 58,000 ʦ̛та̛̥̦ ʪ ̭тату̭ Одој̸ад ʺала деца (p = 0,0039) N % N % Те̹ка деф̛ц̛је̦ц̛ја 6 8 18 23 ʪеф̛ц̛је̦ц̛ја 12 17 23 30 И̦̭уф̛ц̛је̦ц̛ја 17 23 12 16 ВДД 35 48 53 69 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 38 52 24 31 ˄К˄ʿʻО 73 100 77 100 37 Ɍɚɛɟɥɚ ɛɪ. 5ɛ ɋɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ, ɫɬɚɧɞɚɪɞɧɚ ɝɪɟɲɤɚ, ɧɚјɦɚʃɚ ɢ ɧɚјɜɟʄɚ ɭɬɜɪђɟɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɚ ɯɟɦɚɬɨɥɢɲɤɢɯ ɢ ɛɢɨɯɟɦɢјɫɤɢɯ ɩɚɪɚɦɟɬɚɪɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ С̬ед. ̬̏ед̦о̭т Ст̦̌д. ̬̐ешк̌ М̛̛̦̥у̥ М̌к̛̭̥у̥ В̛т̛̥̦̌ Д 33,072 1,9785 3,000 70,000 П̬̌̌т̵о̬̥о̦ 25,096 3,0075 4,580 156,340 ˈе̥о̐ло̛̦̍ 109,740 1,2603 81,000 186,70 ˈе̥̌ток̛̬т 0,331 0,0034 0,280 0,410 К̌л̶̛ју̥ 2,283 0,0224 1,900 2,800 ˇо̴̭̌т̛ ;̦ео̬̦̭̐̌к̛Ϳ 1,703 0,0300 0,980 2,490 Алк̌л̦̌ ̴о̴̭̌т̌̌̚ 472,438 21,5242 227,000 1132,000 Укуп̛̦ п̬оте̛̛̦ 74,233 0,7110 41,000 87,000 Ал̍у̛̛̥̦ 46,370 0,5174 28,000 58,000 Ɍɚɛɟɥɚ ɛɪ. 5ɰ ɋɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ, ɫɬɚɧɞɚɪɞɧɚ ɝɪɟɲɤɚ, ɧɚјɦɚʃɚ ɢ ɧɚјɜɟʄɚ ɭɬɜɪђɟɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɚ ɯɟɦɚɬɨɥɢɲɤɢɯ ɢ ɛɢɨɯɟɦɢјɫɤɢɯ ɩɚɪɚɦɟɬɚɪɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ С̬ед. ̬̏ед̦о̭т Ст̦̌д. ̬̐ешк̌ М̛̛̦̥у̥ М̌к̛̭̥у̥ В̛т̛̥̦̌ Д 22,103 1,6812 3,000 70,000 П̬̌̌т̵о̬̥о̦ 36,507 2,9537 6,32 180,19 ˈе̥о̐ло̛̦̍ 111,584 1,5013 68,000 143,000 ˈе̥̌ток̛̬т 0,339 0,0038 0,240 0,400 К̌л̶̛ју̥ 2,202 0,0372 0,950 2,900 ˇо̴̭̌т̛ ;̦ео̬̦̭̐̌к̛Ϳ 1,657 0,0340 0,980 2,900 Алк̌л̦̌ ̴о̴̭̌т̌̌̚ 428,013 33,5962 198,000 2133,000 Укуп̛̦ п̬оте̛̛̦ 75,690 0,6922 61,000 88,000 Ал̍у̛̛̥̦ 45,844 0,4800 32,000 54,000 ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 5 ɩɪɢɤɚɡɚɧ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ. ɍɨɱɚɜɚɦɨ, ɞɚ ʁɟ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɛɢɥɚ ɡɚɫɬɭɩʂɟɧɢʁɚ ɭ ɞɟɰɟ ɦɭɲɤɨɝ ɩɨɥɚ, ɞɨɤ ʁɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɢ ɨɩɬɢɦɚɥɧɭ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɢɦɚɥɨ ɜɢɲɟ ɞɟɰɟ ɠɟɧɫɤɨɝ ɩɨɥɚ. 38 Ƚɪɚɮɢɤɨɧ ɛɪ. 5 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ Ɍɚɛɟɥɚ ɛɪ. 6 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɫɜɢɯ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ ɇɚ ɬɚɛɟɥɢ ɛɪ. 6 ɭɨɱɚɜɚɦɨ, ɞɚ ʁɟ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, 22% ɢɫɩɢɬɚɧɢɤɚ ɦɭɲɤɨɝ ɩɨɥɚ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 26% ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 11% ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (59% ɢɫɩɢɬɢɜɚɧɟ ɦɭɲɤɟ ɞɟɰɟ ʁɟ ɢɦɚɥɨ ȼȾȾ). ɍ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɠɟɧɫɤɨɝ ɩɨɥɚ, ɭɱɟɫɬɚɥɨɫɬ ɬɟɲɤɟ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ʁɟ ɛɢɥɚ 10%, ɞɟɮɢɰɢʁɟɧɰɢʁɟ 21% ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ 27% (58% ɢɫɩɢɬɢɜɚɧɟ ɠɟɧɫɤɟ ɞɟɰɟ ʁɟ ɢɦɚɥɨ ȼȾȾ). ʦ̛та̛̥̦ ʪ ̭тату̭ ʺу̹к̛ Же̦̭к̛ (p = 0,0333) N % N % Те̹ка деф̛ц̛је̦ц̛ја 16 22 8 10 ʪеф̛ц̛је̦ц̛ја 19 26 16 21 И̦̭уф̛ц̛је̦ц̛ја 8 11 21 27 ВДД 43 59 45 58 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 30 41 32 42 ˄К˄ʿʻО 73 100 77 100 16 19 8 30 8 16 21 32 0 5 10 15 20 25 30 35 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ ʺу̹к̛ пол Же̦̭к̛ пол 39 Ɍɚɛɟɥɚ ɛɪ. 7 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ Ɍɚɛɟɥɚ ɛɪ. 8 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ ɂɚɤɨ ʁɟ ɬɟɫɬɢɪɚʃɟɦ ɭɬɜɪђɟɧɨ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25(Ɉɇ(D) ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɩɨɥɚ ɢɫɩɢɬɚɧɢɤɚ (ɪ=0,03), ɨɧɚ ɜɚɪɢɪɚ ɢɡɦɟђɭ ɤɚɬɟɝɨɪɢʁɚ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɭ ɨɞɨʁɱɚɞɢ (ɪ=0,25), ɭ ɦɚɥɟ ɞɟɰɟ (ɪ=0,08), ɬɚɤɨ ɞɚ ʁɟ ɧɚʁɢɫɩɪɚɜɧɢʁɢ ɡɚɤʂɭɱɚɤ, ɞɚ ɧɟɦɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɟ ɪɚɡɥɢɤɟ ɭ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25(Ɉɇ(D) ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɩɨɥɚ ɢɫɩɢɬɚɧɢɤɚ (ɬɚɛɟɥɚ ɛɪ. 6, 7 ɢ 8). ɇɚɫɭɩɪɨɬ ɩɨɞɚɰɢɦɚ ɢɡ ɥɢɬɟɪɚɬɭɪɟ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɱɟɲʄɢ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɠɟɧɫɤɟ ɞɟɰɟ, ɬɨɤɨɦ ɧɚɲɢɯ ɢɫɩɢɬɢɜɚʃɚ ɧɢɫɦɨ ɭɬɜɪɞɢɥɢ ɫɬɚɬɢɫɬɢɱɢ ɡɧɚɱɚʁɧɭ ɪɚɡɥɢɤɭ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢɡɦɟђɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ. ɇɚɩɨɦɢʃɟɧɨ ɞɚ ʁɟ ɫɬɭɞɢʁɚ ɪɚђɟɧɚ ɧɚ ɦɚɥɨɦ ɛɪɨʁɭ ɢɫɩɢɬɚɧɢɤɚ ɤɨʁɢ ɫɭ ɞɨɲɥɢ ɧɚ ɤɨɧɬɪɨɥɧɢ ɩɪɟɝɥɟɞ ɢ ɞɚ ɧɟ ɩɪɟɞɫɬɚɜʂɚ ɩɨɩɭɥɚɰɢɨɧɭ ɫɬɭɞɢʁɭ. ɇɚ ɬɚɛɟɥɢ ɛɪ. 9 ɜɢɞɢɦɨ ɞɚ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɚ (ȼȾȾ) ɢɦɚɥɨ 40% ɨɞɨʁɱɚɞɢ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ ɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ 72% ɨɞɨʁɱɚɞɢ ɫɚ ɧɟɚɞɟɤɜɚɬɧɨɦ ɩɪɨɮɢɥɚɤɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɢʁɟɞɧɨ ɨɞɨʁɱɟ ɤɨʁɟ ʁɟ ɞɨɛɢʁɚɥɨ ɚɞɟɤɜɚɬɧɭ ɫɭɩɥɟɦɟɧɬɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ ɧɢʁɟ ɢɦɚɥɨ ɬɟɠɚɤ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ. ʦ̛та̛̥̦ ʪ ̭тату̭ ʺу̹к̛ Же̦̭к̛ (p = 0,2483) N % N % Те̹ка деф̛ц̛је̦ц̛ја 5 14 1 3 ʪеф̛ц̛је̦ц̛ја 6 16 6 16 И̦̭уф̛ц̛је̦ц̛ја 6 17 11 30 ВДД 17 47 18 49 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 19 53 19 51 ˄К˄ʿʻО 36 100 37 100 ʦ̛та̛̥̦ ʪ ̭тату̭ ʺу̹к̛ Же̦̭к̛ (p = 0,0831) N % N % Те̹ка деф̛ц̛је̦ц̛ја 11 30 7 17 ʪеф̛ц̛је̦ц̛ја 13 35 10 25 И̦̭уф̛ц̛је̦ц̛ја 2 5 10 25 ВДД 26 70 27 67 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 11 30 13 33 ˄К˄ʿʻО 37 100 40 100 40 Ɍɚɛɟɥɚ ɛɪ. 9 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɭ ɨɞɧɨɫɭ ɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢјɭ ɜɢɬɚɦɢɧɚ Д ɂɡɦɟђɭ ɝɪɭɩɟ ɨɞɨʁɱɚɞɢ ɫɚ ɚɞɟɤɜɚɬɧɨɦ ɢ ɧɟɚɞɟɤɜɚɬɧɨɦ ɩɪɨɮɢɥɚɤɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ ɭɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ (ɪ=0,0001). ɇɚ ɨɫɧɨɜɭ ɧɚɲɢɯ ɪɟɡɭɥɬɚɬɚ, ɩɨɞɚɰɢ ɨ ɜɟʄɨʁ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɭ ɨɞɨʁɱɚɞɢ ɫɚ ɧɟɚɞɟɤɜɚɬɧɨɦ ɫɭɩɥɟɦɟɧɬɚɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɤɥɚɩɚʁɭ ɫɟ ɫɚ ɪɟɡɭɥɬɚɬɢɦɚ ɦɧɨɝɨɛɪɨʁɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ, ɭ ɤɨʁɢɦɚ ɧɟɞɨɜɨʂɧɚ, ɢɥɢ ɧɟɚɞɟɤɜɚɬɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɩɪɟɞɫɬɚɜʂɚ ʁɟɞɚɧ ɨɞ ɝɥɚɜɧɢɯ ɮɚɤɬɨɪɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ. Ƚɪɚɮɢɤɨɧ ɛɪ. 6 ɋɬɪɭɤɬɭɪɚ ɜɪɫɬɟ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ (ɩɨɞɨј ɢ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ) ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 6 ʁɟ ɩɪɢɤɚɡɚɧɚ ɫɬɪɭɤɬɭɪɚ ɜɪɫɬɟ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɭ ɞɟɰɟ ɨɞ ɦɟɫɟɰ ɞɚɧɚ ɞɨ ɧɚɜɪɲɟɧɢɯ 24 ɦɟɫɟɰɚ ɠɢɜɨɬɚ. ɉɪɢɦɟʄɭʁɟɦɨ ɞɚ ʁɟ ɨɞ 119 (100%) ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɠɢɜɨɬɚ, 94 (79%) ɞɟɰɟ ɛɢɥɨ ɧɚ ɩɨɞɨʁɭ, ɞɨɤ ʁɟ ɦɚʃɢ ɩɪɨɰɟɧɚɬ, ɫɚɦɨ 25 (21%) ɢɫɩɢɬɚɧɢɤɚ ɞɨɛɢʁɚɥɨ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ. ʦ̛та̛̥̦ ʪ ̭тату̭ ʤдек̏ат. ʻеадек̏ат. (p = 0,0001) N % N % Те̹ка деф̛ц̛је̦ц̛ја 0 0 6 33 ʪеф̛ц̛је̦ц̛ја 9 16 3 17 И̦̭уф̛ц̛је̦ц̛ја 13 24 4 22 ВДД 22 40 13 72 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 33 60 5 28 ˄К˄ʿʻО 55 100 18 100 ʿодој 79% ʺле̸̦е фо̬̥уле 21% 41 Ƚɪɚɮɢɤɨɧ ɛɪ. 7 ɋɬɪɭɤɬɭɪɚ ɜɪɫɬɟ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɞɨј(ɩɨɞɨј ɢ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨј) ɍ ɝɪɭɩɢ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ ɢɡɞɜɨʁɢɥɢ ɫɦɨ ɞɜɟ ɝɪɭɩɟ. ɍ ɩɪɜɭ ɝɪɭɩɭ ɫɜɪɫɬɚɧɚ ɫɭ ɞɟɰɚ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ, ɢ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ ɚɞɟɤɜɚɬɧɭ ɞɨɩɭɧɫɤɭ ɢɫɯɪɚɧɭ, 66 (70%). ɍ ɞɪɭɝɭ ɝɪɭɩɭ ɫɜɪɫɬɚɧɚ ɫɭ ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɤɨʁɚ ɛɢɥɚ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ (ɭɡ ɧɟɚɞɟɤɜɚɬɧɭ ɞɨɩɭɧɫɤɭ ɢɫɯɪɚɧɭ) ɢɥɢ ɩɪɨɞɭɠɟɧɨɦ ɩɨɞɨʁɭ, 28 (30%), ɲɬɨ ʁɟ ɩɪɢɤɚɡɚɧɨ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 7. Ɋɟɡɭɥɬɚɬɢ ɢɫɩɢɬɢɜɚʃɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɩɪɢɤɚɡɚɧɢ ɫɭ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 8. Ɍɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɛɢɥɚ ɧɚʁɡɚɫɬɭɩʂɟɧɢʁɚ ɭ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ. Ⱦɟɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɭ ɛɢɥɚ ɡɚɫɬɭɩʂɟɧɚ ɭ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ ɢ ɟɤɫɤɥɭɡɢɜɧɨɦ ɢɥɢ ɩɪɨɞɭɠɟɧɨɦ ɩɨɞɨʁɭ, ɞɨɤ ʁɟ ɫɚɦɨ ʁɟɞɚɧ ɢɫɩɢɬɚɧɢɤ ɤɨʁɢ ʁɟ ɞɨɛɢʁɚɨ ɦɥɟɱɧɭ ɮɨɪɦɭɥɭ, ɢɦɚɨ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɂɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɛɢɥɚ ɩɪɢɛɥɢɠɧɨ ɡɚɫɬɭɩʂɟɧɚ ɭ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ. Јɟɞɚɧ ɢɫɩɢɬɚɧɢɤ ɤɨʁɢ ʁɟ ɛɢɨ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ ʁɟ ɢɦɚɨ ɨɩɬɢɦɚɥɧɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ʿодој 70% ʫк̭клу̚. подој 30% 42 Ƚɪɚɮɢɤɨɧ ɛɪ. 8 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ Ɍɚɛɟɥɚ ɛɪ. 10 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ (ɩɨɞɨј ɢ ɜɟɲɬɚɱɤɭ ɢɫɯɪɚɧɭ (ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ)) Ɋɟɡɭɥɬɚɬɢ ɫɬɚɬɢɫɬɢɱɤɟ ɚɧɚɥɢɡɟ (ɪ=0,09) ɩɨɤɚɡɭʁɭ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɢ ɞɟɰɟ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ (ɬɚɛɟɥɚ ɛɪ. 10). ʦ̛та̛̥̦ ʪ ̭тату̭ ʿодој Фо̬̥уле (p = 0,0921) N % N % Те̹ка деф̛ц̛је̦ц̛ја 3 5 2 8 ʪеф̛ц̛је̦ц̛ја 14 21 1 4 И̦̭уф̛ц̛је̦ц̛ја 8 12 7 28 ВДД 25 38 10 40 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 41 62 15 60 ˄К˄ʿʻО 66 100 25 100 3 14 8 41 2 1 7 1513 8 6 1 0 10 20 30 40 50 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ ʿодој ʺле̸̦е фо̬̥уле ʫк̭клу̚. подој 43 Ɍɚɛɟɥɚ ɛɪ. 11 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ (ɩɨɞɨј ɢ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨј) Ɋɟɡɭɥɬɚɬɢ ɫɬɚɬɢɫɬɢɱɤɟ ɚɧɚɥɢɡɟ (ɪ=0,09) ɩɨɤɚɡɭʁɭ ɞɚ ɧɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɢ ɞɟɰɟ ɧɚ ɩɪɨɞɭɠɟɧɨɦ ɢ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ (ɬɚɛɟɥɚ ɛɪ. 11). Ɍɚɛɟɥɚ ɛɪ. 12 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ (ɜɟɲɬɚɱɤɚ ɢɫɯɪɚɧɚ ɢ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨј) ɇɚ ɬɚɛɟɥɚɦɚ ɛɪ. 10, 11 ɢ 12, ɭɨɱʂɢɜɨ ʁɟ, ɞɚ ʁɟ, 5% ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, 8% ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ, ɢ 46% ɞɟɰɟ ɤɨʁɚ ɫɭ ɩɪɨɞɭɠɟɧɨ ɫɢɫɚɥɚ ɢɥɢ ɛɢɥɚ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ, ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. Ⱦɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɢɦɚɥɨ 21% ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, 4% ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ ɢ 29% ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ. ɂɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ʁɟ ɛɢɥɚ ɫɥɢɱɧɨ ɡɚɫɬɭɩʂɟɧɚ ɭ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ɞɟɰɟ, ɭ 12% ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, 28% ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ ɢ 21% ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ. Ɉɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɢɦɚɥɨ 62% ʦ̛та̛̥̦ ʪ ̭тату̭ ʿодој ʫк̭кл.подој (p = 0,0921) N % N % Те̹ка деф̛ц̛је̦ц̛ја 3 5 13 46 ʪеф̛ц̛је̦ц̛ја 14 21 8 29 И̦̭уф̛ц̛је̦ц̛ја 8 12 6 21 ВДД 25 38 27 96 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 41 62 1 4 ˄К˄ʿʻО 66 100 28 100 ʦ̛та̛̥̦ ʪ ̭тату̭ Фо̬̥уле ʫк̭кл.подој (p< 0,0001) N % N % Те̹ка деф̛ц̛је̦ц̛ја 2 8 13 46 ʪеф̛ц̛је̦ц̛ја 1 4 8 29 И̦̭уф̛ц̛је̦ц̛ја 7 28 6 21 ВДД 10 40 27 96 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 15 60 1 4 ˄К˄ʿʻО 25 100 28 100 44 ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, 60% ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ, ɞɨɤ ʁɟ ɫɚɦɨ 4% ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁ ɢɦɚɥɨ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ȼɢɫɨɤɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ<0,0001) ɭ ɭɱɟɫɬɚɥɨɫɬɢ ȼȾȾ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɩɪɢɫɭɬɧɚ ʁɟ ɢɡɦɟђɭ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ ɢ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ (ɬɚɛɟɥɚ ɛɪ. 15). Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ ɋɬɪɭɤɬɭɪɚ ɭɱɟɫɬɚɥɨɫɬɢ ȼȾȾ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨʁɭ ɤɨɠɟ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɢɤɚɡɚɧɚ ʁɟ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 9. ɍ 11% ɢɫɩɢɬɚɧɢɤɚ ɛɟɥɟ ɪɚɫɟ ɧɚђɟɧɚ ʁɟ ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɭ 20% ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ, ɞɨɤ ʁɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɢɦɚɥɨ 22% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ. Ɉɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɢɦɚɥɨ 47% ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ. Ƚɪɚɮɢɤɨɧ ɛɪ. 9 ɋɬɪɭɤɬɭɪɚ ɭɱɟɫɬɚɥɨɫɬɢ ɢɧɫɭɮɢɰɢјɟɧɰɢјɟ ɢ ɞɟɮɢɰɢјɟɧɰɢјɟ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ) Ƚɪɚɮɢɤɨɧ ɛɪ. 10 ɋɬɪɭɤɬɭɪɚ ɭɱɟɫɬɚɥɨɫɬɢ ɢɧɫɭɮɢɰɢјɟɧɰɢјɟ ɢ ɞɟɮɢɰɢјɟɧɰɢјɟ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ (ɬɚɦɧɨ ɩɪɟɛɨјɟɧɚ ɤɨɠɚ, ɪɨɦɫɤɚ ɧɚɰɢɨɧɚɥɧɨɫɬ) Те̹ка деф̛ц̛ј. 11% ʪеф̛ц̛ј. 20% И̦̭уф̛ц̛ј. 22% Опт̛̥. ̬̏ед̦о̭т̛ 47% Те̹ка деф̛ц̛ј. 27% ʪеф̛ц̛ј. 32% И̦̭уф̛ц̛ј . 14% Опт̛̥. ̬̏ед̦о̭т̛ 27% 45 Ɋɟɡɭɥɬɚɬɢ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪɨɦɫɤɟ ɧɚɰɢɨɧɚɥɧɨɫɬɢ) ɩɪɢɤɚɡɚɧɢ ɫɭ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 10. ɍ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ, 73% ɞɟɰɟ ʁɟ ɢɦɚɥɨ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ (27% ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 32% ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ 14% ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ). ɋɬɚɬɢɫɬɢɱɤɨɦ ɨɛɪɚɞɨɦ ɞɨɛɢʁɟɧɢɯ ɩɨɞɚɬɚɤɚ ɭɬɜɪɞɢɥɢ ɫɦɨ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɢɡɦɟђɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɛɨʁɨɦ ɤɨɠɟ ɢ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ (ɪ=0,0123). Ɍɚɛɟɥɚ ɛɪ. 13 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨјɟɧɨɫɬ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ ɢ ɪɨɦɢ) ɇɚ ɬɚɛɟɥɢ ɛɪ. 13 ɩɪɢɤɚɡɚɧɨ ʁɟ ɞɚ ʁɟ ɭ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɢɫɩɢɬɚɧɨ 106 ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ ɢ 44 ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪɨɦɫɤɟ ɧɚɰɢɨɧɚɥɧɨɫɬɢ). ɍɬɜɪђɟɧɨ ʁɟ ɞɚ ʁɟ 53% ɢɫɩɢɬɚɧɢɤɚ ɛɟɥɟ ɪɚɫɟ ɢɦɚɥɨ ȼȾȾ, ɞɨɤ ʁɟ ȼȾȾ ɛɢɥɚ ɡɚɫɬɭɩʂɟɧɚ ɭ 73% ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪɨɦɢ). ɋɬɚɬɢɫɬɢɱɤɨɦ ɨɛɪɚɞɨɦ ɞɨɛɢʁɟɧɢɯ ɩɨɞɚɬɚɤɚ ɨ ɭɱɟɫɬɚɥɨɫɬɢ ȼȾȾ ɢɡɦɟђɭ ɢɫɩɢɬɚɧɢɤɚ ɛɟɥɟ ɪɚɫɟ ɢ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪɨɦɫɤɚ ɧɚɰɢɨɧɚɥɧɨɫɬ) ɭɬɜɪɞɢɥɢ ɫɦɨ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ȼȾȾ ɢɡɦɟђɭ ɨɜɢɯ ɝɪɭɩɚ (ɪ=0,0123). ȼɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɫɭ ɛɢɥɟ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧɟ ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɬɚɛɟɥɚ ɛɪ. 13). Ƚɪɚɮɢɤɨɧ ɛɪ. 11 ɩɪɢɤɚɡɭʁɟ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨʁɟɧɨɫɬ ɤɨɠɟ. ɋɚ ɝɪɚɮɢɤɨɧɚ ɫɟ ʁɚɫɧɨ ɜɢɞɢ ɞɚ ʁɟ ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɛɢɥɚ ɜɢɲɟ ɡɚɫɬɭɩʂɟɧɚ ɭ ɨɞɨʁɱɚɞɢ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ. ȼɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ʁɟ ɛɢɥɚ ɩɨɞʁɟɞɧɚɤɨ ɡɚɫɬɭɩʂɟɧɚ ɭ ɨɛɟ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ, ɞɨɤ ʁɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɛɢɥɚ ɜɢɲɟ ɩɪɢɫɭɬɧɚ ɭ ɨɞɨʁɱɚɞɢ ɛɟɥɟ ɪɚɫɟ. ʦ̛та̛̥̦ ʪ ̭тату̭ Бела ̬а̭а ˀо̛̥ (p= 0,0123) N % N % Те̹ка деф̛ц̛је̦ц̛ја 12 11 12 27 ʪеф̛ц̛је̦ц̛ја 21 20 14 32 И̦̭уф̛ц̛је̦ц̛ја 23 22 6 14 ВДД 56 53 32 73 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 50 47 12 27 ˄К˄ʿʻО 106 100 44 100 46 Ƚɪɚɮɢɤɨɧ ɛɪ. 11 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɨɞɨјɱɚɞɢ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨјɟɧɨɫɬ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ ɢ ɪɨɦɢ) Ɍɚɛɟɥɚ ɛɪ. 14 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨјɟɧɨɫɬ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ ɢ ɪɨɦɢ) Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɤɨʁɢ ɫɭ ɩɪɢɤɚɡɚɧɢ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 11 ɢ ɬɚɛɟɥɢ ɛɪ. 14 ɩɨɤɚɡɭʁɭ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɨɞɨʁɱɚɞɢ ɛɟɥɟ ɪɚɫɟ ɢ ɨɞɨʁɱɚɞɢ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪ=0,1472). ʦ̛та̛̥̦ ʪ ̭тату̭ Бела ̬а̭а ˀо̛̥ (p= 0,1472) N % N % Те̹ка деф̛ц̛је̦ц̛ја 2 4 4 16 ʪеф̛ц̛је̦ц̛ја 6 13 6 24 И̦̭уф̛ц̛је̦ц̛ја 12 25 5 20 ВДД 20 42 15 60 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 28 58 10 40 ˄К˄ʿʻО 48 100 25 100 2 6 12 28 4 6 5 10 0 5 10 15 20 25 30 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ Бела ̬ а̭а ˀо̛̥ 47 Ƚɪɚɮɢɤɨɧ ɛɪ. 12 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨјɧɨɫɬ ɤɨɠɟ Ƚɪɚɮɢɤɨɧ ɛɪ. 12 ɩɪɢɤɚɡɭʁɟ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨʁɟɧɨɫɬ ɤɨɠɟ. ɇɚ ɝɪɚɮɢɤɨɧɭ ɡɚɩɚɠɚɦɨ ɞɚ ʁɟ ɜɟʄɚ ɭɱɟɫɬɚɥɨɫɬ ɬɟɲɤɟ ɞɟɮɢɰɢʁɟɧɰɢʁɟ, ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɭ ɦɚɥɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ, ɲɬɨ ɫɟ ɧɟ ɨɞɧɨɫɢ ɢ ɧɚ ɩɪɨɰɟɧɚɬ ȼȾȾ ɭ ɩɨʁɟɞɢɧɢɦ ɝɪɭɩɚɦɚ. Ɍɚɛɟɥɚ ɛɪ. 15 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨјɟɧɨɫɬ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ ɢ ɪɨɦɢ) ɂɡɦɟђɭ ɝɪɭɩɟ ɦɚɥɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ ɢ ɝɪɭɩɟ ɦɚɥɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪɨɦɢ) ɭɬɜɪɞɢɥɢ ɫɦɨ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɭ ɪɚɡɥɢɤɭ (ɪ=0,0168) ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɍɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ʁɟ ɛɢɥɚ ɜɟʄɚ ɭ ɦɚɥɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (89%), ɧɟɝɨ ɭ ɦɚɥɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ (62%), ɲɬɨ ʁɟ ɩɪɢɤɚɡɚɧɨ ɧɚ ɬɚɛɟɥɢ ɛɪ. 15. ʦ̛та̛̥̦ ʪ ̭тату̭ Бела ̬а̭а ˀо̛̥ (p= 0,0168) N % N % Те̹ка деф̛ц̛је̦ц̛ја 10 17 8 42 ʪеф̛ц̛је̦ц̛ја 15 26 8 42 И̦̭уф̛ц̛је̦ц̛ја 11 19 1 5 ВДД 36 62 17 89 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 22 38 2 11 ˄К˄ʿʻО 58 100 19 100 10 15 11 22 8 8 1 2 0 5 10 15 20 25 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ Бела ̬ а̭а ˀо̛̥ 48 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ ɛɪ. 13 Дɢɫɬɪɢɛɭɰɢјɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɢɫɭɫɬɜɨ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ɤɨјɢ ɭɤɚɡɭјɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Д ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 13 ɩɪɟɞɫɬɚɜʂɟɧɚ ʁɟ ɞɢɫɬɪɢɛɭɰɢʁɚ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɩɪɟɦɚ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɢɫɭɫɬɜɨ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɍ 11 ɢɫɩɢɬɚɧɢɤɚ ɛɢɥɢ ɫɭ ɩɪɢɫɭɬɧɢ ɤɥɢɧɢɱɤɢ ɡɧɚɰɢ ɤɨʁɢ ɦɨɝɭ ɞɚ ɭɤɚɠɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ. ɍ 14 ɢɫɩɢɬɚɧɢɤɚ ɛɢɥɢ ɫɭ ɩɪɢɫɭɬɧɢ ɤɥɢɧɢɱɤɢ ɡɧɚɰɢ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɞɟɮɢɰɢʁɟɧɰɢʁɚ, ɞɨɤ ʁɟ ɫɟɞɦɨɪɨ ɢɫɩɢɬɚɧɢɤɚ ɢɦɚɥɨ ɩɪɢɫɭɬɧɟ ɤɥɢɧɢɱɤɟ ɡɧɚɤɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɜɢɬɚɦɢɧ Ⱦ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ. ɍ ɬɪɨʁɟ ɞɟɰɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɛɢɥɢ ɫɭ ɩɪɢɫɭɬɧɢ ɡɧɚɰɢ ɤɨʁɢ ɦɨɝɭ ɞɚ ɭɤɚɡɭʁɭ ɧɚ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ. ɇɚ ɝɪɚɮɢɤɨɧɭ ʁɟ ɭɨɱʂɢɜɨ ɞɚ ʁɟ ɬɟɲɤɚ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɧɚђɟɧɚ ɭ 13 ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ, ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɭ 21, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɭ 22 ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ. 11 14 7 3 13 21 22 59 0 10 20 30 40 50 60 70 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭ пи та̦ ик а ʦита̥и̦ Д ̭ тату̭ ʿ̛̬̭ут̛̦ кл̸̛̛̦к̛ ̚ ̦ац̛ ʻа̛̐̚лед ̚ д̬а̏а деца 49 Ɍɚɛɟɥɚ ɛɪ. 16 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɢɫɭɫɬɜɨ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ɤɨјɢ ɭɤɚɡɭјɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Д ɇɚ ɬɚɛɟɥɢ ɛɪ. 16 ɜɢɞɢɦɨ ɞɚ ʁɟ 35 ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɢɦɚɥɨ ɤɥɢɧɢɱɤɟ ɡɧɚɤɟ ɤɨʁɢ ɦɨɝɭ ɞɚ ɭɤɚɠɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɤ ʁɟ 115 ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɛɢɥɨ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɨ (ɛɟɡ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ȼȾȾ). Ɉɞ 35 ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ȼȾȾ, 31% ʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 40% ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ 20% ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (91% ȼȾȾ). Ɉɞ 115 ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɢɯ ɢɫɩɢɬɚɧɢɤɚ, 12% ʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ, 18% ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ 19% ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ (49% ȼȾȾ). ɇɚɲɚ ɢɫɬɪɚɠɢɜɚʃɚ ɫɟ ɩɨɤɥɚɩɚʁɭ ɫɚ ɦɧɨɝɢɦ ɫɬɭɞɢʁɚɦɚ ɭ ɫɜɟɬɭ, ɝɞɟ ʁɟ ɞɨɤɚɡɚɧɨ ɞɚ ʁɟ ɫɭɛɨɩɬɢɦɚɥɚɧ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ, 25(OH)D ≤30 ng/ml, ɜɪɥɨ ɱɟɫɬ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ (Gordon, et al. 2008). Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɉɪɟɦɚ ɤɪɢɬɟɪɢʁɭɦɢɦɚ ɋɜɟɬɫɤɟ ɡɞɪɚɜɫɬɜɟɧɟ ɨɪɝɚɧɢɡɚɰɢʁɟ ɩɨ ɤɨʁɢɦɚ ʁɟ ɝɪɚɧɢɱɧɚ ɜɪɟɞɧɨɫɬ ɯɟɦɨɝɥɨɛɢɧɚ (HЛ) ɡɚ ɞɟɰɭ ɭɡɪɚɫɬɚ ɨɞ 6 НШ 59 ɦɟɫɟɰɢ 110 Р/L, ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ HЛ<110Р/L ɫɜɪɫɬɚɜɚɧɚ ɫɭ ɭ ɝɪɭɩɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɚɧɟɦɢʁɨɦ. Ɋɟɡɭɥɬɚɬɢ ɢɫɩɢɬɢɜɚʃɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ (ɤɨɧɰɟɧɬɪɚɰɢʁɭ Hb) ɩɪɢɤɚɡɚɧɢ ɫɭ ɧɚ ɬɚɛɟɥɢ ɛɪ. 17. ɍɨɱʂɢɜɨ ʁɟ, ɞɚ ʁɟ ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ (Hb<110 g/L) ɭ 150 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ʦ̛та̛̥̦ ʪ ̭тату̭ ʿ̛̬̭ут̛̦ кл̛̦. ̦̚ац̛ ʻа̛̐̚лед ̚д̬а̏а деца (p< 0,0001) N % N % Те̹ка деф̛ц̛је̦ц̛ја 11 31 13 12 ʪеф̛ц̛је̦ц̛ја 14 40 21 18 И̦̭уф̛ц̛је̦ц̛ја 7 20 22 19 ВДД 32 91 56 49 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 3 9 59 51 ˄К˄ʿʻО 35 100 115 100 50 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ ɦɟɫɟɰ ɞɚɧɚ ɞɨ 36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ ɢɡɧɨɫɢɥɚ 49 (32,7%), ɞɨɤ 101 (67,3%) ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɧɢʁɟ ɛɢɥɨ ɚɧɟɦɢɱɧɨ. Ɍɚɛɟɥɚ ɛɪ. 17 Ɋɚɫɩɨɞɟɥɚ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Д ɢ ɜɪɟɞɧɨɫɬɢ ɯɟɦɨɝɥɨɛɢɧɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ƚɪɚɮɢɤɨɧ ɛɪ. 14 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɟɞɧɨɫɬ ɯɟɦɨɝɥɨɛɢɧɚ (Hb<110 Р/L) ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 14 ʁɟ ɜɢɞʂɢɜɨ, ɞɚ ʁɟ, ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ ɢɦɚɥɨ 39%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ 25%, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ 16% ɢɫɩɢɬɚɧɢɤɚ. Ɉɩɬɢɦɚɥɧɚ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɚɧɟɦɢʁɚ ɧɚђɟɧɚ ʁɟ ɭ 20% ɢɫɩɢɬɚɧɢɤɚ. Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɭɤɚɡɭʁɭ ɧɚ ɩɨɜɟʄɚɧɭ ɭɞɪɭɠɟɧɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɢ ɫɢɞɟɪɨɩɟɧɢʁɫɤɟ ɚɧɟɦɢʁɟ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ʦ̛та̛̥̦ ʪ ̭тату̭ Hb < 110g/L Hb ≥110 Р/L (p= 0,0091) N % N % Те̹ка деф̛ц̛је̦ц̛ја 19 39 5 5 ʪеф̛ц̛је̦ц̛ја 12 25 23 23 И̦̭уф̛ц̛је̦ц̛ја 8 16 21 21 ВДД 39 80 49 49 Опт̛̥̌л̦е ̬̏ед̦о̭т̛ 10 20 52 51 ˄К˄ʿʻО 49 100 101 100 Те̹ка деф̛ц̛ј. 39% ʪеф̛ц̛ј. 25% И̦̭уф̛ц̛ј 16% Опт̛̥. ̬̏ед̦о̭т̛ 20% 51 Ƚɪɚɮɢɤɨɧ ɛɪ. 15 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɟɞɧɨɫɬ ɯɟɦɨɝɥɨɛɢɧɚ (Hb≥110 g/L) ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 15 ɩɪɢɤɚɡɚɧ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɟɞɧɨɫɬ ɯɟɦɨɝɥɨɛɢɧɚ (HЛ≥110 Р/L). ɍɨɱʂɢɜɨ ʁɟ ɞɚ 5% ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 23% ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɢ 21% ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɧɢʁɟ ɛɢɥɨ ɚɧɟɦɢɱɧɨ. KШɞ 51% ɢɫɩɢɬɚɧɢɤɚ ɫɭ ɧɚђɟɧɟ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɚ HЛ≥110 Р/L. Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɭɤɚɡɭʁɭ ɧɚ ɱɢʃɟɧɢɰɭ ɞɚ ʁɟ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ (49%) ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɢ ɭ ɞɟɰɟ ɤɨʁɚ ɧɢɫɭ ɛɢɥɚ ɚɧɟɦɢɱɧɚ. Ɍɟɫɬɢɪɚʃɟɦ ɧɢɜɨɚ ɡɧɚɱɚʁɧɨɫɬɢ ɪɚɡɥɢɤɟ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ȼȾȾ ɢ ɫɢɞɟɪɨɩɟɧɢʁɫɤɨɦ ɚɧɟɦɢʁɨɦ (ɋȺ) ɢ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ȼȾȾ ɛɟɡ ɚɧɟɦɢʁɟ ɞɨɛɢʁɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ=0,0091), ɲɬɨ ʁɟ ɩɪɢɤɚɡɚɧɨ ɧɚ ɬɚɛɟɥɢ ɛɪ. 20. ɂɫɩɢɬɢɜɚʃɟɦ ɤɨɪɟɥɚɰɢʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢ ɯɟɦɨɝɥɨɛɢɧɚ (HЛ) ɭɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ (r=0,3189, (ɪ=0,0001) ɢɡɦɟђɭ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D ɢ ɜɪɟɞɧɨɫɬɢ HЛ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɢ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ (r=0,315; p=0,0066), ɢ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ (r=0,420, p=0,0001), ɲɬɨ ʁɟ ɩɪɢɤɚɡɚɧɨ ɧɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 16. Те̹ка деф̛ц̛ј. 5% ʪеф̛ц̛ј. 23% И̦̭уф̛ц̛ј. 21% Опт̛̥ал̦е ̬̏ед̦о̭т̛ 51% 52 Ƚɪɚɮɢɤɨɧ ɛɪ. 16 Кɨɪɟɥɚɰɢјɚ ɤɨɧɰɟɧɬɪɚɰɢјɟ 25(Ɉɇ)D ɫɚ ɤɨɧɰɟɧɬɪɚɰɢјɨɦ Hb ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɍɩɨɪɟђɭʁɭʄɢ ɪɟɡɭɥɬɚɬɟ ɧɚɲɢɯ ɢɫɬɪɚɠɢɜɚʃɚ ɨ ɭɞɪɭɠɟɧɨɫɬɢ ɚɧɟɦɢʁɟ ɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ, ɧɚɢɲɥɢ ɫɦɨ ɧɚ ɦɧɨɝɨɛɪɨʁɧɚ ɢɫɬɪɚɠɢɜɚʃɚ ɤɨʁɚ ɭɤɚɡɭʁɭ ɧɚ ɩɨɜɟʄɚɧɭ ɭɱɟɫɬɚɥɨɫɬ ɮɟɪɨɞɟɮɢɰɢɬɚɪɧɟ (ɧɭɬɪɢɬɢɜɧɟ) ɚɧɟɦɢʁɟ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ. ɑɚɤ ɢ ɭ ɚɫɢɦɩɬɨɦɚɬɫɤɢɦ ɫɥɭɱɚʁɟɜɢɦɚ, ɞɟɮɢɰɢɬ ɝɜɨɠђɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ ɦɨɝɭ ɫɟ ʁɚɜɢɬɢ, ɧɚɪɨɱɢɬɨ ɭ ɩɟɪɢɨɞɭ ɨɞɨʁɱɟɬɚ ɢ ɦɚɥɟ ɞɟɰɟ, ɤɚɞɚ ɞɟɰɚ ɭɛɪɡɚɧɨ ɪɚɫɬɭ. 0 10 20 30 40 50 60 70 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Вɢɬɚɦɢɧ Д (ng/ml) Хе ɦɨ гɥ ɨɛ ɢɧ (g /L ) (g /L ) r = 0,3189 p = 0,0001 53 Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɛɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢјɭɦɚ (ɋɚ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ ɛɪ. 17 Ɋɚɫɩɨɞɟɥɚ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Д ɢ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɨɝ ɋɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 17 ɩɪɟɞɫɬɚɜʂɟɧɚ ʁɟ ɪɚɫɩɨɞɟɥɚ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ (ɋɚ) ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Јɚɫɧɨ ɫɟ ɭɨɱɚɜɚ ɞɚ ɫɭ ɜɪɟɞɧɨɫɬɢ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ (<1,9 ЦЦШХ/L) ɛɢɥɟ ɩɪɢɫɭɬɧɟ ɭ ɨɫɦɨɪɨ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɍɪɨʁɟ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ʁɟɞɧɨ ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ʁɟɞɧɨ ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɢ ɞɜɨʁɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ʁɟ ɢɦɚɥɨ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ < 1,9 ЦЦШХ/L. Ɋɟɡɭɥɬɚɬɢ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ʁɟ ɯɢɩɨɤɚɥɰɢɟɦɢʁɭ (ɋɚ<1,9 ЦЦШХ/L) ɢɦɚɨ ɦɚɥɢ ɛɪɨʁ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɚʁɜɟʄɢ ɩɪɨɰɟɧɚɬ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɯɢɩɨɤɚɥɰɢɟɦɢʁɨɦ ʁɟ ɛɢɨ ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɞɨɤ ɫɭ ɧɢɫɤɟ 0 10 20 30 40 50 60 70 3,0 2,8 2,6 2,4 2,2 2,0 1,8 1,6 1,4 1,2 1,0 0,8 0,6 0,4 0,2 0,0 Кɚ ɥɰ ɢјɭ ɦ ( m m o l/L ) (m m o l/L ) Вɢɬɚɦɢɧ Д (ng/ml) r = 0,1828 p = 0,0252 54 ɜɪɟɞɧɨɫɬɢ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ ɧɚђɟɧɟ ɢ ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɢ ɫɭɛɨɩɬɢɦɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. Ɋɟɡɭɥɬɚɬɢ ɫɬɚɬɢɫɬɢɱɤɟ ɚɧɚɥɢɡɟ ɩɨɤɚɡɭʁɭ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ (r=0,1828, p=0,0025) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ʉɚɨ ɲɬɨ ɡɧɚɦɨ, ɧɚɜɚɠɧɢʁɢ ɟɮɟɤɚɬ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɚɩɫɨɪɩɰɢʁɚ ɤɚɥɰɢʁɭɦɚ. ɍ ȼȾȾ, ɫɚ ɫɦɚʃɟʃɟɦ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ, ɩɪɟɦɚ ɬɪɟɧɭɬɧɨʁ ɬɟɨɪɢʁɢ, ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɭ ɫɢɧɬɟɡɢ ɊɌɇ ɭɫɥɟɞ ɫɟɤɭɧɞɚɪɧɨɝ ɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ. Ɉɧ ɩɨɜɟʄɚɜɚ ɤɚɥɰɢʁɭɦ ɭ ɫɟɪɭɦɭ ɚɤɭɬɧɨɦ ɦɨɛɢɥɢɡɚɰɢʁɨɦ ɢɡ ɤɨɫɬɢʁɭ. Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ (ɊɈ4) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ. ɛɪ 18 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 18 ɫɭ ɩɪɟɞɫɬɚɜʂɟɧɟ ɜɪɟɞɧɨɫɬɢ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɏɢɩɨɮɨɫɮɚɬɟɦɢʁɚ ʁɟ ɧɚђɟɧɚ ɫɚɦɨ ɭ 6 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, 5 ɭ ɝɪɭɩɢ ɫɚ 0 10 20 30 40 50 60 70 3,0 2,8 2,6 2,4 2,2 2,0 1,8 1,6 1,4 1,2 1,0 0,8 0,6 0,4 0,2 0,0 Вɢɬɚɦɢɧ Д (ng/ml) Не ɨɪ гɚɧ ɫɤ ɢ ɮ ɨɫ ɮɚ ɬ ( m m o l/L ) (m m o l/L ) r = 0,2085 p = 0,0105 55 ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ 1 ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɧɚɜɨɞɢɦɚ ɢɡ ɥɢɬɟɪɚɬɭɪɟ. Ɇɧɨɝɨɛɪɨʁɧɚ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ɫɭ ɦɨɝɭʄɟ ɦɧɨɝɟ ɜɚɪɢʁɚɰɢʁɟ. ɇɟ ɪɟɬɤɨ, ɞɟɰɚ ɫɚ ɢɡɪɚɡɢɬɨɦ ɯɢɩɨɤɚɥɰɢɟɦɢʁɨɦ ɢ ɫɟɤɭɧɞɚɪɧɢɦ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɨɦ ɢɦɚʁɭ ɧɨɪɦɚɥɚɧ ɢɥɢ ɩɨɜɢɲɟɧ ɧɢɜɨ ɮɨɫɮɚɬɚ, ɲɬɨ ʁɟ ɦɨɝɭʄɟ ɭɫɥɟɞ ɭɬɢɰɚʁɚ ɩɚɪɚɬɢɪɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ), ɤɚɤɨ ɧɚ ɤɨɫɬɢ, ɬɚɤɨ ɢ ɧɚ ɛɭɛɪɟɝɟ ɭɫɥɟɞ ɩɪɨɞɭɠɟɧɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ (Robinson, et al. 2006; Ladhani, et al. 2004). Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALЈ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ. ɛɪ 19 ɋɬɪɭɤɬɭɪɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɫɟɪɭɦɭ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 19 ɭɨɱɚɜɚɦɨ, ɞɚ ʁɟ ɫɚɦɨ 20 ɞɟɰɟ ɢɦɚɥɨ ɩɨɜɢɲɟɧɭ ɜɪɟɞɧɨɫɬ ALP ɭ ɫɟɪɭɦɭ, ɞɨɤ ɫɭ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ALP ɧɚђɟɧɟ ɭ 130 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 20 ɩɪɢɤɚɡɚɧɚ ʁɟ ɫɬɪɭɤɬɭɪɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɫɟɪɭɦɭ. Ɉɩɬɢɦɚɥɧɚ ɜɪɟɞɧɨɫɬ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɧɚɲɨʁ ɥɚɛɨɪɚɬɨɪɢʁɢ ɤɪɟɬɚɥɚ ɫɟ ɞɨ 644 U/L. 9 4 4 3 15 31 25 59 0 10 20 30 40 50 60 70 Те̹ка деф̛ц̛је̦ц̛ја ʪеф̛ц̛је̦ц̛ја И̦̭уф̛ц̛је̦ц̛ја Опт̛̥ал̦е ̬̏ед̦о̭т̛ ʥ̬ ој и̭п ита ̦и ка ʦита̥и̦ Д ̭тату̭ >644 U/L ≤644 U/L 56 Ʉɨɧɰɟɧɬɪɚɰɢʁe ALP>644 U/L ɬɨɤɨɦ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɨɡɧɚɱɟɧɟ ɫɭ ɤɚɨ ɩɨɜɢɲɟɧɟ ɜɪɟɞɧɨɫɬɢ ȺLP. Ɉɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɫɟɪɭɦɭ, ɢɦɚɥɨ ʁɟ, 45% ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 20% ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɢ 21% ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. Ƚɪɚɮɢɤɨɧ. ɛɪ 20 ɋɬɪɭɤɬɭɪɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟɭ ɫɟɪɭɦɭ (АLP>644 U/L)) Ƚɪɚɮɢɤɨɧ ɛɪ 21 ɋɬɪɭɤɬɭɪɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Д ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (АLP) ɭ ɫɟɪɭɦɭ Те̹ка деф̛ц̛ј. 45% ʪеф̛ц̛ј. 20% И̦̭уф̛ц̛ј. 21% Опт̛̥ал̦е ̬̏ед̦о̭т̛ 15% 0 10 2 30 4 50 60 70 2500 2300 2100 1900 1700 1500 1300 1100 900 700 500 300 100 Вɢɬɚɦɢɧ Д (ng/ml) Аɥ ɤɚ ɥɧ ɚ ɮ ɨɫ ɮɚ ɬɚ ɡɚ (U /L ) (U /L ) r = -0,1474 p = 0,0719 57 ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 21 ɩɪɢɤɚɡɚɧɚ ʁɟ ɫɬɪɭɤɬɭɪɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALP) ɭ ɫɟɪɭɦɭ. ɋɬɚɬɢɫɬɢɱɤɨɦ ɨɛɪɚɞɨɦ ɞɨɛɢʁɟɧɢɯ ɩɨɞɚɬɚɤɚ (Fisher-ov test) ɭɬɜɪɞɢɥɢ ɫɦɨ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ=0,07) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ȺLP ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɚɲɟ ɢɫɬɪɚɠɢɜɚʃɟ ɩɨɤɚɡɭʁɟ ɞɚ ɜɪɟɞɧɨɫɬɢ ɫɟɪɭɦɫɤɨɝ 25(OH)D ɭ ɞɟɰɟ, ɧɢɫɭ ɭɜɟɤ ɭ ɤɨɪɟɥɚɰɢʁɢ ɫɚ ɩɨɜɟʄɚɧɢɦ ɫɟɪɭɦɫɤɢɦ ɚɥɤɚɥɧɢɦ ɮɨɫɮɚɬɚɡɚɦɚ, ɲɬɨ ɞɨɤɚɡɭʁɭ ɢ ɦɧɨɝɨɛɪɨʁɧɟ ɫɬɭɞɢʁɟ ɭ ɫɜɟɬɭ. ɋɚɦɢɦ ɬɢɦ, ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ ɫɟ ɧɟ ɦɨɠɟ ɤɨɪɢɫɬɢɬɢ ɤɚɨ ɫɤɪɢɧɢɧɝ ɬɟɫɬ ɤɚɤɨ ɛɢ ɫɟ ɢɫɤʂɭɱɢɨ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɢ ɜɪɟɞɧɨɫɬɢ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ ɢ ɚɥɛɭɦɢɧɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ (<65 g/L) ɢ ɚɥɛɭɦɢɧɚ (<38 Р/L) ɧɚђɟɧɟ ɫɭ ɫɚɦɨ ɭ ɩɨɬɯɪɚʃɟɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (<Ɋ3). Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ ɛɪ. 22 ɋɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 30,95 25,1 36,51 0 5 10 15 20 25 30 35 40 ˁ̛̏ ̛̭п̛та̛̦ц̛ Одој̸ад ʺала деца Па ̬а тхо ̬̥ о̦ (x )̄( p g / m l) ʧ̬упе и̭пита̦ика 58 ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 22 ɫɭ ɩɪɢɤɚɡɚɧɟ ɫɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ȼɪɟɞɧɨɫɬ ɊɌɇ ɫɟ ɤɪɟɬɚɥɚ ɨɞ 4,58 ɞɨ 186,7 pg/ml. ɋɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɧɢɜɨɚ ɊɌɇ ɭ ɫɜɢɯ ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɢɡɧɨɫɢɥɚ 30,95 pg/ml, ɭ ɨɞɨʁɱɚɞɢ 25,1 pg/ml, ɞɨɤ ʁɟ ɭ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ ɢɡɧɨɫɢɥɚ 36,51 pg/ml. Ƚɪɚɮɢɤɨɧ ɛɪ. 23 Вɢɬɚɦɢɧ Д ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɫɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ (pg/ml) ɭ ɫɟɪɭɦɭ ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 23 ɫɭ ɩɪɢɤɚɡɚɧɟ ɫɪɟɞʃɟ ɜɪɟɞɧɨɫɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ. ɍ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɊɌɇ ʁɟ ɛɢɥɚ 87,6 pg/ml, ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ - 39,4 pР/ЦХ, ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ - 16,5 pР/ЦХ, ɭ ɞɟɰɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D<40 ЧР/ЦХ - 13 pg/ml, <50 ng/ml - 10,5 pg/ml, <60 ng/ml - 8,1 pg/ml ɢ ɭ ɞɟɰɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D <70 ЧР/ЦХ - 7,4 pg/ml. ɉɪɢɦɟʄɭʁɟɦɨ ɞɚ ɫɭ ɞɨɛɢʁɟɧɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɭ ɪɟɰɢɩɪɨɱɧɨɦ ɨɞɧɨɫɭ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɦɧɨɝɨɛɪɨʁɧɢɦ ɢɫɬɪɚɠɢɜɚʃɢɦɚ ɭ ɫɜɟɬɭ. 59 Ƚɪɚɮɢɤɨɧ ɛɪ. 24 Кɨɪɟɥɚɰɢјɚ ɤɨɧɰɟɧɬɪɚɰɢјɟ 25(Ɉɇ)D ɫɚ ɤɨɧɰɟɧɬɪɚɰɢјɨɦ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 24 ɫɟ ʁɚɫɧɨ ɜɢɞɢ ɞɚ ɫɭ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɩɨʁɟɞɢɧɢɯ ɢɫɩɢɬɚɧɢɤɚ, ɢ ɩɨɪɟɞ ʁɚɤɨ ɧɢɫɤɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ, ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ (<50 pР/ЦХ), ɞɨɤ ʁɟ ɜɟʄɢ ɩɪɨɰɟɧɚɬ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɢɦɚɨ ɜɪɟɞɧɨɫɬɢ ɊɌɇ>50pР/ЦХ. ɍ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɫɭ ɛɢɥɟ ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɧɢɯ, ɢɡɭɡɟɜ 3 ɫɥɭɱɚʁɚ, ɚ ɭ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ (ɫɭɛɨɩɬɢɦɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ) ɢ ɨɩɬɢɦɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɧɢɫɭ ɩɪɨɧɚђɟɧɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ>50 pР/ЦХ (r=-0,6906, p<0,0001). ɇɚ ɝɪɚɮɢɤɨɧɭ ʁɟ ɜɢɞʂɢɜɨ ɞɚ ʁɟ ɧɢɜɨ ɊɌɇ ɩɨɱɟɨ ɞɚ ɨɞɪɠɚɜɚ ɩɥɚɬɨ ɤɚɞɚ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɛɢɥɟ ɢɡɦɟђɭ 30 ɢ 40 ЧР/ЦХ. ɂɚɤɨ ɫɦɨ ɧɚɲɥɢ ɧɟɝɚɬɢɜɧɭ ɤɨɪɟɥɚɰɢʁɭ (r=-0,6906) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ ɭ ɧɚɲɟɦ ɢɫɬɪɚɠɢɜɚʃɭ, ɨɜɚʁ ɩɥɚɬɨ ɧɢʁɟ ɭɛɟɞʂɢɜ, ʁɟɪ ʁɟ ɧɟɞɨɜɨʂɚɧ ɛɪɨʁ ɢɫɩɢɬɚɧɢɤɚ ɢɦɚɨ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D>40 ЧР/ЦХ. 0 10 20 30 40 50 60 70 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Вɢɬɚɦɢɧ Д (ng/ml) Пɚ ɪɚ ɬɯ ɨɪ ɦɨ ɧ ( pg /m l) (p g/ m l) r = -0,6906 p < 0,0001 60 Ƚɪɚɮɢɤɨɧ ɛɪ. 25 Кɨɪɟɥɚɰɢјɚ ɤɨɧɰɟɧɬɪɚɰɢјɟ ALP ɫɚ ɤɨɧɰɟɧɬɪɚɰɢјɨɦ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 25 ɜɢɞʂɢɜɨ ʁɟ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ (r=0,442; p=0.00) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ȺLP ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɍɪɟɧɭɬɧɢ ɞɨɤɚɡɢ ɩɨʁɚɲʃɚɜɚʁɭ ɞɚ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ ɊɌɇ ʁɟ ɡɚ ɫɚɞɚ, ɧɚʁɛɨʂɢ ɢɧɞɢɪɟɤɬɧɢ ɩɨɤɚɡɚɬɟʂ ɫɢɫɬɟɦɫɤɢɯ ɟɮɟɤɚɬɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ). ɇɟɨɩɯɨɞɧɨ ʁɟ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɬɭɦɚɱɢɬɢ ɡɚʁɟɞɧɨ ɫɚ ɧɢɜɨɨɦ ɊɌɇ, ɚ ɧɟ ɢɡɨɥɨɜɚɧɨ ʁɟɞɚɧ ɨɞ ɞɪɭɝɨɝ ɩɚɪɚɦɟɬɪɚ. ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 26 ʁɟ ɩɪɢɤɚɡɚɧɚ ɤɨɪɟɥɚɰɢʁɚ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ (ɋɚ) ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɋɬɚɬɢɫɬɢɱɤɨɦ ɨɛɪɚɞɨɦ ɞɨɛɢʁɟɧɢɯ ɩɨɞɚɬɚɤɚ ɧɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɢ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɚɧɢɤɚ (r=-0,151; p=0,0645), ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɪɟɡɭɥɬɚɬɢɦɚ ɦɧɨɝɨɛɪɨʁɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ ɭ ɫɜɟɬɭ. 0 250 500 750 1000 1250 1500 1750 2000 2250 2500 200 180 160 140 120 100 80 60 40 20 0 Ⱥɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ (U/L) ɉɚ ɪɚ ɬɯɨ ɪɦ ɨɧ (p g/ m l) (p g/ m l) r = 0,4416 p < 0,0001 61 Ƚɪɚɮɢɤɨɧ ɛɪ. 26 Кɨɪɟɥɚɰɢјɚ ɤɨɧɰɟɧɬɪɚɰɢјɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢјɭɦɚ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢјɨɦ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ƚɪɚɮɢɤɨɧ ɛɪ. 27 Кɨɪɟɥɚɰɢјɚ ɤɨɧɰɟɧɬɪɚɰɢјɟ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢјɨɦ ɊɌɇ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6 1,8 2,0 2,2 2,4 2,6 2,8 3,0 200 180 160 140 120 100 80 60 40 20 0 Ʉɚɥɰɢјɭɦ (mmol/L) ɉɚ ɪɚ ɬɯɨ ɪɦ ɨɧ (p g/ m l) r = -0,1513 p = 0,0645 0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6 1,8 2,0 2,2 2,4 2,6 2,8 3,0 200 180 160 140 120 100 80 60 40 20 0 ɇɟɨɪɝɚɧɫɤɢ ɮɨɫɮɚɬ (mmol/L) ɉɚ ɪɚ ɬɯɨ ɪɦ ɨɧ (p Р/Ц Х) (p g/m l) r = -0,3098 p = 0,0001 62 ɇɚ ɝɪɚɮɢɤɨɧɭ ɛɪ. 27 ʁɟ ɩɪɢɤɚɡɚɧɚ ɤɨɪɟɥɚɰɢʁɚ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɉɢɪɫɨɧɨɜɢɦ ɬɟɫɬɨɦ ɤɨɪɟɥɚɰɢʁɟ ɭɬɜɪђɟɧɨ ʁɟ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ ɭ ɫɟɪɭɦɭ ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ (r=-0,3, p=0,0001). 63 ȾɂɋɄɍɋɂȳȺ Ɉɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ ɢɦɚʁɭ ɛɪɡɢ ɪɚɫɬ ɢ ɪɚɡɜɨʁ, ɚ ɫɚɦɢɦ ɬɢɦ ɢ ɜɟɥɢɤɟ ɩɨɬɪɟɛɟ ɡɚ ɯɪɚɧʂɢɜɢɦ ɦɚɬɟɪɢʁɚɦɚ. Ɇɚɥɨ ʁɟ ɞɨɫɬɭɩɧɢɯ ɫɬɭɞɢʁɚ ɢ ɩɨɞɚɬɚɤɚ ɨ ɤɨɥɢɱɢɧɢ ɩɨʁɟɞɢɧɢɯ ɧɭɬɪɢʁɟɧɚɬɚ ɤɨʁɟ ɛɢ ɡɚɞɨɜɨʂɢɥɟ ʃɢɯɨɜɟ ɩɨɬɪɟɛɟ ɭ ɢɫɯɪɚɧɢ (Koletzko, et al. 2004; Atkinson and Koletzko, 2007). ɂɫɬɪɚɠɢɜɚʃɚ Ⱥɬɤɢɧɫɨɧɚ ɢ Ʉɨɟɰɤɨɝ ɫɭ ɩɨɤɚɡɚɥɚɞɚ ʁɟ ɭɧɨɫ ɮɨɥɚɬɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ ɦɧɨɝɨ ɢɫɩɨɞ ɩɨɠɟʂɧɢɯ ɧɢɜɨɚ, ɲɬɨ ʁɟ ɩɨɜɟɡɚɧɨ ɫɚ ɧɢɫɤɢɦ ɤɨɧɰɟɧɬɪɚɰɢʁɚɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ɉɨɫɬɢɡɚʃɟ ɚɞɟɤɜɚɬɧɨɝ ɭɧɨɫɚ ɮɨɥɚɬɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɫɬɢɠɟ ɫɟ ɭɧɨɫɨɦ ɩɨʁɚɱɚɧɟ ɯɪɚɧɟ ɢ ɫɭɩɥɟɦɟɧɚɬɚ ɭ ɨɞɝɨɜɚɪɚʁɭʄɨʁ ɞɨɡɢ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɂɚɤɨ ɫɟ ɡɚ ɜɢɬɚɦɢɧ Ⱦ ɡɧɚ ɝɨɬɨɜɨ 100 ɝɨɞɢɧɚ, ɨɧ ɢ ɞɚʂɟ ɨɫɬɚʁɟ ɜɟɥɢɤɚ ɧɟɩɨɡɧɚɧɢɰɚ (Barret and McElduff, 2010). ɉɪɟɜɚɥɟɧɰɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɜɟɬɭ ʁɟ ɭ ɩɨɪɚɫɬɭ. ɍ ɧɚɲɨʁ ɫɬɭɞɢʁɢ ɜɪɲɟɧɚ ɫɭ ɤɥɢɧɢɱɤɚ ɢ ɥɚɛɨɪɚɬɨɪɢʁɫɤɚ ɢɫɩɢɬɢɜɚʃɚ ɭ 150 ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɂɫɩɢɬɢɜɚɧɚ ɫɭ ɨɞɨʁɱɚɞ ɨɞ ɧɚɜɪɲɟɧɢɯ ɦɟɫɟɰ ɞɚɧɚ ɞɨ 12 ɦɟɫɟɰК ɠɢɜɨɬɚ (ɇ=73) ɢ ɦɚɥɚ ɞɟɰɚ ɭɡɪɚɫɬɚ ɨɞ 13 ɞɨ 36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ (ɇ=77). ɍ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɭ ɭɡɪɚɫɬɭ ɨɞɨʁɱɚɞɢ, 36 ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɛɢɥɨ ɦɭɲɤɨɝ ɩɨɥɚ, ɞɨɤ ʁɟ 37 ɢɫɩɢɬɚɧɢɤɚ ɛɢɥɨ ɠɟɧɫɤɨɝ ɩɨɥɚ. ɍ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ, 37 ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɛɢɥɨ ɦɭɲɤɨɝ ɩɨɥɚ, ɚ 40 ɠɟɧɫɤɨɝ ɩɨɥɚ. ɂɫɩɢɬɭʁɭʄɢ ɭɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɧɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɭɱɟɫɬɚɥɨɫɬɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɨɜɟ ɞɜɟ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ, ʁɟɪ ʁɟ ɫɬɭɞɢʁɚ ɪɚђɟɧɚ ɧɚ ɦɚɥɨɦ ɛɪɨʁɭ ɢɫɩɢɬɚɧɢɤɚ. Ɋɟɡɭɥɬɚɬɢ ɜɟʄɢɧɟ ɛɪɨʁɚ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ʁɟ ɭɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɜɟʄɚ ɭ ɨɫɨɛɚ ɠɟɧɫɤɨɝ ɩɨɥɚ, ɞɨɤ ɞɪɭɝɚ ɝɪɭɩɚ ɧɚɭɱɧɢɤɚ ɫɦɚɬɪɚ ɞɚ ɧɢʁɟ ɧɚɩɪɚɜʂɟɧ ɞɨɜɨʂɚɧ ɛɪɨʁ ɫɬɭɞɢʁɚ ɨ ɤɨɧɰɟɧɬɪɚɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɤɨʁɢ ɛɢ ɭɬɜɪɞɢɨ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ɭ ɨɞɧɨɫɭ ɧɚ ɩɨɥ. ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ, ɧɚ ɨɫɧɨɜɭ ɩɨɞɟɥɟ ɢɫɩɢɬɚɧɢɤɚ ɩɪɟɦɚ ɤɨɧɰɟɧɬɪɚɰɢʁɢ 25(Ɉɇ)D, ɞɨɛɢɥɢ ɫɦɨ ɩɨɞɚɬɚɤ ɞɚ ʁɟ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (ȼȾȾ) ɧɚђɟɧ ɭ 58% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɩɨɜɟʄɚɧɨɦ ɭɱɟɫɬɚɥɨɲʄɭ ɜɢɬɚɦɢɧ Ⱦ 64 ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɭ ɡɟɦʂɚɦɚ ɲɢɪɨɦ ɫɜɟɬɚ, ɛɟɡ ɨɛɡɢɪɚ ɧɚ ɝɟɨɝɪɚɮɫɤɭ ɲɢɪɢɧɭ ɢ ɛɪɨʁ ɫɭɧɱɚɧɢɯ ɞɚɧɚ. ɉɪɟɦɚ ɪɟɡɭɥɬɚɬɢɦɚ ɩɪɟɫɟɤ ɫɬɭɞɢʁɟ ɭ ʁɭɧɭ ɦɟɫɟɰɭ ɨɞ ɫɬɪɚɧɟ Ⱥɪɯɢɜɚ ɩɟɞɢʁɚɬɪɢʁɟ, ɩɨɫɬɨʁɢ ɡɚɛɪɢɧɭɬɨɫɬ ɨ ɩɨɜɟʄɚɧɨʁ ɭɱɟɫɬɚɥɨɫɬɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɤɨʁɚ ɫɭ ɡɚɛɟɥɟɠɟɧɚ ɭ ɋȺȾ-ɭ ɨɞ Ⱥʂɚɫɤɟ, Ⱥʁɨɜɟ, ɇɟɜɚɞɟ, Ʉɚɥɢɮɨɪɧɢʁɟ, ɋɟɜɟɪɧɟ Ʉɚɪɨɥɢɧɟ, Ɍɟɤɫɚɫɚ, Ȼɨɫɬɨɧɚ (Bauchner, 2008).ɍ Ȼɨɫɬɨɧɭ ʁɟ ɭ 12% ɨɞɨʁɱɚɞɢ ɧɚђɟɧɚ ɢɫɭɮɢɰɢʁɟɧɰɢʁɚ ɢ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɤ ʁɟ 40% ɨɞɨʁɱɚɞɢ ɢɦɚɥɨ ɧɢɠɭ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɨɞ ɩɨɬɪɟɛɧɟ. ɇɚ ɨɫɧɨɜɭ ɢɫɩɢɬɢɜɚʃɚ ɪɚɫɩɪɨɫɬɪɚʃɟɧɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɭ Ʉɟɧɢʁɢ, ɭ ɩɟɪɢɨɞɭ ɨɞ ɚɩɪɢɥɚ 2010. ɝɨɞɢɧɟ ɞɨ ɦɚɪɬɚ 2011. ɝɨɞɢɧɟ, ɢɫɩɢɬɢɜɚɧɚ ɫɭ ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ (ɩɪɨɫɟɱɚɧ ɭɡɪɚɫɬ 22 ɦɟɫɟɰɚ). ȼɢɲɟ ɨɞ ɩɨɥɨɜɢɧɟ (58%) ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɢɦɚɥɨ ɫɭɛɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ (25(Ɉɇ)D<30 ЧР/ЦХ) ɢ 39% ȼȾȾ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 25(Ɉɇ)D<20 ЧР/ЦХ. Ɉɫɨɛɟ ɤɨʁɟ ɫɭ ɭ ɩɨɫɟɛɧɨʁ ɨɩɚɫɧɨɫɬɢ ɨɞ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɨɧɢ ɫɚ: 1. ɉɨɜɟʄɚɧɢɦ ɩɨɬɪɟɛɚɦɚ (ɬɪɭɞɧɢɰɟ, ɞɨʁɢʂɟ, ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ, ɞɟɰɚ ɢɡ ɛɥɢɡɚɧɚɱɤɟ ɢ ɜɢɲɟɫɬɪɭɤɟ ɬɪɭɞɧɨʄɟ, ɚɞɨɥɟɫɰɟɧɬɧɢ, ɝɨʁɚɡɧɢ), 2. ɋɦɚʃɟɧɢɦ ɢɡɥɚɝɚʃɟɦ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ, ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ, ɧɟɩɨɤɪɟɬɧɢ ɢ ɫɥɚɛɨ ɩɨɤɪɟɬɧɢ ɢ ɤɨʁɢ ɤɨɪɢɫɬɟ ɩɪɟɬɟɪɚɧɟ ɤɨɥɢɱɢɧɟ ɤɪɟɦɚ ɡɚ ɫɭɧɱɚʃɟ, 3. ɇɚ ɨɝɪɚɧɢɱɟɧɨʁ ɞɢʁɟɬɢ, ɜɟɝɟɬɚɪɢʁɚɧɰɢ ɢ ɜɟɝɚɧɢ, ɧɚ ɩɪɨɞɭɠɟɧɨɦ ɞɨʁɟʃɭ, ɞɢʁɟɬɢ ɛɟɡ ɦɥɟɤɚ ɭɫɥɟɞ ɚɥɟɪɝɢʁɟ, ɫɚ ɦɚɥɚɩɫɨɪɩɰɢʁɨɦ, ɛɨɥɟɫɬɢɦɚ ʁɟɬɪɟ ɢ ɛɭɛɪɟɝɚ, ɞɟɰɚ ɫɚ ɦɚɥɨɦ ɩɨɪɨђɚʁɧɨɦ ɦɚɫɨɦ (PM<2500 g) (Agarwal, et al. 2012), ɤɚɨ ɢ ɨɫɨɛɟ ɤɨʁɟ ɤɨɪɢɫɬɟ ɥɟɤɨɜɟ ɤɨʁɢ ɫɦɚʃɭʁɭ ʃɟɝɨɜɭ ɚɩɫɨɪɩɰɢʁɭ (ɚɧɬɢɤɨɧɜɭɥɡɢɜɢ, ɚɧɬɢɬɭɛɟɪɤɭɥɨɬɢɰɢ). ɂɚɤɨ ʁɟ ɫɭɧɰɟ ɭɨɛɢɱɚʁɟɧɢ ɢɡɜɨɪ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɫɯɪɚɧɚ ʁɟ ɧɚɪɚɜɧɨ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ. ɉɨɫɟɛɧɨ ʁɟ ɜɚɠɧɨ ɞɚ ɫɟ ɫɩɪɟɱɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ ɫɚ ɨɝɪɚɧɢɱɟɧɢɦ ɭɧɨɫɨɦ ɤɚɥɰɢʁɭɦɚ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ ɢ ɢɫɯɪɚɧɭ ɛɨɝɚɬɭ ɤɚɥɰɢјɭɦɨɦ ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɡɚɤʂɭɱɢɥɢ ɫɦɨ ɞɚ ʁɟ ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ (79%) ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ, ɛɢɥɨ ɧɚ ɩɪɢɪɨɞɧɨʁ ɢɫɯɪɚɧɢ ɦɚʁɱɢɧɢɦ ɦɥɟɤɨɦ (ɧɚ ɩɨɞɨʁɭ). ɍ ɝɪɭɩɢ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ ɢɡɞɜɨʁɢɥɢ ɫɦɨ ɞɜɟ ɝɪɭɩɟ. ɍ ɩɪɜɭ ɝɪɭɩɭ ɭɜɪɫɬɚɧɚ ɫɭ ɞɟɰɚ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ, ɢ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ 65 ɚɞɟɤɜɚɬɧɭ ɞɨɩɭɧɫɤɭ ɢɫɯɪɚɧɭ, 66 (70%). ɍ ɞɪɭɝɭ ɝɪɭɩɭ ɭɜɪɫɬɚɧɚ ɫɭ ɨɞɨʁɱɚɞ ɢ ɦɚɥɚ ɞɟɰɚ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɤɨʁɚ ɛɢɥɚ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ (ɭɡ ɧɟɚɞɟɤɜɚɬɧɭ ɞɨɩɭɧɫɤɭ ɢɫɯɪɚɧɭ) ɢɥɢ ɩɪɨɞɭɠɟɧɨɦ ɩɨɞɨʁɭ, 28 (30%). ɇɚ ɨɫɧɨɜɭ ɞɨɛɢʁɟɧɢɯ ɚɧɤɟɬɧɢɯ ɨɞɝɨɜɨɪɚ ɨ ɜɪɫɬɢ ɢ ɤɨɥɢɱɢɧɢ ɞɨɩɭɧɫɤɟ ɢɫɯɪɚɧɟ ɨɞɨʁɱɚɞɢ ɧɚ ɩɪɢɪɨɞɧɨʁ ɢɫɯɪɚɧɢ, ɫɚɡɧɚɥɢ ɫɦɨ ɞɚ ʁɟ ɭɧɨɫ ɦɟɫɚ, ɩɨɜɪʄɚ (ɧɚɪɨɱɢɬɨ ɦɚɯɭɧɚɪɤɢ ɢ ɡɟɥɟɧɨɝ ɥɢɫɧɚɬɨɝ ɩɨɜɪʄɚ) ɭ ɜɟɥɢɤɨɝ ɛɪɨʁɚ ɞɟɰɟ, ɧɚɪɨɱɢɬɨ ɭ ɝɪɭɩɢ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ ɛɢɨ ɧɟɞɨɜɨʂɚɧ. ȼɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɧɢʁɟ ɞɨɛɢʁɚɨ ɦɟɫɨ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ. ɍɧɨɫ ʁɚʁɚ, ɪɢɛɟ, ɡɟɥɟɧɨɝ ɥɢɫɧɚɬɨɝ ɩɨɜɪʄɚ ʁɟ ɛɢШ ɱɟɫɬɨ, ɢɥɢ ʁɚɤɨ ɨɫɤɭɞɚɧ ɢ ɧɟɞɨɜɨʂɚɧ, ɚ ɭ ɧɟɤɟ ɞɟɰɟ ɨɫɢɦ ɩɨɞɨʁɚ, ɦɥɟɱɧɢ ɩɪɨɢɡɜɨɞɢ ɧɢɫɭ ɛɢɥɢ ɭɜɪɲɬɟɧɢ ɭ ɢɫɯɪɚɧɭ. ɇɚʁɧɨɜɢʁɚ ɫɚɡɧɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ʁɟ ɜɟɥɢɤɢ ɛɪɨʁ ɟɬɢɨɥɨɲɤɢɯ ɮɚɤɬɨɪɚ ɤɨʁɢ ɭɡɪɨɤɭʁɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. Ɂɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɫɟ ɨɤɪɢɜʂɭʁɟ ɩɨɞɨʁ (ɧɚɪɨɱɢɬɨ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨʁ ɢ ɩɪɨɞɭɠɟɧɨ ɞɨʁɟʃɟ) ɭ ɭɡɪɚɫɬɭ ɨɞɨʁɱɚɞɢ, ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɠɢɜɨɬɚ. Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚʃɚ ɭ Јɨɪɞɚɧɭ ɫɭ ɩɨɤɚɡɚɥɚ ɞɚ ɫɭ, ɠɟɧɫɤɢ ɩɨɥ, ɦɚɥɚ ɢɡɥɨɠɟɧɨɫɬ ɫɭɧɰɭ ɢ ɟɤɫɤɥɭɡɢɜɧɨ ɞɨʁɟʃɟ, ɝɥɚɜɧɢ ɮɚɤɬɨɪɢ ɪɢɡɢɤɚ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ. Ʉɚɨ ɡɧɚɱɚʁɚɧ ɮɚɤɬɨɪ ɢɫɬɢɱɟ ɫɟ ɢɡɥɚɝɚʃɟ ɫɭɧɰɭ ɤɪɚʄɟ ɨɞ 30 ɦɢɧɭɬɚ ɞɧɟɜɧɨ (Abdul- Razzak, et al. 2011). ɂɫɬɪɚɠɢɜɚʃɟ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 6-23 ɦɟɫɟɰɢ ɧɚ Ⱥʂɚɫɰɢ ɬɨɤɨɦ 2001. ɢ 2002. ɝɨɞɢɧɟ, ɩɨɤɚɡɚɥɨ ʁɟ, ɞɚ ɫɭ ɜɟʄɟ ɲɚɧɫɟ ɡɚ ɚɛɧɨɪɦɚɥɧɨ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɢ ɫɪɟɞʃɟ ɧɢɫɤɢɦ ɜɪɟɞɧɨɫɬɢɦɚ, ɢɦɚɥɚ ɞɟɰɚ ɤɨʁɚ ɫɭ ɛɢɥɚ ʁɨɲ ɭɜɟɤ ɧɚ ɩɨɞɨʁɭ (Gessner, et al. 2003). Ɇɚʁɱɢɧɨ ɦɥɟɤɨ ɤɨɞ ɠɟɧɚ ɤɨʁɟ ɢɦɚʁɭ ɚɞɟɤɜɚɬɧɭ ɞɨɡɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ, ɫɚɞɪɠɢ ɜɪɥɨ ɦɚɥɨ ɜɢɬɚɦɢɧɚ Ⱦ, ɭ ɩɪɨɫɟɤɭ ɨɞ 22 IJ/L (ɨɞ 15 ɞɨ 50 IJ/L) (Leerbeck and Sondergaard, 1980), ɲɬɨ ɨɛʁɚɲʃɚɜɚ ɨɛɚɜɟɡɧɭ ɫɭɩɥɟɦɟɧɬɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɢɡɥɚɝɚʃɟ ɞɟɱʁɟ ɤɨɠɟ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ. Ⱦɭɝɨ ɞɨʁɟʃɟ ɫɟ ɩɨɜɟɡɭʁɟ ɫɚ ɫɩɨɪɢʁɢɦ ɪɚɫɬɨɦ ɢ ɧɢɠɢɦ ȻɆɂ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ. ȼɟɥɢɤɢ ɛɪɨʁ ɢɫɬɪɚɠɢɜɚʃɚ ɢɫɬɢɱɟ ɩɨɞɨʁ ɭɡ ɧɟɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɤɚɨ ʁɟɞɚɧ ɨɞ ɜɨɞɟʄɢɯ ɟɬɢɨɥɨɲɤɢɯ ɮɚɤɬɨɪɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ. ɍɨɛɢɱɚʁɟɧɚ ɢɫɯɪɚɧɚ ɨɞɨʁɱɚɞɢ ʁɟ ɫɢɪɨɦɚɲɧɚ ɭ ɜɢɬɚɦɢɧɭ Ⱦ. ɍ ɦɚʁɱɢɧɨɦ ɦɥɟɤɭ ɝɚ ɢɦɚ ɦɚɥɨ (10 IJ/100ЦХ), ɞɨɤ ʁɟ ɭ ɤɪɚɜʂɟɦ ɦɥɟɤɭ ʃɟɝɨɜɚ ɤɨɧɰɟɬɪɚɰɢʁɚ ʁɨɲ ɧɢɠɚ (4 IJ/100ЦХ). ɀɢɬɚɪɢɰɟ, ɩɨɜɪʄɟ ɢ ɜɨʄɟ ɢɦɚʁɭ ɫɚɦɨ ɧɟɡɧɚɬɧɟ ɤɨɥɢɱɢɧɟ ɜɢɬɚɦɢɧɚ Ⱦ. ȼɟʄɢɧɚ ɤɪɚɜʂɟɝ ɦɥɟɤɚ ɧɚ ɬɪɠɢɲɬɭ ʁɟ ɨɛɨɝɚʄɟɧɚ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɤɚɨ ɢ ɫɜɟ ɮɨɪɦɭɥɟ ɤɪɚɜʂɟɝ ɦɥɟɤɚ. Ʉɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɱɢɧɨɦ ɦɥɟɤɭ ʁɟ ɜɟɪɨɜɚɬɧɨ ɞɨɜɨʂɧɚ ɡɚ ɨɞɨʁɱɟ, ɭɤɨɥɢɤɨ ʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɦɚʁɤɟ ɤɨʁК ɫɟ ɞɨɜɨʂɧɨ ɢɡɥɚɠɟ ɫɭɧɱɟɜɨʁ 66 ɫɜɟɬɥɨɫɬɢ ɨɩɬɢɦɚɥɧɚ (ɚ ɞɨɤɚɡɚɧɨ ʁɟ ɞɚ ɧɢʁɟ ɨɩɬɢɦɚɥɧɚ). ɋɭɩɥɟɦɟɧɬɟ ɛɢ ɬɪɟɛɚɥɨ ɞɚɬɢ ɨɞɨʁɱɚɞɢ ɫɚ ɬɚɦɧɨɦ ɤɨɠɨɦ, ɤɨʁɚ ɫɟ ɧɟ ɢɡɥɚɠɭ ɞɨɜɨʂɧɨ ɞɭɝɨ ɫɭɧɱɟɜɨʁ ɫɜɟɬɥɨɫɬɢ. Ɇɚʁɤɟ ɤɨʁɟ ɞɨʁɟ ɫɜɨʁɭ ɞɟɰɭ, ɚ ɢɦɚʁɭ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ, ɫɜɨʁɨʁ ɞɟɰɢ ɞɚʁɭ ɦɧɨɝɨ ɦɚʃɟ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɞɨʁɟɦ. ɉɨɫɬɨʁɟ ɩɪɟɩɨɪɭɤɟ ɞɚ ɫɟ ɦɚʁɤɚɦɚ ɤɨʁɟ ɞɨʁɟ ɞɚʁɟ 4000 IJ ɜɢɬɚɦɢɧ Ⱦ ɞɧɟɜɧɨ, ɤɚɤɨ ɛɢ ɫɟ ɧɢɜɨ ʃɢɯɨɜɨɝ 25(OH)D ɩɨɜɟʄɚɨ ɧɚ ɜɪɟɞɧɨɫɬɢ ɢɡɧɚɞ 30 ЧР/ЦХ ɢ ɤɚɤɨ ɛɢ ɫɟ ɡɚɞɨɜɨʂɢɥɟ ɩɨɬɪɟɛɟ ɞɟɰɟ ɡɚ ɜɢɬɚɦɢɧɨɦ Ⱦ. ɇɟɞɚɜɧɟ ɫɬɭɞɢʁɟ ɩɨɤɚɡɭʁɭ ɞɚ ɫɟ ɨɩɬɢɦɚɥɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɦɨɠɟ ɩɨɫɬɢʄɢ ɚɤɨ ɦɚʁɤɚ ɭɧɨɫɢ ɦɧɨɝɨ ɜɟʄɟ ɞɨɡɟ ɨɞ ɩɪɟɩɨɪɭɱɟɧɟ (4000 ɞɨ 6400 ʁɟɞɢɧɢɰɚ ɞɧɟɜɧɨ). Ɉɜɚɤɚɜ ɩɪɢɫɬɭɩ ɫɟ ɧɟ ɩɪɟɩɨɪɭɱɭʁɟ ɦɚʁɤɚɦɚ (Basile, et al. 2006; Wagner and Greer, 2008). ɉɨɞɚɰɢ ɨ ɭɱɟɫɬɚɥɢɦ ɩɨʁɚɜɚɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ʁɚɜʂɚʁɭ ɫɟ ɢ ɭ ɞɪɠɚɜɚɦɚ ɝɞɟ ʁɟ ɢɡɜɪɲɟɧɚ ɮɨɪɬɢɮɢɤɚɰɢʁɚ ɦɥɟɤɚ ɢ ɞɪɭɝɟ ɯɪɚɧɟ, ɤɚɨ ɲɬɨ ɫɭ ɋȺȾ ɢ Ʉɚɧɚɞɚ. Ⱦɟɰɚ ɤɨʁɚ ɞɨɛɢʁɚʁɭ ɚɞɚɩɬɢɪɚɧɟ ɮɨɪɦɭɥɟ ɤɪɚɜʂɟɝ ɦɥɟɤɚ ≥ 500 ЦХ ɞɧɟɜɧɨ, ɩɭɬɟɦ ɦɥɟɤɚ ɭɧɟɫɭ 200 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɞɚɧ. Јɨɲ ɭɜɟɤ ɩɨɫɬɨʁɟ ɨɩɪɟɱɧɚ ɦɢɲʂɟʃɚ ɨ ɧɟɨɩɯɨɞɧɨʁ ɤɨɥɢɱɢɧɢ ɜɢɬɚɦɢɧɚ Ⱦ ɤɚɤɨ ɛɢ ɫɟ ɡɚɞɨɜɨʂɢɥɟ ɩɨɬɪɟɛɟ ɨɪɝɚɧɢɡɦɚ ɢ ɫɩɪɟɱɢɥО ɞɚɥɟɤɨɫɟɠɧɟ ɩɨɫɥɟɞɢɰɟ ɩɨ ɡɞɪɚɜʂɟ, ɭɤʂɭɱɭʁɭʄɢ ɨɲɬɟʄɟʃɟ ɨɪɝɚɧɚ, ɫɤɟɥɟɬɚ, ɞɟɮɨɪɦɢɬɟɬɟ ɢ ɱɟɫɬɟ ɩɪɟɥɨɦɟ, ɤɚɨ ɢ ɧɚɫɬɚʁɚʃɟ ɩɪɟɜɪɟɦɟɧɟ ɨɫɬɟɨɩɨɪɨɡɟ ɭ ɤɚɫɧɢʁɟɦ ɠɢɜɨɬɭ. Ⱥɦɟɪɢɱɤɚ ɚɤɚɞɟɦɢʁɚ ɩɟɞɢʁɚɬɚɪɚ (ȺȺɊ) ʁɟ 2008. ɝɨɞɢɧɟ ɞɚɥɚ ɩɪɟɩɨɪɭɤɟ ɞɚ ɞɟɰɚ ɧɚ ɩɨɞɨʁɭ ɢɥɢ ɨɧɚ ɤɨʁɚ ɤɨɧɡɭɦɢɪɚʁɭ ɦɚʃɟ ɨɞ ʁɟɞɚɧ ɥɢɬɚɪ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ ɞɧɟɜɧɨ ɬɪɟɛɚ ɞɚ ɞɨɛɢʁɚʁɭ 400 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ ɤɚɤɨ ɛɢ ɫɟ ɨɞɪɠɚɨ ɞɨɜɨʂɚɧ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɱʁɟɦ ɨɪɝɚɧɢɡɦɭ (Misra, et al. 2008; Wagner and Greer, 2008). Ɏɨɪɬɢɮɢɤɚɰɢɨɧɟ ɦɥɟɱɧɟ ɮɨɪɦɭɥɟ ɡɚ ɨɞɨʁɱɚɞ ɧɢɫɭ ɡɚɞɨɜɨʂɚɜɚɥɟ ɧɢɜɨ ɤɨʁɢ ɛɢ ɨɦɨɝɭʄɢɨ ɚɞɟɤɜɚɬɧɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ, ʁɟɪ FDA (Food and Drug Administration) ɫɦɚɬɪɚ ɞɚ ɦɥɟɤɚ ɬɪɟɛɚ ɞɚ ɛɭɞɭ ɨɛɨɝɚʄɟɧɚ ɜɢɬɚɦɢɧɨɦ Ⱦ ɫɚ 40-100 IJ/100 kcal (Wagner and Greer, 2008). ɉɨɲɬɨ ɫɟ ɫɦɚɬɪɚ ɞɚ ɜɟʄɢɧɚ ɨɞɨʁɱɚɞɢ ɤɨʁɚ ɞɨɛɢʁɚ ɮɨɪɦɭɥɟ ɤɪɚɜʂɟɝ ɦɥɟɤɚ, ɞɧɟɜɧɨ ɭɧɨɫɢ ɨɤɨ ɥɢɬɚɪ ɦɥɟɤɚ, ɲɬɨ ɡɚɞɨɜɨʂɚɜɚ ɩɨɬɪɟɛɟ ɡɚ ɞɧɟɜɧɨɦ ɞɨɡɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɨɞ 400 IJ, ɡɚ ɞɟɰɭ ɤɨʁɚ ɫɭ ɧɚ ɞɜɨɜɪɫɧɨʁ ɢɫɯɪɚɧɢ ɢ ɤɨʁɚ ɨɫɢɦ ɩɨɞɨʁɚ ɞɨɛɢʁɚʁɭ ɦɥɟɱɧɭ ɮɨɪɦɭɥɭ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɛɥɢɤɭ ɫɭɩɥɟɦɟɧɬɚ ɬɚɤɨђɟ ɬɪɟɛɚ ɞɚ ɢɡɧɨɫɢ 400 IJ ɧɚ ɞɚɧ (Wagner and Greer, 2008). Ʉɚɧɚɞɫɤɢ ɉɟɞɢʁɚɬɪɢʁɫɤɢ ɉɪɨɝɪɚɦ ɇɚɞɡɨɪɚ (CPSP) ɧɟɞɚɜɧɨ ʁɟ ɭɤʂɭɱɢɨ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (ɪɚɯɢɬɢɫɚ) ɭ ɫɜɨʁ ɧɚɰɢɨɧɚɥɧɢ ɩɪɨɝɪɚɦ ɡɚ ɧɚɞɡɨɪ (Prentice and Goldberg, 2008). 104 ɫɥɭɱɚʁɚ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɩɪɢʁɚɜʂɟɧɚ ɬɨɤɨɦ ɞɜɨɝɨɞɢɲʃɟɝ ɩɟɪɢɨɞɚ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɨɞ ɤɨʁɢɯ ʁɟ 96,2% ɛɢɥɨ ɧɚ 67 ɩɨɞɨʁɭ. 86,5% ɨɜɟ ɞɟɰɟ ɧɢʁɟ ɞɨɛɢʁɚɥɨ ɜɢɬɚɦɢɧ Ⱦ. ɒɟɫɬɨɪɨ ɞɟɰɟ ʁɟ ɯɪɚʃɟɧɨ ɦɥɟɱɧɢɦ ɮɨɪɦɭɥɚɦɚ. ɋɜɢɯ ɲɟɫɬɨɪɨ ɫɭ ɛɢɥɢ ɪɨђɟɧɢ ɭ ɬɟɪɦɢɧɭ, ɠɢɜɟɥɢ ɧɚ ɩɪɢɛɥɢɠɧɨ 54. ɩɚɪɚɥɟɥɢ ɝɟɨɝɪɚɮɫɤɟ ɲɢɪɢɧɟ, ɞɨɛɢʁɚɥɢ ɫɭ ɮɨɪɦɭɥɟ ɨɛɨɝɚʄɟɧɟ ɜɢɬɚɦɢɧɨɦ Ⱦ ɢ ɞɨɛɪɨ ɫɭ ɧɚɩɪɟɞɨɜɚɥɢ. Ʉɨɧɰɟɧɬɪɚɰɢʁɚ 25 ɯɢɞɪɨɤɫɢ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥɚ ʁɟ ɛɢɥɚ ɢɫɩɨɞ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ ɭ ɫɜɟ ɨɞɨʁɱɚɞɢ. Ʉɨɧɰɟɧɬɪɚɰɢʁɚ 25 ɯɢɞɪɨɤɫɢ ɯɨɥɟɤɚɥɰɢɮɟɪɨɥɚ, (25(OH)D) je ɭɪɚђɟɧ ɤɨɞ ɞɜɟ ɦɚʁɤɟ, ɢ ɛɢɨ ʁɟ ɞɟɮɢɰɢɬɚɪɚɧ (16 ЧЦШХ/L (< 6,5 ЧР/ЦХ) ɢ <15 ЧЦШХ/L (< 6 ЧР/ЦХ). Ȼɢɥɨ ʁɟ ɜɢɲɟ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɡɚ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ, ɭɤʂɭɱɭʁɭʄɢ: ɬɚɦɧɢʁɭ ɩɢɝɦɟɧɬɚɰɢʁɭ ɤɨɠɟ, ɫɦɚʃɟɧɨ ɢɡɥɚɝɚʃɟ ɤɨɠɟ ɫɭɧɰɭ, ɛɨɪɚɜɚɤ ɧɚ ɫɟɜɟɪɧɨʁ ɝɟɨɝɪɚɮɫɤɨʁ ɲɢɪɢɧɢ ɨɞ 54º, ɤɚɨ ɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɤɢ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ. Ⱦɨ ɫɚɞɚ ʁɟ ɦɚʃɟ ɢɫɩɢɬɢɜɚɧɚ ɝɪɭɩɚ ɦɚɥɟ ɞɟɰɟ, ɤɨʁɚ ɞɨɛɢʁɚʁɭ ɧɟɦɥɟɱɧɭ ɯɪɚɧɭ, ɢ ɪɚɡɧɟ ɜɪɫɬɟ ɦɥɟɤɚ ɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ (Gordon, et al. 2008). ɍ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ ɚɤɰɟɧɚɬ ɫɟ ɞɚʁɟ ɧɟɞɨɜɨʂɧɨɦ ɭɧɨɫɭ ɦɥɟɤɚ ɢ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ. ɂɡ ɚɧɤɟɬɧɢɯ ɨɞɝɨɜɨɪɚ ɞɨɲɥɢ ɫɦɨ ɞɨ ɩɨɞɚɬɤɚ ɞɚ ɧɟɤɚ ɞɟɰɚ ɭɨɩɲɬɟ ɧɟ ɭɡɢɦɚʁɭ (ɧɟ ɜɨɥɟ) ɦɥɟɤɨ. ɑɟɫɬɨ ʁɟ ɭ ɬɟ ɞɟɰɟ ɢ ɭɧɨɫ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ (ɤɚɨ ɡɧɚɱɚʁɚɧ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ) ɛɢɨ ɧɟɞɨɜɨʂɚɧ. Ɉɧɢ ɤɨʁɢ ɫɭ ɩɢɥɢ ɦɥɟɤɨ ɪɟђɟ ɨɞ ʁɟɞɧɨɦ ɧɟɞɟʂɧɨ ɫɭ ɛɢɥɢ ɦɟђɭ ɧɚʁɪɢɡɢɱɧɢʁɢɦɚ ɡɚ ɧɚɫɬɚɧɚɤ ɞɟɮɢɰɢɬɚ ɜɢɬɚɦɢɧɚ Ⱦ (Med J Aust. 2013). ɍ Ȼɨɫɬɨɧɭ ʁɟ ɜɪɲɟɧɨ ɢɫɬɪɚɠɢɜɚʃɟ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ 247 ɨɞɨʁɱɚɞɢ ɢ 133 ɦɚɥɟ ɞɟɰɟ (ɭɡɪɚɫɬɚ ɨɞ 1-2 ɝɨɞɢɧɟ). Јɟɞɢɧɢ ɡɚʁɟɞɧɢɱɤɢ ɮɚɤɬɨɪɢ ɡɚ ɧɢɫɤɭ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɩɪɟɞɫɬɚɜʂɚɥɢ ɞɨʁɟʃɟ ɛɟɡ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɭɧɨɫ ɦɚɥɟ ɤɨɥɢɱɢɧɟ ɦɥɟɤɚ ɭ ɦɚɥɟ ɞɟɰɟ (Bauchner, 2008). ɍɬɜɪђɟɧɚ ʁɟ ɞɟɮɢɰɢʁɟɧɰɢʁɚ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ 70% ɚɦɟɪɢɱɤɟ ɞɟɰɟ. ɂɫɬɪɚɠɢɜɚʃɚ ɭ Ⱥɭɫɬɪɚɥɢʁɢ ɢɡ 2013. ɝɨɞɢɧɟ ɩɨɤɚɡɚɥɚ ɫɭ ɞɚ ʁɟ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ɛɢɥɚ ɧɚʁɜɟʄɚ ɭ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ ɤɨʁɚ ɫɭ ɩɢɥɚ ɦɥɟɤɨ (ɤɚɨ ɡɧɚɱɚʁɚɧ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ) ɪɟђɟ ɨɞ ʁɟɞɧɨɦ ɧɟɞɟʂɧɨ. ɉɭɬɟɦ ɢɫɯɪɚɧɟ ʂɭɞɢ ɦɨɝɭ ɞɚ ɩɨɤɪɢʁɭ ɨɤɨ 10% ɦɢɧɢɦɚɥɧɢɯ ɩɨɬɪɟɛɚ ɡɚ ɜɢɬɚɦɢɧɨɦ Ⱦ. ɂɡɭɡɢɦɚʁɭʄɢ ɪɢɛʂɟ ɭʂɟ, ɥɨɫɨɫ, ɬɭɧɭ, ɯɚɪɢɧɝɟ, ɫɚɪɞɢɧɟ ɢ ɞɪɭɝɟ ɦɨɪɫɤɟ ɪɢɛɟ, ɠɭɦɚɧɰɟ, ɛɭɬɟɪ, ɚɜɨɤɚɞɨ, ɤɚʁɦɚɤ, ɝɨɜɟɞɢɧɭ, ɰɪɧɭ џɢɝɟɪɢɰɭ, ɩɟɱɭɪɤɟ ɢ ɤɜɚɫɚɰ, ɯɪɚɧɚ ʁɟ ɞɨɫɬɚ ɨɫɤɭɞɧɚ ɭ ɜɢɬɚɦɢɧɭ Ⱦ, ɬɟ ɫɟ ɡɧɚɱɚʁɚɧ ɞɟɨ ɮɢɡɢɨɥɨɲɤɢɯ ɩɨɬɪɟɛɚ ɭ ɨɜɨɦ ɦɢɤɪɨɧɭɬɪɢʁɟɧɬɭ ɨɫɬɜɚɪɭʁɟ ɮɨɬɨɥɢɡɨɦ 7-ɞɟɯɢɞɪɨ-ɯɨɥɟɫɬɟɪɨɥɚ ɭ ɤɨɠɢ ɟɤɫɩɨɧɢɪɚɧɨʁ ɭɥɬɪɚʂɭɛɢɱɚɫɬɢɦ ɡɪɚɰɢɦɚ ɬɚɥɚɫɧɟ ɞɭɠɢɧɟ 270-300 ЧЦ. ɉɪɨɜɢɬɚɦɢɧ Ⱦ (7- ɞɟɯɢɞɪɨɯɨɥɟɫɬɟɪɨɥ), ɧɚɫɬɚʁɟ ɭ ʁɟɬɪɢ ɢɡ ɯɨɥɟɫɬɟɪɨɥɚ ɢ ɞɟɩɨɧɭʁɟ ɫɟ ɭ ɤɨɠɢ. 68 ɋɥɢɤɚ ɛɪ. 4 ɍɬɢɰɚј ɫɭɧɱɟɜɟ ɫɜɟɬɥɨɫɬɢ ɢ ɜɢɬɚɦɢɧɚ Д ɭ ɯɪɚɧɢ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Д ɭ ɨɪɝɚɧɢɡɦɭ ɇɚʁɩɨɡɧɚɬɢʁɢ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ ɭ ɢɫɯɪɚɧɢ ɫɭ: ɦɥɟɤɨ, ɦɥɟɱɧɢ ɩɪɨɢɡɜɨɞɢ, ɦɚɯɭɧɚɪɤɟ, ɡɟɥɟɧɨ ɥɢɫɧɚɬɨ ɩɨɜɪʄɟ, ʁɚʁɟ (ɠɭɦɚɧɚɰ), ɫɚɪɞɢɧɟ, ɱɨɤɨɥɚɞɚ. ɇɟɤɟ ɨɫɨɛɟ ɢɦɚʁɭ ɩɨɬɟɲɤɨʄɟ ɫɚ ɜɚɪɟʃɟɦ ɦɥɟɤɚ ʁɟɪ ɫɟ ɩɨɞ ɞɟʁɫɬɜɨɦ ɯɥɨɪɨɜɨɞɨɧɢɱɧɟ ɤɢɫɟɥɢɧɟ ɢɡ ɠɟɥɭɰɚ ɫɬɜɚɪɚ ɫɢɪɧɢ ɭɝɪɭɲɚɤ - ɤɚɥɰɢʁɭɦ-ɤɚɡɟɢɧ ɤɨɦɩɥɟɤɫ, ɤɨʁɢ ʁɟ ɬɟɲɤɨ ɫɜɚɪʂɢɜ, ɧɚɪɨɱɢɬɨ ɤɨɞ ɫɬɚɪɢʁɢɯ, ɤɨɞ ɤɨʁɢɯ ʁɟ ɫɦɚʃɟɧɚ ɤɨɥɢɱɢɧɚ ɟɧɡɢɦɚ ɤɨʁɚ ʁɟ ɜɚɠɧɚ ɡɚ ʃɟɝɨɜɨ ɪɚɡɥɚɝɚʃɟ. Ʉɨɞ ɞɪɭɝɢɯ ɨɫɨɛɚ, ɤɨʁɟ ɢɦɚʁɭ ɢɧɬɨɥɟɪɚɧɰɢʁɭ ɧɚ ɥɚɤɬɨɡɭ, ɭɫɥɟɞ ɧɟɞɨɫɬɚɬɤɚ ɟɧɡɢɦɚ ɥɚɤɬɚɡɟ ɤɨʁɢ ɪɚɡɥɚɠɟ ɥɚɤɬɨɡɭ ɧɚ ɝɥɭɤɨɡɭ ɢ ɝɚɥɚɤɬɨɡɭ, ɩɪɢ ɱɟɦɭ ɫɟ ɨɫɥɨɛɚђɚ ɦɥɟɱɧɚ ɤɢɫɟɥɢɧɚ ɤɨʁɚ ɨɛɟɡɛɟђɭʁɟ ɪɇ=5 ɭ ɞɢɝɟɫɬɢɜɧɨɦ ɬɪɚɤɬɭ, ɚ ɲɬɨ ʁɟ ɜɚɠɧɨ ɡɚ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ, ɬɨ ɫɟ ɪɟɲɚɜɚ ɭɩɨɬɪɟɛɨɦ ɮɟɪɦɟɧɬɢɫɚɧɢɯ ɦɥɟɱɧɢɯ ɩɪɨɢɡɜɨɞɚ, ɤɚɨ ɲɬɨ ɫɭ ʁɨɝɭɪɬ ɢ ɫɭɪɭɬɤɚ. ɍ ʃɢɦɚ ɫɟ ɩɨɞ ɞɟʁɫɬɜɨɦ ɥɚɤɬɨɛɚɰɢɥɚ ɢ ɛɢɮɢɞɭɫ ɛɚɤɬɟɪɢʁɚ ɫɬɜɚɪɚ ɟɧɡɢɦ ɥɚɤɬɚɡɚ ɤɨʁɚ ɩɨɬɩɨɦɚɠɟ ɯɢɞɪɨɥɢɡɭ ɥɚɤɬɨɡɟ. ɇɚ ɨɫɧɨɜɭ ɧɚɜɟɞɟɧɨɝ, ɦɨɠɟɦɨ ɡɚɤʂɭɱɢɬɢ, ɞɚ, ɚɞɟɤɜɚɬɚɧ ɭɧɨɫ ɤɚɥɰɢʁɭɦɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɦɚ ɡɧɚɱɚʁɧɭ ɭɥɨɝɭ ɭ ɩɪɟɜɟɧɰɢʁɢ ɨɫɬɟɨɩɨɪɨɡɟ ɭ ɞɟɰɟ ɢ ɫɬɚɪɢʁɢɯ (Jackson, et al. 2006). ȼɢɬɚɦɢɧ Ⱦ ʁɟ ɧɟɨɩɯɨɞɚɧ ɡɚ ɭɝɪɚɞʃɭ ɤɚɥɰɢʁɭɦɚ ɭ ɤɨɫɬɢ, ɚɥɢ ɢɫɬɪɚɠɢɜɚʃɚ ɫɭ ɞɨɤɚɡɚɥɚ ɞɚ ɨɞɨʁɱɚɞ ɢ ɞɟɰɚ ɤɨʁɚ ɧɟ ɞɨɛɢʁɚʁɭ ɞɨɜɨʂɧɨ ɤɚɥɰɢʁɭɦɚ ɢɡ ɯɪɚɧɟ ɢ ɦɥɟɤɚ ɢɦɚʁɭ ɜɟʄɟ ɲɚɧɫɟ ɞɚ ɞɨɛɢʁɭ ɪɚɯɢɬɢɫ (Pettifor, 2004). Ɉɫɢɦ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, ɩɪɟɩɨɪɭɱɭʁɟ ɫɟ ɫɜɚɤɨɞɧɟɜɧɨ ɭɧɨɫ 500 ЦР ɤɚɥɰɢʁɭɦɚ ɩɭɬɟɦ ɯɪɚɧɟ (Bauchner, 2008). Ʉɨɞ ɧɢɫɤɨɝ ɭɧɨɫɚ ɤɚɥɰɢʁɭɦɚ, ɭɤɭɩɧɚ ˁу̸̦ање ;ϮϬ ̛̥̦утаͿ ʺлеко ;ϭ ̹ољаͿ Ло̭о̭ ;ϭϬϬ ̬̐а̥аͿ Јаје ʺа̬̐а̛̬̦ ;ϭ ка̛̹каͿ Џ̛̐е̛̬ца ;ϭϬϬ ̬̐а̥аͿ Ка̸ка̏аљ ;ϯϬ ̬̐а̥аͿ 69 ɤɨɥɢɱɢɧɚ ɚɩɫɨɪɛɨɜɚɧɨɝ ɤɚɥɰɢʁɭɦɚ ʁɟ ɧɢɫɤɚ, ɧɟɡɚɜɢɫɧɨ ɨ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ. ȿɮɢɤɚɫɧɨɫɬ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ ɪɚɫɬɟ ɫɚ ɩɨɪɚɫɬɨɦ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɭ ɭɫɥɨɜɢɦɚ ɧɢɫɤɨɝ ɭɧɨɫɚ ɤɚɥɰɢʁɭɦɚ. Ɂɛɨɝ ɬɨɝɚ, ɫɤɨɪɨ ʁɟ ɧɟɦɨɝɭʄɟ ɨɫɬɜɚɪɢɬɢ ɚɞɟɤɜɚɬɧɭ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɛɟɡ ɚɤɬɢɜɧɟ ɚɩɫɨɪɩɰɢʁɟ ɩɨɫɪɟɞɨɜɚɧɟ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɩɚ ɢ ɩɪɢ ʁɚɤɨ ɦɚɥɨɦ ɭɧɨɫɭ ɤɚɥɰɢʁɭɦɚ. ɋɚɦɢɦ ɬɢɦ ɦɨɠɟɦɨ ɡɚɤʂɭɱɢɬɢ ɞɚ ʁɟ ɡɚ ɚɞɟɤɜɚɬɧɭ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ ɢɡ ɰɪɟɜɚ, ɧɟɨɩɯɨɞɚɧ, ɢ ɨɞɝɨɜɚɪɚʁɭʄɢ ɭɧɨɫ ɤɚɥɰɢʁɭɦɚ, ɢ ɨɞɝɨɜɚɪɚʁɭʄɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɍ ɫɜɨʁɢɦ ɢɫɬɪɚɠɢɜɚʃɢɦɚ ɭ ɬɨɤɭ 2013. ɝɨɞɢɧɟ, Нr LУТХУКЧК JurčОvТć HКrtЧОв ɨɛʁɚɲʃɚɜɚ, ɞɚ ɫɚɦɨɦ ɚɩɫɨɪɩɰɢʁɨɦ ɤɚɥɰɢʁɭɦɚ, ɧɟ ɨɛɟɡɛɟђɭʁɟɦɨ ɞɚ ʄɟ ɫɟ ɨɧ ɫɢɝɭɪɧɨ ɭɝɪɚɞɢɬɢ ɧɚ ɠɟʂɟɧɚ ɦɟɫɬɚ, ɚ ɬɨ ɫɭ ɡɭɛɢ ɢ ɤɨɫɬɢ, ɜɟʄ ʁɟ ɡɚ ɬɨ ɨɞɝɨɜɨɪɚɧ ɜɢɬɚɦɢɧ Ʉ. ɂ ɩɨɪɟɞ ɚɞɟɤɜɚɬɧɨɝ, ɱɚɤ ɢ ɩɨɜɟʄɚɧɨɝ ɭɧɨɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɤɚɥɰɢʁɭɦɚ, ɚ ɭɫɥɟɞ ɦɚʃɤɚ ɜɢɬɚɦɢɧɚ Ʉ, ɦɨɠɟ ɞɨʄɢ ɞɨ ɨɞɥɚɝɚʃɚ ɤɚɥɰɢʁɭɦɚ ɭ ɧɟɤɚ ɞɪɭɝɚ ɧɟɠɟʂɟɧɚ ɦɟɫɬɚ, ɤɚɨ ɲɬɨ ɫɭ ɦɟɤɚ ɬɤɢɜɚ (ɛɭɛɪɟɡɢ, ɤɪɜɧɢ ɫɭɞɨɜɢ ɢ ɞɪ.). Ȼɟɡ ɜɢɬɚɦɢɧɚ Ⱦ, ɫɚɦɨ 10-15% ɞɢʁɟɬɟɬɫɤɨɝ ɤɚɥɰɢʁɭɦɚ ɢ ɨɤɨ 60% ɮɨɫɮɨɪɚ ɫɟ ɚɩɫɨɪɛɭʁɟ. ɂɧɬɟɪɚɤɰɢʁɚ 1,25(Ɉɇ)2D ɫɚ ȼȾɊ ɩɨɜɟʄɚɜɚ ɟɮɢɤɚɫɧɨɫɬ ɢɧɬɟɫɬɢɧɚɥɧɟ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ ɧɚ 30-40% ɢ ɚɩɫɨɪɩɰɢʁɭ ɮɨɫɮɚɬɚ ɧɚ ɨɤɨ 80% (Holick, 2007). ɉɪɢɞɪɭɠɟɧɢ ɮɚɤɬɨɪɢ ɤɨјɢ ɭɬɢɱɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɉɨɲɬɨ ɫɟ ɢɧɬɪɚɭɬɟɪɢɧɨ ɜɢɬɚɦɢɧ Ⱦ ɬɪɚɧɫɩɥɚɰɟɧɬɚɪɧɨ ɩɪɟɧɨɫɢ ɭ ɨɪɝɚɧɢɡɚɦ ɮɟɬɭɫɚ ɭ ɡɚɞʃɟɦ ɬɪɢɦɟɫɬɪɭ ɬɪɭɞɧɨʄɟ, ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɭ ɞɢɪɟɤɬɧɨʁ ʁɟ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɦɚɬɟɪɧɚɥɧɨɝ ɜɢɬɚɦɢɧɚ Ⱦ, ɤɨʁɢ ɡɚɜɢɫɢ ɨɞ ɫɬɟɩɟɧɚ ɢɡɥɨɠɟɧɨɫɬɢ ɦɚʁɱɢɧɟ ɤɨɠɟ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ, ɤɚɨ ɢ ɤɜɚɥɢɬɟɬɚ ʃɟɧɟ ɢɫɯɪɚɧɟ. Ɂɚɬɨ ʁɟ ɧɟɨɩɯɨɞɧɨ ɩɪɚʄɟʃɟ ɦɚɬɟɪɧɚɥɧɨɝ ɫɬɚɬɭɫɚ ɤɚɥɰɢʁɭɦɚ, ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ, ɧɢɜɨɚ ɩɚɪɚɬɯɨɪɦɨɧɚ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɤɚɨ ɢ ɟɜɟɧɬɭɚɥɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɭ ʃɟɧɨɦ ɪɟɩɪɨɞɭɤɬɢɜɧɨɦ ɩɟɪɢɨɞɭ. ɍ ɜɪɟɦɟ ɪɨђɟʃɚ, 76% ɦɚʁɤɢ ɢ 81% ɧɨɜɨɪɨђɟɧɱɚɞɢ ɫɭ ɢɦɚɥɟ ɦɚʃɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɚɤɨ ɫɭ ɠɟɧɟ ɬɨɤɨɦ ɬɪɭɞɧɨʄɟ ɭɡɢɦɚɥɟ 600 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ (RШvЧОr КЧН O’BrТОЧ, 2008). Ⱥɤɨ ɦɚʁɤɚ ɭ ɬɨɤɭ ɬɪɭɞɧɨʄɟ ɢɦɚ ɢɡɪɚɠɟɧɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ, ɜɟʄɟ ɫɭ ɲɚɧɫɟ ɞɚ ɢ ɞɟɬɟ ɞɨɛɢʁɟ ɪɚɯɢɬɢɫ. ɀɟɧɟ ɤɨʁɟ ɢɦɚʁɭ ɬɚɦɧɢʁɭ ɤɨɠɭ, ɢ ɠɟɧɟ ɤɨʁɟ ɧɟ ɢɡɥɚɠɭ ɞɨɜɨʂɧɨ ɫɜɨʁɭ ɤɨɠɭ ɫɭɧɰɭ, ɱɟɲʄɟ ɢɦɚʁɭ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (Wagner and Greer, 2008). Ⱥɤɨ ʁɟ ɠɟɧɚ ɬɪɭɞɧɚ, ɬɪɟɛɚ ɪɚɡɦɨɬɪɢɬɢ ɞɨɩɭɧɭ ɜɢɬɚɦɢɧɚ Ⱦ, ɧɚɪɨɱɢɬɨ ɤɨɞ ɨɧɢɯ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ, ɢɥɢ ɤɨɞ ɬɪɭɞɧɢɰɚ ɤɨʁɟ ɫɭ ɫɥɚɛɢʁɟ ɢɡɥɨɠɟɧɟ ɫɭɧɰɭ. ɋɚɜɟɬ 70 ɩɪɟɩɨɪɭɱɭʁɟ ɬɪɭɞɧɢɰɚɦɚ ɭɡɢɦɚʃɟ 4000 ɞɨ 6000 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɫɜɚɤɨɝ ɞɚɧɚ ɭ ɬɪɭɞɧɨʄɢ. Ⱦɪɭɝɟ ɨɪɝɚɧɢɡɚɰɢʁɟ ɭ ɋȺȾ-ɭ ɩɪɟɩɨɪɭɱɭʁɭ ɪɚɡɥɢɱɢɬɟ ɞɧɟɜɧɟ ɤɨɥɢɱɢɧɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɨɛɢɱɧɨ ɦɧɨɝɨ ɦɚʃɟ. Ɉɞɛɨɪ ɡɚ ɯɪɚɧɭ ɢ ɢɫɯɪɚɧɭ ɩɪɟɩɨɪɭɱɭʁɟ 600 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɫɜɚɤɨɝ ɞɚɧɚ ʁɟɪ ɫɦɚɬɪɚ ɞɚ ʁɨɲ ɭɜɟɤ ɧɟɦɚ ɞɨɜɨʂɧɨ ɢɫɬɪɚɠɢɜɚʃɚ ɤɨʁɚ ɛɢ ɞɨɤɚɡɚɥɚ ɞɚ ɩɪɟɩɨɪɭɱɟɧɟ ɞɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ ɬɪɟɛɚ ɞɚ ɛɭɞɭ ɜɟʄɟ. ɇɚɭɱɧɢ ɩɨɞɚɰɢ ɤɨʁɢ ɝɨɜɨɪɟ ɨ ɧɟɨɩɯɨɞɧɨʁ ɫɭɩɥɟɦɟɧɬɚɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɤɢ ɬɨɤɨɦ ɥɚɤɬɚɰɢʁɟ ɫɭ ʁɨɲ ɭɜɟɤ ɧɟɞɨɜɨʂɧɨ ɩɪɨɭɱɟɧɢ. Ⱦɧɟɜɧɢ ɩɪɟɩɨɪɭɱɟɧɢ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɤɢ ɤɨʁɟ ɞɨʁɟ ɢɡɧɨɫɢ 400 IJ (10 ЦР/ɞɚɧ). Ɉɜɚʁ ɭɧɨɫ ɛɢ ɬɪɟɛɚɨ ɞɚ ɨɦɨɝɭʄɢ ɧɨɪɦɚɥɚɧ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɚʁɤɢ ɢ ɨɞɨʁɱɚɞɢ ɧɚ ɩɨɞɨʁɭ, ɧɚɪɨɱɢɬɨ ɭ ɝɪɭɩɢ ɬɚɦɧɨ ɩɢɝɦɟɧɬɨɜɚɧɢɯ ɢɫɩɢɬɚɧɢɤɚ. ɍ ɫɬɭɞɢʁɢ ɤɨʁɚ ʁɟ ɢɫɩɢɬɢɜɚɥɚ ɜɪɟɞɧɨɫɬ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɦɚʁɤɢ ɤɨʁɟ ɫɭ ɞɨɛɢʁɚɥɟ 2000 (1600 IJ ɜɢɬɚɦɢɧɚ Ⱦ2 ɢ 400 IJ ɜɢɬɚɦɢɧɚ Ⱦ3) ɢ 4000 IJ/ɞɚɧ ɜɢɬɚɦɢɧɚ Ⱦ, ɞɨɲɥɨ ʁɟ ɞɨ ɩɨɜɟʄɚʃɚ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɨɛɟɦɚ ɝɪɭɩɚɦɚ. Ʉɨɧɰɟɧɬɪɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɦɥɟɤɭ ʁɟ ɩɨɪɚɫɥɚ ɡɚ 34,2 IJ/L ɭ ɝɪɭɩɢ ɤɨʁɚ ʁɟ ɞɨɛɢʁɚɥɚ 2000 IJ/ɞɚɧ, ɚ ɡɚ 94,2 IJ/L ɭ ɝɪɭɩɢ ɤɨʁɚ ʁɟ ɞɨɛɢʁɚɥɚ 4000 IJ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ. Ɂɚɤʂɭɱɟɧɨ ʁɟ, ɞɚ, ɦɚʁɱɢɧ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɤɨɥɢɱɢɧɢ ɨɞ 4000 IJ ɞɧɟɜɧɨ, ɦɨɠɟ ɞɚ ɩɨɫɬɢɝɧɟ ɡɧɚɱɚʁɚɧ ɧɚɩɪɟɞɚɤ ɤɚ ɩɨɛɨʂɲɚʃɭ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ ɤɨɞ ɦɚʁɤɢ, ɢ ɤɨɞ ɞɟɰɟ ɤɨʁɚ ɫɭ ɧɚ ɩɨɞɨʁɭ, ɚ ɞɚ ɧɟ ɞɨђɟ ɞɨ ɢɧɬɨɤɫɢɤɚɰɢʁɟ ɜɢɬɚɦɢɧɨɦȾ (Hollis and Wagner, 2004). ɍɧɨɫ ɯɪɚɧɟ ɫɢɪɨɦɚɲɧɟ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɧɟɞɨɜɨʂɧɨ ɢɡɥɚɝɚʃɟ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ ɭ ɞɟɰɟ ɢ ɨɞɪɚɫɥɢɯ ɡɚɯɬɟɜɚ ɩɨɜɟʄɚɧ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ (800-1000 IJ/ɞɚɧ). ɉɨɬɯɪɚʃɟɧɨɫɬ (ɯɢɩɨɬɪɨɮɢʁɚ), ɥɨɲɢ ɫɨɰɢɨɟɤɨɧɨɦɫɤɢ ɫɬɚɬɭɫ, ɥɨɲɚ ɨɛɚɜɟɲɬɟɧɨɫɬ ɦɚʁɤɢ ɨ ɩɪɚɜɢɥɧɨʁ ɢɫɯɪɚɧɢ ɞɟɰɟ ɭ ɩɟɪɢɨɞɭ ɨɞɨʁɱɟɬɚ ɢ ɦɚɥɨɝ ɞɟɬɟɬɚ (ɞɪɭɝɚ ɢ ɬɪɟʄɚ ɝɨɞɢɧɚ ɠɢɜɨɬɚ), ɩɪɢɞɪɭɠɟɧɟ ɛɨɥɟɫɬɢ (ɚɬɨɩɢʁɫɤɚ ɤɨɧɫɬɢɬɭɰɢʁɚ, ɚɥɟɪɝɢʁɫɤɟ ɛɨɥɟɫɬɢ (ɚɫɬɦɚ)), ɛɨɥɟɫɬɢ ɛɭɛɪɟɝɚ, ɞɟɰɚ ɢɡ ɦɭɥɬɢɩɧɢɯ ɬɪɭɞɧɨʄɚ ɢ ɤɨɪɢɲʄɟʃɟ ɩɨʁɟɞɢɧɢɯ ɥɟɤɨɜɚ, ɜɟɪɨɜɚɬɧɨ ɫɭ ɭɬɢɰɚɥɢ ɧɚ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɭ ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ. ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɭɬɜɪђɟɧɚ ʁɟ ȼȾȾ ɭ ɞɟɬɟɬɚ ɫɚ ɧɟɮɪɨɬɫɤɢɦ ɫɢɧɞɪɨɦɨɦ, ɲɬɨ ɨɞɝɨɜɚɪɚ ɧɚɥɚɡɢɦɚ ɩɪɢɤɚɡɚɧɢɦ ɭ ɥɢɬɟɪɚɬɭɪɢ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨјɭ ɤɨɠɟ Ʉɚɨ ʁɟɞɚɧ ɨɞ ɡɧɚɱɚʁɧɢɯ ɟɬɢɨɥɨɲɤɢɯ ɮɚɤɬɨɪɚ ɞɟɮɢɰɢɬɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɱɟɫɬɨ ɫɟ ɭ ɥɢɬɟɪɚɬɭɪɢ ɩɨɦɢʃɟ ɢ ɩɪɟɛɨʁɟɧɨɫɬ ɤɨɠɟ. 71 Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɩɨɤɚɡɭʁɭ ɞɚ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɦɟђɭ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ ɢ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ (ɪ=0,0123). ɇɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ (ɪ=0,1472), ɞɨɤ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ=0,0168) ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɧɨɫɭ ɧɚ ɩɪɟɛɨʁɟɧɨɫɬ ɤɨɠɟ (ɛɟɥɚ ɪɚɫɚ ɢ ɪɨɦɢ), ɧɚђɟɧɚ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ. ɍɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɛɢɥɚ ʁɟ ɜɟʄɚ ɭ ɦɚɥɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ. Ɉɜɨ ɦɨɠɟ ɞɚ ɫɟ ɨɛʁɚɫɧɢ, ɜɟɪɨɜɚɬɧɨ, ɢ ɦɚʃɢɦ ɭɧɨɫɨɦ ɤɚɥɰɢʁɭɦɚ ɩɭɬɟɦ ɯɪɚɧɟ ɭ ɦɚɥɟ ɞɟɰɟ. ɍɧɨɫɨɦ 2 ɲɨʂɟ (500 ЦХ) ɤɪɚɜʂɟɝ ɦɥɟɤɚ ɞɧɟɜɧɨ, ɨɞɪɠɚɜɚ ɫɟ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D>30 ЧР/ЦХ ɫɚ ɦɢɧɢɦɚɥɧɢɦ ɧɟɝɚɬɢɜɧɢɦ ɭɬɢɰɚʁɟɦ ɫɟɪɭɦɫɤɨɝ ɮɟɪɢɬɢɧɚ ɭ ɜɟʄɢɧɢ ɦɚɥɟ ɞɟɰɟ. Ⱦɟɰɚ ɫɚ ɬɚɦɧɢʁɨɦ ɛɨʁɨɦ ɤɨɠɟ ɧɟ ɩɪɢɦɚʁɭ ɜɢɬɚɦɢɧ Ⱦ ɬɨɤɨɦ ɡɢɦɟ, ɬɚɤɨ ɞɚ ʁɟ ɭ ɡɢɦɫɤɨɦ ɩɟɪɢɨɞɭ ɭ ɨɜɟ ɞɟɰɟ ɧɟɨɩɯɨɞɧɨ ɞɚ ɫɟ ɭɧɟɫɟ 3-4 ɲɨʂɟ ɦɥɟɤɚ, ɤɚɤɨ ɛɢ ɫɟ ɨɞɪɠɚɥɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D>30 ЧР/ЦХ. ɍ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ, ɤɚɨ ɭɡɪɨɤ ȼȾȾ, ɨɫɢɦ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɟ ɤɨɠɟ (ɦɟɥɚɧɢɧɚ), ɤɨʁɢ ɫɩɪɟɱɚɜɚ ɫɭɧɱɟɜɟ ɡɪɚɤɟ ɞɚ ɩɪɨɞɪɭ ɭ ɤɨɠɭ ɢ ɬɚɤɨ ɨɧɟɦɨɝɭʄɚɜɚ ɫɬɜɚɪɚʃɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɫɬɨʁɚɥɚ ʁɟ ɭɞɪɭɠɟɧɨɫɬ ɞɪɭɝɢɯ ɮɚɤɬɨɪɚ, ɜɟɪɨɜɚɬɧɨ ɨɞɝɨɜɨɪɧɢɯ ɡɚ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ, ɤɚɨ ɲɬɨ ɫɭ: ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨʁ, ɧɟɚɞɟɤɜɚɬɧɚ ɧɟɦɥɟɱɧɚ ɢɫɯɪɚɧɚ, ɢɫɯɪɚɧɚ ɫɢɪɨɦɚɲɧɚ ɭ ɜɢɬɚɦɢɧɭ Ⱦ ɢ ɤɚɥɰɢʁɭɦɭ, ɩɨɬɯɪɚʃɟɧɨɫɬ (ɦɚɥɚ ɬɟɥɟɫɧɚ ɬɟɠɢɧɚ ɡɚ ɭɡɪɚɫɬ ɢ ɜɢɫɢɧɭ), ɥɨɲ ɫɨɰɢɨɟɤɨɧɨɦɫɤɢ ɫɬɚɬɭɫ, ɩɪɢɞɪɭɠɟɧɚ ɫɢɞɟɪɨɩɟɧɢʁɫɤɚ ɚɧɟɦɢʁɚ ɉɨɜɟʄɚɧɚ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ ɫɟ ɨɛʁɚɲʃɚɜɚ ɱɢʃɟɧɢɰɨɦ ɞɚ ʁɚɱɚ ɩɢɝɦɟɧɬɚɰɢʁɚ ɩɨɞɪɚɡɭɦɟɜɚ ɜɟʄɟ ɩɪɢɫɭɫɬɜɨ ɦɟɥɚɧɢɧɚ ɭ ɤɨɠɢ. Ɇɟɥɚɧɢɧ ʁɟ ɩɢɝɦɟɧɬ ɤɨʁɢ ɫɩɪɟɱɚɜɚ ɫɭɧɱɟɜɟ ɡɪɚɤɟ ɞɚ ɩɪɨɞɪɭ ɭ ɤɨɠɭ ɢ ɬɚɤɨ ɦɨɠɟ ɨɧɟɦɨɝɭʄɢɬɢ ɫɬɜɚɪɚʃɟ ɜɢɬɚɦɢɧɚ Ⱦ. ɀɟɧɟ ɤɨʁɟ ɢɦɚʁɭ ɬɚɦɧɢʁɭ ɤɨɠɭ ɢ ɠɟɧɟ ɤɨʁɟ ɧɟ ɢɡɥɚɠɭ ɞɨɜɨʂɧɨ ɫɜɨʁɭ ɤɨɠɭ ɫɭɧɰɭ ɱɟɲʄɟ ɢɦɚʁɭ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ (Wagner and Greer, 2008). ɍ ɧɟɞɚɜɧɢɦ ɢɫɬɪɚɠɢɜɚʃɢɦɚ, ɝɞɟ ʁɟ ɨɬɤɪɢɜɟɧɨ 166 ɫɥɭɱɚʁɟɜɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢɬɚɪɧɨɝ ɪɚɯɢɬɢɫɚ ɭ ɚɦɟɪɢɱɤɟ ɞɟɰɟ ɦɥɚђɟ ɨɞ 5 ɝɨɞɢɧɚ ɭ ɩɟɪɢɨɞɭ ɨɞ 1986 ɢ 2003. Ƚɨɞɢɧɟ, 83% ɫɭ Ⱥɮɪɨɚɦɟɪɢɱɤɚ ɞɟɰɚ, ɚ 96% ɞɟɰɟ ʁɟ ɛɢɥɨ ɧɚ ɩɨɞɨʁɭ (Weisberg, et al. 2004). ɍ ɋɟɜɟɪɧɨʁ Ʉɚɪɨɥɢɧɢ ɩɪɢʁɚɜʂɟɧɨ ʁɟ 30 ɫɥɭɱɚʁɟɜɚ ɪɚɯɢɬɢɫɚ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɢɡ ɝɪɭɩɟ Ⱥɮɪɨɚɦɟɪɢɱɤɟ ɞɟɰɟ ɭ ɩɟɪɢɨɞɭ ɢɡɦɟђɭ 1990. ɢ 1999. ɝɨɞɢɧɟ, ɢ 17 ɫɥɭɱɚʁɟɜɚ ɭ ɩɟɪɢɨɞɭ ɨɞ 1998 ɢ 1999. ɝɨɞɢɧɟ (Kreiter, et al. 2000). ɂɫɬɪɚɠɢɜɚʃɟ ɢɡ ȼɟɥɢɤɟ Ȼɪɢɬɚɧɢʁɟ ɭɬɜɪɞɢɥɨ ʁɟ ɞɚ ɨɤɨ 1 ɭ 100 ɞɟɰɟ ɤɨʁɚ ɧɢɫɭ ɛɟɥɟ ɪɚɫɟ ɢɦɚ ɪɚɯɢɬɢɫ (Ashraf and Mughal, 2002). Ɋɚɯɢɬɢɫ ʁɟ ɱɟɲʄɢ ɤɨɞ ɞɟɰɟ ɤɨʁɚ ɢɦɚʁɭ ɬɚɦɧɢʁɭ ɤɨɠɭ ɢ ɤɨɞ ɞɟɰɟ ɤɨʁɢ ɫɭ ɧɚ ɩɨɞɨʁɭ, ɧɟɝɨ ɞɟɰɚ ɯɪɚʃɟɧɚ ɧɚ ɮɥɚɲɢɰɭ(Ashraf and Mughal, 2002). 72 ɍ ɫɬɭɞɢʁɢ ɭ ɭɪɛɚɧɨʁ ɚɦɛɭɥɚɧɬɢ ɭ ɋȺȾ-ɭ, ɝɞɟ ʁɟ ɢɫɩɢɬɢɜɚɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ 380 ɡɞɪɚɜɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɬɜɪђɟɧɚ ʁɟ ɩɪɢɛɥɢɠɧɚ ɭɱɟɫɬɚɥɨɫɬ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɚ ɩɢɝɦɟɧɬɚɰɢʁɚ ɤɨɠɟ ɧɢʁɟ ɭɬɢɰɚɥɚ ɧɚ ɭɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ (Gordon, et al. 2008). Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɭ ɨɞɧɨɫɭ ɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢјɭ ɜɢɬɚɦɢɧɚ Ⱦ Ɂɛɨɝ ɝɥɨɛɚɥɧɟ ɩɨʁɚɜɟ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɢ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ, ɤɨʁɢ ɩɪɟɞɫɬɚɜʂɚʁɭ ɱɟɫɬɨ ɛɢɬɚɧ ɟɬɢɨɩɚɬɨɝɟɧɟɬɫɤɢ ɱɢɧɢɥɚɰ ɭ ɪɚɡɜɨʁɭ ɪɚɡɧɢɯ ɦɚɥɢɝɧɢɯ, ɚɭɬɨɢɦɭɧɢɯ, ɞɟɝɟɧɟɪɚɬɢɜɧɢɯ, ɚɥɟɪɝɢʁɫɤɢɯ ɢ ɞɪɭɝɢɯ ɨɛɨʂɟʃɚ, ɫɟ, (Carlberg, 2014) ɭ ɰɢʂɭ ɨɱɭɜɚʃɚ ɡɞɪɚɜʂɚ, ɞɚɧɚɫ ɞɨɞɚɬɧɢ ɭɧɨɫ ɜɢɬɚɦɢɧɚ Ⱦ ɯɪɚɧɨɦ ɢ ɫɭɩɥɟɦɟɧɬɢɦɚ ɫɦɚɬɪɚ ɧɟɨɩɯɨɞɧɢɦ (Prentice, 2008). Ɍɨ ɫɟ ɨɞɧɨɫɢ ɧɚ ɫɜɚ ɠɢɜɨɬɧɚ ɪɚɡɞɨɛʂɚ, ɚ ɩɨɫɟɛɧɨ ɧɚ ɩɟɪɢɨɞɟ ɪɚɫɬɚ ɢ ɪɚɡɜɨʁɚ, ɝɪɚɜɢɞɢɬɟɬɚ ɢ ɥɚɤɬɚɰɢʁɟ (Bendik, et al. 2014). ɇɚ ɨɫɧɨɜɭ ɧɚɱɢɧɚ ɢ ɤɨɥɢɱɢɧɟ ɭɧɨɫɚ ɩɪɟɩɨɪɭɱɟɧɟ ɞɧɟɜɧɟ ɞɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ (400 ɂЈ) ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɢɡɞɜɨʁɢɥɢ ɫɦɨ ɞɜɟ ɝɪɭɩɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ: ɨɞɨʁɱɚɞ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ ɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɨɞɨʁɱɚɞ ɫɚ ɧɟɚɞɟɤɜɚɬɧɨɦ ɩɪɨɮɢɥɚɤɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. Ⱥɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ (ɫɭɩɥɟɦɟɧɬɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ) ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ ɞɨɛɢɥɨ ʁɟ 75% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ. ɇɢʁɟɞɧɨ ɨɞ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɤɨʁɟ ʁɟ ɞɨɛɢʁɚɥɨ ɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɧɢʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. Ⱦɟɮɢɰɢʁɟɧɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɭ 16% ɨɞɨʁɱɚɞɢ ɫɚ ɚɞɟɤɜɚɬɧɨɦ ɩɪɨɮɢɥɚɤɫɨɦ, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɚ ɭ 24%, ɚ ɨɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɛɢɥɟ ɫɭ ɡɚɫɬɭɩʂɟɧɟ ɭ 60% ɢɫɩɢɬɚɧɢɤɚ. Ɍɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ʁɟ ɢɦɚɥɨ 33%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ 17%, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ 22% ɨɞɨʁɱɚɞɢ ɤɨʁɚ ɧɢɫɭ ɞɨɛɢʁɚɥɚ ɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɜɢɬɚɦɢɧɚ Ⱦ. Ɉɩɬɢɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚђɟɧɟ ɫɭ ɭ 5 ɨɞɨʁɱɚɞɢ ɢ ɩɨɪɟɞ ɧɟɚɞɟɤɜɚɬɧɟ ɩɪɨɮɢɥɚɤɫɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɲɬɨ ɫɟ ɨɛʁɚɲʃɚɜɚ ɨɩɬɢɦɚɥɧɢɦ ɦɚɬɟɪɧɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨʁɢ ʁɟ ɞɟɬɟ ɧɚɫɥɟɞɢɥɨ ɬɪɚɧɫɩɥɚɰɟɧɬɚɪɧɨ, ɩɪɚɜɢɥɧɨɦ ɢɫɯɪɚɧɨɦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɟɜɟɧɬɭɚɥɧɨ ɢ ɝɟɧɟɬɫɤɢɦ ɮɚɤɬɨɪɢɦɚ ɤɨʁɢ ɫɭ ɱɟɫɬɨ ɨɞɝɨɜɨɪɧɢ ɡɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɨʁɱɚɞɢ. ɂɡɦɟђɭ ɝɪɭɩɟ ɨɞɨʁɱɚɞɢ ɫɚ ɚɞɟɤɜɚɬɧɨɦ ɢ ɧɟɚɞɟɤɜɚɬɧɨɦ ɩɪɨɮɢɥɚɤɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ ɭɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ (ɪ=0,0001). 73 ɇɚ ɨɫɧɨɜɭ ɧɚɲɢɯ ɪɟɡɭɥɬɚɬɚ, ɩɨɞɚɰɢ ɨ ɜɟʄɨʁ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɭ ɨɞɨʁɱɚɞɢ ɭɫɥɟɞ ɧɟɚɞɟɤɜɚɬɧɟ ɩɪɨɮɢɥɚɤɫɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɤɥɚɩɚʁɭ ɫɟ ɫɚ ɪɟɡɭɥɬɚɬɢɦɚ ɦɧɨɝɨɛɪɨʁɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ, ɭ ɤɨʁɢɦɚ ɧɟɞɨɜɨʂɧɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɩɪɟɞɫɬɚɜʂɚ ʁɟɞɚɧ ɨɞ ɝɥɚɜɧɢɯ ɮɚɤɬɨɪɚ ȼȾȾ ɭ ɞɟɰɟ. Ɉɫɢɦ ɚɞɟɤɜɚɬɧɟ, ɩɪɟɩɨɪɭɱɟɧɟ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ (400 IJ/ɞɚɧ - ɞɨɫɚɞɚɲʃɟ ɩɪɟɩɨɪɭɤɟ), ɞɨɤɚɡɚɧɨ ʁɟ, ɞɚ ɧɚ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ɢɦɚʁɭ ɭɥɨɝɭ ɢ ɦɧɨɝɢ ɞɪɭɝɢ ɮɚɤɬɨɪɢ. ɇɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɡɧɚɱɚʁɧɨ ɭɬɢɱɭ ɢ ɦɚɬɟɪɧɚɥɧɢ ɜɢɬɚɦɢɧ Ⱦ, ɛɨʁɚ ɤɨɠɟ, ɫɨɰɢɨɟɤɨɧɨɦɫɤɢ ɫɬɚɬɭɫ, ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɩɪɢɫɭɬɚɧ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨʁ, ɧɟɚɞɟɤɜɚɬɧɚ ɞɨɩɭɧɫɤɚ ɢɫɯɪɚɧɚ, ɩɨɬɯɪɚʃɟɧɨɫɬ, ɤɚɨ ɢ ɢɧɞɢɜɢɞɭɚɥɧɢ ɝɟɧɟɬɫɤɢ ɮɚɤɬɨɪɢ. ɍɞɪɭɠɟɧɨɫɬ ɩɨɞɨʁɚ, ɧɚɪɨɱɢɬɨ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨʁ, ɤɨʁɢ ʁɟ ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɛɢɨ ɡɚɫɬɭɩʂɟɧ ɦɟђɭ ɢɫɩɢɬɢɜɚɧɨɦ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɨɦ ɞɟɰɨɦ (ɭɡɪɚɫɬɚ ɞɨ 2 ɝɨɞɢɧɟ), ɩɪɟɛɨʁɟɧɨɫɬ ɤɨɠɟ, ɩɨɬɯɪɚʃɟɧɨɫɬ, ɚɧɟɦɢʁɚ, ɝɨʁɚɡɧɨɫɬ, ɧɟɩɨɡɧɚɬɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɦɚɬɟɪɧɚɥɧɨɝ ɜɢɬɚɦɢɧɚ Ⱦ, ɨɞɨʁɱɚɞ ɪɨђɟɧɚ ɭ ɡɢɦɫɤɨɦ ɩɟɪɢɨɞɭ ɢ ɱɟɫɬɨ ɧɟɞɨɜɨʂɧɨ ɢɡɥɚɝɚʃɟ ɤɨɠɟ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ ɫɭ ɧɚʁɜɟɪɨɜɚɬɧɢʁɟ, ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɛɢɥɢ ɭɡɪɨɤ ɜɢɬɚɦɢɧ Ⱦ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɢ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɭ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ. ɇɢɜɨ 25(OH)D ɭ ɫɟɪɭɦɭ ɩɨɫɬɢɝɧɭɬ ɭɧɨɲɟʃɟɦ ɩɟɪɨɪɚɥɧɨ ɢɫɬɟ ɞɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ ɜɚɪɢɪɚ ɤɨɞ ɩɨʁɟɞɢɧɚɰɚ (Heaney, et al. 2003; Aloia, et al. 2008). ȼɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɤɨʁɢ ɫɭ ɛɢɬɧɢ ɭ ɧɚɫɬɚʁɚʃɭ ɤɥɢɧɢɱɤɢɯ ɫɢɦɩɬɨɦɚ ɢ ɡɧɚɤɨɜɚ ɜɟɪɨɜɚɬɧɨ ɡɚɜɢɫɟ ɨɞ ɭɧɨɫɚ ɤɚɥɰɢʁɭɦɚ, ɪɚɫɟ, ɫɬɚɪɨɫɬɢ, ɤɨɥɢɱɢɧɟ ɦɚɫɬɢ ɭ ɬɟɥɭ ɢ ɢɧɞɢɜɢɞɭɚɥɧɢɯ ɝɟɧɟɬɫɤɢɯ ɮɚɤɬɨɪɚ, ɢ ɫɜɢ ɦɨɝɭ ɭɬɢɰɚɬɢ ɧɚ ɯɨɦɟɨɫɬɚɡɭ ɤɚɥɰɢʁɭɦɚ ɭ ɨɪɝɚɧɢɡɦɭ. Ƚɟɧɟɬɢɱɤɚ ɜɚɪɢʁɚɛɢɥɧɨɫɬ ɩɪɟɞɫɬɚɜʂɟɧɚ ɩɨɥɢɦɨɪɮɢɡɦɨɦ ɩɨʁɟɞɢɧɢɯ ɝɟɧɚ ɭ ɦɟɬɚɛɨɥɢɱɤɨɦ ɩɭɬɭ ɜɢɬɚɦɢɧɢɦɚ Ⱦ ɨɛʁɚɲʃɚɜɚ ɧɟɤɟ ɨɞ ɢɧɬɟɪɢɧɞɢɜɢɞɭɚɥɧɢɯ ɜɚɪɢʁɚɛɢɥɧɨɫɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D, ɧɚɪɨɱɢɬɨ ɪɚɡɥɢɱɢɬɨɫɬ ɟɧɡɢɦɚ 7-ɞɟɯɢɞɪɨɯɨɥɟɫɬɟɪɨɥ ɪɟɞɭɤɬɚɡɟ ɭ ɤɨɠɢ, ɰɢɬɨɯɪɨɦ Ɋ450 25-ɯɢɞɪɨɤɫɢɥɚɡɟ ɭ ʁɟɬɪɢ, ɢ ɜɢɬɚɦɢɧ Ⱦ-ɜɟɡɭʁɭʄɟɝ ɩɪɨɬɟɢɧɚ ɭ ɰɢɪɤɭɥɚɰɢʁɢ (Ahn, et al. 2010). Ȼɟɡ ɨɛɡɢɪɚ ɧɚ ɦɧɨɝɨɛɪɨʁɧɚ ɞɨɫɚɞɚɲʃɚ ɢɫɬɪɚɠɢɜɚʃɚ, ʁɨɲ ɭɜɟɤ ɧɢɫɭ ɧɚɩɪɚɜʂɟɧɟ ɞɭɝɨɪɨɱɧɟ ɫɬɭɞɢʁɟ ɤɨʁɟ ɛɢ ɤɨɧɚɱɧɨ ɩɨɤɚɡɚɥɟ, ɤɨɥɢɤɟ ɫɭ ɬɚɱɧɟ ɞɧɟɜɧɟ ɩɨɬɪɟɛɟ ɞɟɰɟ ɡɚ ɜɢɬɚɦɢɧɨɦ Ⱦ ɤɨʁɚ ɢɦɚʁɭ ɧɟɞɨɫɬɚɬɚɤ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɨɜɨɝ ɜɢɬɚɦɢɧɚ ɭ ɫɟɪɭɦɭ. Ɉɜɟ ɫɬɭɞɢʁɟ ɬɪɟɛɚ ɞɚ ɭɬɜɪɞɟ ɤɨɥɢɤɚ ʁɟ ɚɞɟɤɜɚɬɧɚ ɤɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨʁɚ ʁɟ ɧɟɨɩɯɨɞɧɚ ɞɚ ɫɟ ɭɧɟɫɟ ɭ ɨɪɝɚɧɢɡɚɦ ɬɨɤɨɦ ɞɚɧɚ ɤɚɤɨ ɛɢ ɫɟ ɩɨɫɬɢɝɚɨ ɨɩɬɢɦɚɥɧɢ ɧɢɜɨ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɨɞ 30 ЧР/ЦХ. Ⱥɦɟɪɢɱɤɨ ɞɪɭɲɬɜɨ ɟɧɞɨɤɪɢɧɨɥɨɝɚ ɞɚɥɨ ʁɟ ɧɚʁɧɨɜɢʁɟ ɫɦɟɪɧɢɰɟ, ɧɚ ɨɫɧɨɜɭ ɤɨʁɢɯ ɫɟ ɨɞɨʁɱɚɞɢ ɩɪɟɩɨɪɭɱɭʁɟ 400-1000 IJ/ɞɚɧ ɜɢɬɚɦɢɧɚ Ⱦ, ɡɚ ɞɟɰɭ ɫɬɚɪɢʁɭ ɨɞ ɝɨɞɢɧɭ ɞɚɧɚ 600-1000 IJ/ɞɚɧ, ɞɨɤ ɨɫɨɛɟ ɫɬɚɪɢʁɟ ɨɞ 19 ɝɨɞɢɧɚ ɬɪɟɛɚ ɞɚ ɭɡɢɦɚʁɭ 1500-2000 IJ/ɞɚɧ 74 ɜɢɬɚɦɢɧɚ Ⱦ, ɤɚɤɨ ɛɢ ɨɞɪɠɚɥɟ ɧɢɜɨ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɧɚ ɜɪɟɞɧɨɫɬɢ ɢɡɧɚɞ ɨɩɬɢɦɚɥɧɨɝ ɧɢɜɨɚ ɨɞ 30 ЧР/ЦХ (Paramyothin and Holick, 2012). ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɞɟɮɢɧɢɫɚɧɨ ʁɟ ɩɨɫɬɨʁɚʃɟ ɝɨʁɚɡɧɨɫɬɢ (ɨɛɟɡɢɬɟɬɚ) ɤɨɞ 11-ɨɪɨ ɞɟɰɟ (>Ɋ97). Јɟɞɧɨ ɞɟɬɟ (ɭɡɪɚɫɬɚ 15 ɦɟɫɟɰɢ), ʁɟ, ɩɨɪɟɞ ɝɨʁɚɡɧɨɫɬɢ, ɢɦɚɥɨ, ɫɢɞɟɪɨɩɟɧɢʁɫɤɭ ɚɧɟɦɢʁɭ, ɚɬɨɩɢʁɫɤɭ ɤɨɧɫɬɢɬɭɰɢʁɭ ɢ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. Јɟɞɧɨ ɝɨʁɚɡɧɨ ɞɟɬɟ, ɭɡɪɚɫɬɚ 3 ɝɨɞɢɧɟ, ʁɟ ɢɦɚɥɨ ɤɨɧɰɟɧɬɪɚɰɢʁɭ 25(Ɉɇ)D < 10ЧР/ЦХ ɭ ɫɟɪɭɦɭ, ɞɨɤ ɫɭ ɩɪɟɨɫɬɚɥɚ 5 ɢɫɩɢɬɚɧɢɤɚ ɢɦɚɥɚ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɚ ɨɫɧɨɜɭ ɦɚɥɨɝ ɛɪɨʁɚ ɭɡɨɪɤɚ, ɧɟ ɦɨɠɟɦɨ ɞɚ ɬɜɪɞɢɦɨ ɞɚ ʁɟ ɝɨʁɚɡɧɨɫɬ ʁɟɞɢɧɢ ɭɡɪɨɤ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɭ ɢɫɩɢɬɢɜɚɧɟ ɝɨʁɚɡɧɟ ɞɟɰɟ. ɍ ɝɨʁɚɡɧɟ ɞɟɰɟ ɫɟ ɩɪɟɩɨɪɭɱɭʁɟ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɜɢɬɚɦɢɧɨɦ Ⱦ ɤɚɞɚ ɫɭ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ < 20ЧР/ЦХ (Paxton, et al. 2013). Ɂɧɚɦɨ ɞɚ ɫɭ ɪɟɰɟɩɬɨɪɢ ɡɚ ɜɢɬɚɦɢɧ Ⱦ ɩɪɢɫɭɬɧɢ ɭ ɦɧɨɝɢɦ ʄɟɥɢʁɚɦɚ ɢ ɬɤɢɜɢɦɚ ɭ ɨɪɝɚɧɢɡɦɭ, ɤɚɨ ɢ ɟɧɡɢɦ 25(OH)D-1α-ɯɢɞɪɨɤɫɢɥɚɡɚ, ɭɤʂɭɱɭʁɭʄɢ ɢ ɞɨɤɚɡɟ ɡɚ ɭɥɨɝɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɚɞɢɩɨɝɟɧɟɡɢ ɢ ɦɟɬɚɛɨɥɢɡɦɭ ɚɞɢɩɨɰɢɬɚ, ɱɢɦɟ ɫɟ ɞɟɥɢɦɢɱɧɨ ɦɨɝɭ ɨɛʁɚɫɧɢɬɢ ɧɚɜɟɞɟɧɢ ɟɮɟɤɬɢ. ȼɟʄɢɧɚ ɧɚɥɚɡɚ ɨ ɫɧɢɠɟɧɨʁ ɤɨɧɰɟɧɬɪɚɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɝɨʁɚɡɧɟ ɞɟɰɟ, ɭɤɚɡɭʁɭ ɧɚ ɬɨ, ɞɚ ɫɭ ɩɨɬɪɟɛɟ ɝɨʁɚɡɧɟ ɞɟɰɟ ɡɚ ɜɢɬɚɦɢɧɨɦ Ⱦ ɜɟʄɟ, ɧɟɝɨ ɭ ɞɟɰɟ ɫɚ ɧɨɪɦɚɥɧɨɦ ɬɟɠɢɧɨɦ ɡɚ ɭɡɪɚɫɬ ɢ ɜɢɫɢɧɭ. ɉɨɲɬɨ ʁɟ ɞɨɛɢʁɚʃɟ ɚɞɟɤɜɚɬɧɟ ɤɨɥɢɱɢɧɟ ɜɢɬɚɦɢɧɚ Ⱦ ɩɭɬɟɦ ɫɭɧɱɟɜɢɯ ɡɪɚɤɚ ɡɛɨɝ ɧɟɞɨɫɬɭɩɧɨɫɬɢ, ɚɥɢ ɢ ɛɪɢɝɟ ɡɛɨɝ ɦɨɝɭʄɟɝ ɪɚɤɚ ɤɨɠɟ ɭɫɥɟɞ ɩɪɟɬɟɪɚɧɨɝ ɢɡɥɚɝɚʃɭ ɍȼ ɡɪɚɰɢɦɚ, ɚ ɯɪɚɧɨɦ ɫɟ ɧɟ ɦɨɠɟ ɭɧɟɬɢ ɞɨɜɨʂɧɨ ɜɢɬɚɦɢɧɚ Ⱦ, ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɝɨʁɚɡɧɟ ɞɟɰɟ ʁɟ ɨɩɪɚɜɞɚɧɚ. ɋɦɚʃɟʃɟ ɟɧɟɪɝɟɬɫɤɨɝ ɭɧɨɫɚ ɢ ɩɨɜɟʄɚɧɚ ɮɢɡɢɱɤɚ ɚɤɬɢɜɧɨɫɬ ɭ ɰɢʂɭ ɫɦɚʃɟʃɚ ɬɟɥɟɫɧɟ ɬɟɠɢɧɟ ɭ ɝɨʁɚɡɧɟ ɞɟɰɟ, ɦɨɝɭ ɞɚ ɩɨɛɨʂɲɚʁɭ ɥɨɲ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ. Oɛɚ ɜɢɬɚɦɢɧɚ, Ⱦ2 ɢ Ⱦ3 ɫɟ ɞɜɚ ɩɭɬɚ ɯɢɞɪɨɥɢɡɭʁɭ ɞɨ ɫɬɜɚɪɚʃɚ ɚɤɬɢɜɧɨɝ ɨɛɥɢɤɚ 1,25(Ɉɇ)2D (ɤɚɥɰɢɬɪɢɨɥɚ) ɤɨʁɟ ɫɟ ɞɟɲɚɜɚ ɭ ɩɪɢɫɭɫɬɜɭ ɟɧɡɢɦɚ 1α-ɯɢɞɪɨɤɫɢɥɚɡɟ. ɂɚɤɨ ɫɟ ɨɜɚʁ ɟɧɡɢɦ ɤɥɚɫɢɱɧɨ ɢɞɟɧɬɢɮɢɤɭʁɟ ɭ ɩɪɨɤɫɢɦɚɥɧɢɦ ɬɭɛɭɥɢɦɚ ɛɭɛɪɟɝɚ, ɟɤɫɩɪɟɫɢʁɚ ɝɟɧɚ ɨɜɨɝ ɟɧɡɢɦɚ ʁɟ ɩɪɢɫɭɬɧɚ ɢ ɧɚ ɦɧɨɝɢɦ ɞɪɭɝɢɦ ɬɤɢɜɢɦɚ, ɦɨɡɝɚ, ɩɚɧɤɪɟɚɫɚ, ɢɦɭɧɨɥɨɲɤɨɝ ɢ ɦɚɫɧɨɝ ɬɤɢɜɚ (Li, et al. 2008; Zehnder, et al. 2001). Ⱥɤɬɢɜɚɰɢʁɚ 25(OH)D ɪɟɡɭɥɬɭʁɟ ɩɨɜɢɲɟɧɢɦ ɧɢɜɨɨɦ ɰɢɪɤɭɥɢɲɭʄɟɝ 1,25(Ɉɇ)2D ɤɨʁɚ ɫɟ ɨɞɜɢʁɚ ɭ ɛɭɛɪɟɡɢɦɚ, ɤɨʁɢ ɫɟ ɡɚɬɢɦ ɜɟɡɭʁɟ ɭ ɰɢʂɧɢɦ ɬɤɢɜɢɦɚ. ȿɤɫɬɪɚɪɟɧɚɥɧɚ ɫɢɧɬɟɡɚ 1,25(Ɉɇ)2D ɢɡɝɥɟɞɚ ɞɚ ɞɟɥɭʁɟ ɥɨɤɚɥɧɨ ɜɟɡɢɜɚʃɟɦ ɡɚ ȼȾɊ ɩɪɢɫɭɬɧɟ ɭɧɭɬɚɪ ɢɫɬɢɯ ɢɥɢ ɫɭɫɟɞɧɢɯ ʄɟɥɢʁɚ. ɉɨɪɟɞ ɨɪɝɚɧɚ ɨɞɝɨɜɨɪɧɢɯ ɡɚ ɤɚɥɰɢʁɭɦ/ɮɨɫɮɚɬ ɯɨɦɟɨɫɬɚɡɭ, ȼȾɊ ɫɭ ɢɡɪɚɠɟɧɢ ɭ ɪɚɡɥɢɱɢɬɢɦ ɬɤɢɜɢɦɚ ɢ ʄɟɥɢʁɚɦɚ, ɤɚɨ ɲɬɨ ɫɭ ɢ ɯɟɩɚɬɨɰɢɬɢ, ɦɢɨɰɢɬɢ, ɚɞɢɩɨɰɢɬɢ, ɛɟɬɚ- ʄɟɥɢʁɟ ɩɚɧɤɪɟɚɫɚ, ɢ ɧɟɤɨɥɢɤɨ ɜɪɫɬɚ ɢɦɭɧɢɯ ʄɟɥɢʁɚ, ɨɞ ɤɨʁɢɯ ɫɭ ɫɜɟ ɩɨɜɟɡɚɧɟ ɫɚ 75 ɝɨʁɚɡɧɨɲʄɭ ɢ ʃɟɧɢɦ ɤɨɦɩɥɢɤɚɰɢʁɚɦɚ (Wang, et al. 2012; Ding, et al. 2012; Mitri, et al. 2011). ȿɮɟɤɚɬ ɜɢɲɤɚ ɬɟɥɟɫɧɟ ɦɚɫɬɢ ɭ ɬɟɥɭ ɬɟɨɪɟɬɫɤɢ: 1) ɩɨɜɟʄɚɜɚ ɦɟɬɚɛɨɥɢɱɤɢ ɤɥɢɪɟɧɫ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ʃɟɝɨɜɢɯ ɦɟɬɚɛɨɥɢɬɚ ɤɪɨɡ ɩɨʁɚɱɚɧɨ ɭɧɨɲɟʃɟ, 2) ɫɦɚʃɭʁɟ ɛɢɨɞɨɫɬɭɩɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟɞɧɨɦ ɞɟɩɨɧɨɜɚɧ ɭ ɚɞɢɩɨɰɢɬɢɦɚ ɢ/ɢɥɢ 3) ɫɬɜɚɪɚ ɜɨɥɭɦɟɬɪɢʁɫɤɨ ɪɚɡɛɥɚɠɟʃɟ ɜɢɬɚɦɢɧɚ Ⱦ ɡɛɨɝ ɜɟʄɟ ɬɟɥɟɫɧɟ ɦɚɫɟ (Drincic, et al. 2012). Ʌɨɧɝɢɬɭɞɭɧɚɥɧɨɦ ɫɬɭɞɢʁɨɦ ɞɟɰɟ ɭ ɛɪɚɡɢɥɫɤɨɦ Ⱥɦɚɡɨɧɭ ɧɚђɟɧ ʁɟ ɟɮɟɤɚɬ ɝɟɧɚ ɡɚ ɝɨʁɚɡɧɨɫɬ (FTO pМ9939609) ɤɨʁɢ ʁɟ ɢɡɪɚɠɟɧɢʁɢ ɤɨɞ ɞɟɰɟ ɫɚ ɧɟɞɨɜɨʂɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (Lourenco, et al. 2014). ȼɢɬɚɦɢɧ Ⱦ ɢɡɝɥɟɞɚ ɞɚ ɢɦɚ ɜɚɠɧɭ ɭɥɨɝɭ ɭ ɦɚɫɧɨɦ ɬɤɢɜɭ ɢ ʃɟɝɨɜɢɦ ɦɟɬɚɛɨɥɢɱɤɢɦ ɩɪɨɰɟɫɢɦɚ, ɚɥɢ ɦɨɥɟɤɭɥɚɪɧɚ ɨɫɧɨɜɚ ɢɧɬɟɪɚɤɰɢʁɟ 25(Ɉɇ)D, 1,25(Ɉɇ)2D ɢ ȼȾɊ ɩɨɫɥɟ ɞɟʂɟʃɚ ɭ ɦɚɫɧɨɦ ɬɤɢɜɭ, ɧɢɫɭ ɞɨɛɪɨ ɪɚɡʁɚɲʃɟɧɢ. Ƚɟɧɢ ɡɚ ȼȾɊ ɢ ɟɧɡɢɦɢ ɭ ɦɟɬɚɛɨɥɢɡɦɭ ɜɢɬɚɦɢɧɚ Ⱦ (CIP27A1, CIP27B1) ɧɚђɟɧɢ ɫɭ, ɢ ɭ ʂɭɞɫɤɢɦ, ɢ ɭ ɠɢɜɨɬɢʃɫɤɢɦ ɚɞɢɩɨɰɢɬɢɦɚ (Ding, et al. 2012; Zoico, et al. 2014). ȼɢɫɨɤɚ ɩɪɟɜɚɥɟɧɰɚ ȼȾȾ ɭ ɨɞɨʁɱɚɞɢ ɫɚ ɦɚɥɨɦ ɩɨɪɨђɚʁɧɨɦ ɦɚɫɨɦ (ɉɆ<2500ɝ), ɤɚɨ ɢ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɪɚɯɢɬɢɫɚ ɭ ɪɚɧɨɦ ɭɡɪɚɫɬɭ, ɧɚɝɥɚɲɚɜɚ ɩɨɬɪɟɛɭ ɞɚ ɫɟ ɢɫɩɢɬɚ ɭɬɢɰɚʁ ɪɚɡɥɢɱɢɬɢɯ ɞɨɡɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɜɢɦ ɝɪɭɩɚɦɚ ɨɞɨʁɱɚɞɢ, ɤɚɤɨ ɛɢ ɫɟ ɢɞɟɧɬɢɮɢɤɨɜɚɥɚ ɨɩɬɢɦɚɥɧɚ ɞɨɡɚ (Agarwalet al. 2012). Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɇɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚʃɚ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ ɭ ɝɪɭɩɢ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɧɚђɟɧɨ ʁɟ ɞɚ ʁɟ, 31% ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 40% ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɢ 20% ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɢɦɚɥɨ ɤɥɢɧɢɱɤɟ ɡɧɚɤɟ ɤɨʁɢ ɭɤɚɡɭʁɭ ɞɚ ɩɨɫɬɨʁɢ ȼȾȾ. ɂɡ ɪɟɡɭɥɬɚɬɚ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɩɪɢɦɟʄɭʁɟɦɨ ɞɚ ʁɟ ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (ɤɨʁɢ ɧɢɫɭ ɢɦɚɥɢ ɬɢɩɢɱɧɟ ɤɥɢɧɢɱɤɟ ɡɧɚɤɨɜɟ ɢ ɫɢɦɩɬɨɦɟ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ) ɢɦɚɥɨ ɧɢɠɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɨɞ ɨɩɬɢɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ. ɍ ɝɪɭɩɢ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, 49% ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɢɦɚɥɨ ȼȾȾ (13 ɞɟɰɟ ʁɟ ɢɦɚɥɨ ɬɟɠɚɤ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ, 21 ɞɟɮɢɰɢʁɟɧɰɢʁɭ, ɚ 22 ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ). 76 ɇɚɲɚ ɢɫɬɪɚɠɢɜɚʃɚ ɫɟ ɩɨɤɥɚɩɚʁɭ ɫɚ ɦɧɨɝɢɦ ɫɬɭɞɢʁɚɦɚ ɭ ɫɜɟɬɭ, ɝɞɟ ʁɟ ɞɨɤɚɡɚɧɨ ɞɚ ʁɟ ɫɭɛɨɩɬɢɦɚɥɚɧ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ, 25(OH)D ≤30 ng/ml, ɜɪɥɨ ɱɟɫɬ ɭ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ (Gordon, et al. 2008). Ʉɥɢɧɢɱɤɟ ɩɨɫɥɟɞɢɰɟ ɛɥɚɝɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɱɟɫɬɨ ɦɚʃɟ ɩɪɟɩɨɡɧɚɬʂɢɜɟ ɢɥɢ ɭɨɩɲɬɟ ɧɢɫɭ ɢɫɩɨʂɟɧɟ. Ɋɚɧɢ ɫɢɦɩɬɨɦɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɱɟɫɬɨ ɧɟɫɩɟɰɢɮɢɱɧɢ, ɬɚɤɨ ɞɚ ɢɯ ʁɟ ɱɟɫɬɨ ɬɟɲɤɨ ɩɪɟɩɨɡɧɚɬɢ. ɂɡ ɚɧɤɟɬɧɢɯ ɨɞɝɨɜɨɪɚ ɞɨɛɢʁɚɥɢ ɫɦɨ ɩɨɞɚɬɚɤ ɞɚ ɥɢ ɫɟ ɞɟɰɚ ɨɛɢɥɧɨ ɡɧɨʁɟ (ɧɚɪɨɱɢɬɨ ɧɨʄɭ), ɲɬɨ ʁɟ ɛɢɨ ɢ ɧɚʁɱɟɲʄɢ ɤɥɢɧɢɱɤɢ ɡɧɚɤ ɤɨʁɢ ɫɭ ɪɨɞɢɬɟʂɢ ɩɪɢʁɚɜʂɢɜɚɥɢ. ɍ ɤɥɢɧɢɱɤɟ ɡɧɚɤɟ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɭɛɪɚʁɚɥɢ ɫɦɨ, ɱɟɬɜɪɬɚɫɬɭ ɝɥɚɜɭ (МКput quКНrКtuЦ), ɡɧɚɤ ɤɨʁɢ ɭ ɩɨʁɟɞɢɧɢɦ ɫɥɭɱɚʁɟɜɢɦɚ ɧɢʁɟ ɬɚɱɧɨ ɭɤɚɡɢɜɚɨ ɞɚ ɥɢ ɫɟ ɪɚɞɢ ɨ ɧɟɞɨɫɬɚɬɤɭ ɜɢɬɚɦɢɧɚ Ⱦ (ɪɚɯɢɬɢɫɭ), ɢɥɢ ɨ ɧɚɫɥɟђɭ, ɢ ɨɫɬɚɥɟ, ɭ ɭɜɨɞɭ ɧɚɜɟɞɟɧɟ ɡɧɚɤɟ ɪɚɯɢɬɢɫɚ. Ʉɨɞ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɫɭ ɭ ɥɢɬɟɪɚɬɭɪɢ ɨɩɢɫɚɧɢ ɦɧɨɝɢ ɡɧɚɰɢ ɢ ɫɢɦɩɬɨɦɢ ɤɨʁɟ ɢ ɪɨɞɢɬɟʂɢ ɬɟɲɤɨ ɭɨɱɟ (ɧɟɪɚɫɩɨɥɨɠɟɧɨɫɬ ("ɤɚɨ ɞɚ ɦɭ ɧɟɲɬɨ ɮɚɥɢ"), ɫɦɚʃɟɧɚ ɛɪɡɢɧɚ ɪɚɫɬɟʃɚ, ɤɜɚɥɢɬɟɬ ɫɧɚ (ɫɥɚɛɨ ɫɩɚɜɚ ɢ ɥɚɤɨ ɫɟ ɛɭɞɢ) ɢ ɫɥ. ɍ ɫɬɚɪɢʁɟ ɨɞɨʁɱɚɞɢ ɢɡ ɚɧɤɟɬɧɢɯ ɨɞɝɨɜɨɪɚ ɞɨɛɢʁɚɥɢ ɫɦɨ ɩɨɞɚɬɚɤ ɞɚ ɥɢ ɞɟɬɟ ɫɚɦɨɫɬɚɥɧɨ ɫɟɞɢ, ɫɬɨʁɢ, ɞɚ ɥɢ ɯɨɞɚ (ɡɚ ɨɞɪɟђɟɧɢ ɭɡɪɚɫɬ). ɍɩɢɫɢɜɚɥɢ ɫɦɨ ɢ ɡɧɚɤɟ, ɤɨʁɢ ɤɚɨ ɢɡɨɥɨɜɚɧɢ (ɛɟɡ ɥɚɛɨɪɚɬɨɪɢʁɫɤɟ ɢ ɪɚɞɢɨɥɨɲɤɟ ɩɨɬɜɪɞɟ) ɧɟ ɭɤɚɡɭʁɭ ɧɚ ɪɚɯɢɬɢɫ, ɤɚɨ ɲɬɨ ɫɭ: ɩɟɪɡɢɫɬɢɪɚʃɟ ɜɟɥɢɤɟ ɮɨɧɬɚɧɟɥɟ (ɧɚɤɨɧ ɜɪɟɦɟɧɚ ɩɪɟɞɜɢђɟɧɨɝ ɡɚ ɡɚɬɜɚɪɚʃɟ), ɛɪɨʁ ɡɭɛɚ (ɞɟɧɬɢɰɢʁɚ) ɢ ɩɪɨɦɟɧɟ ɧɚ ɡɭɛɢɦɚ (ɧɚɫɥɚɝɟ ɧɚ ɝɥɟђɢ), ɟɤɫɬɟɧɡɢɜɧɢ ɤɚɪɢʁɟɫ, ɧɢɡɚɤ ɪɚɫɬ, ɫɤɟɥɟɬɧɢ ɞɟɮɨɪɦɢɬɟɬɢ (ɧɚ ɝɪɭɞɧɨʁ ɤɨɫɬɢ, ɤɨɫɬɢɦɚ ɝɥɚɜɟ, ɤɚɪɥɢɰɟ ɢ ɟɤɫɬɪɟɦɢɬɟɬɚ), ɦɢɲɢʄɧɚ ɫɥɚɛɨɫɬ ɢ ɞɪ. ɍ ɢɫɬɪɚɠɢɜɚʃɭ ɏɨɥɢɤɚ ɢ ɫɚɪɚɞɧɢɤɚ, ɧɚђɟɧɚ ʁɟ ɩɨɜɟɡɚɧɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɤɥɢɧɢɱɤɟ ɫɥɢɤɟ ɞɟɬɟɬɚ. ɍ ɫɥɭɱɚʁɟɜɢɦɚ ɝɞɟ ɫɭ ɜɪɟɞɧɨɫɬɢ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɛɢɥɟ ɧɢɠɟ ɨɞ 11 ɞɨ 15 ЧР/ЦХ ɫɭ ɩɪɢɦɟɬɢɥɢ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɚɧɨɦɚɥɢʁɟ ɫɤɟɥɟɬɚ ɤɚɪɚɤɬɟɪɢɫɬɢɱɧɟ ɡɚ ɜɢɬɚɦɢɧ Ⱦ ɡɚɜɢɫɧɢ ɪɚɯɢɬɢɫ (Holick, 2006; Specker, et al. 1992). ɍ ɭɡɨɪɤɭ ɨɞ 618 ɞɟɰɟ ɢɡ ɬɪɢ ɝɪɭɩɟ (Ȼɚɧɝɥɚɞɟɲ, ɂɧɞɢʁɚ ɢ ɉɚɤɢɫɬɚɧ) ɭɡɪɚɫɬɚ ɞɜɟ ɝɨɞɢɧɟ ɤɨʁɟ ɠɢɜɟ ɭ ȼɟɥɢɤɨʁ Ȼɪɢɬɚɧɢʁɢ, ɡɚ ɚɧɚɥɢɡɭ ɝɜɨɠђɚ ɢ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ, ɧɚɭɱɧɢɰɢ ɫɭ ɭ 20-34% ɭ ɫɜɟ ɬɪɢ ɟɬɧɢɱɤɟ ɝɪɭɩɟ ɧɚɲɥɢ ɜɪɟɞɧɨɫɬ 25(Ɉɇ)D<10 ЧР/ЦХ, ɚ 13- 18% ʁɟ ɢɦɚɥɨ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D<8 ЧР/ЦХ. ɍ 20-29% ɞɟɰɟ ɧɚђɟɧɚ ʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɚ HРЛ<110Р/L, ɲɬɨ ɭɤɚɡɭʁɟ ɧɚ ɫɢɞɟɪɨɩɟɧɢʁɫɤɭ ɚɧɟɦɢʁɭ. ɋɜɚ ɢɫɩɢɬɢɜɚɧɚ ɞɟɰɚ ɫɭ ɛɢɥɚ ɡɞɪɚɜɚ ɢ ɧɢɫɭ ɢɦɚɥɚ ɡɧɚɤɟ ɪɚɯɢɬɢɫɚ. Ɉɤɨ 25% ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ʁɟ ɭɡɢɦɚɥɨ ɫɭɩɥɟɦɟɧɬɟ ɭ ɨɛɥɢɤɭ ɤɚɩɢ ɤɨʁɟ ɫɭ ɫɚɞɪɠɚɥɟ ɜɢɬɚɦɢɧɟ Ⱥ, ɐ ɢ Ⱦ. ȼɢɲɟɫɬɪɭɤɚ ɪɟɝɪɟɫɢɜɧɚ ɚɧɚɥɢɡɚ ʁɟ ɩɨɤɚɡɚɥɚ ɞɚ ʁɟ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ɛɢɨ ɩɨɜɟɡɚɧ ɫɚ ɱɢʃɟɧɢɰɨɦ ɞɚ ɬɚ ɞɟɰɚ ɧɢɫɭ ɞɨɛɢʁɚɥɚ ɩɪɟɩɨɪɭɱɟɧɟ ɞɨɡɟ ɡɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɭ. ȼɪɟɞɧɨɫɬɢ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ 77 ɤɨɞ ɤɨʁɢɯ ʁɟ ɜɪɟɞɧɨɫɬ HЛ ɛɢɥɚ ɧɢɠɚ ɨɞ 110 Р/L ɫɭ ɛɢɥɟ ɩɨɜɟɡɚɧɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚɦɚ 25(Ɉɇ)D<10 ЧР/ЦХ (Lawson, et al. 1998; Grindulis, et al. 1986). ɇɚ ɨɫɧɨɜɭ ɛɪɨʁɚ ɩɪɢʁɚɜʂɟɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɨɛɨɥɟɥɟ ɨɞ ɪɚɯɢɬɢɫɚ ɭ ɩɨɫɥɟɞʃɢɯ 15 ɝɨɞɢɧɚ, ɦɧɨɝɢ ɧɚɭɱɧɢɰɢ ɫɦɚɬɪɚʁɭ ɞɚ ʁɟ ɭ ɩɨɫɥɟɞʃɟ ɜɪɟɦɟ ɬɚʁ ɛɪɨʁ ɭ ɩɨɪɚɫɬɭ. ȼɟʄɢɧɚ ɞɟɰɟ ɨɛɨɥɟɥɟ ɨɞ ɪɚɯɢɬɢɫɚ ɫɭ ɢɡ ɝɪɭɩɟ Ⱥɮɪɨɚɦɟɪɢɱɤɟ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ, ɛɟɡ ɫɭɩɥɟɦɟɧɬɚɰɢʁɟ ɜɢɬɚɦɢɧɨɦ Ⱦ. ɍ ɩɟɪɢɨɞɭ ɢɡɦɟђɭ 1990. ɝɨɞɢɧɟ ɢ 1999. ɭ ɋɟɜɟɪɧɨʁ Ʉɚɪɨɥɢɧɢ ʁɟ ɩɪɢʁɚɜʂɟɧɨ 30 ɫɥɭɱɚʁɟɜɚ ɪɚɯɢɬɢɫɚ ɭ ɞɟɰɟ ɤɨʁɚ ɫɭ ɛɢɥɚ ɧɚ ɩɨɞɨʁɭ, ɞɨɤ ʁɟ ɭ ɩɟɪɢɨɞɭ ɢɡɦɟђɭ 1998. ɢ 1999. ɝɨɞɢɧɟ ɩɪɢʁɚɜʂɟɧɨ 17 ɨɛɨɥɟɥɢɯ ɨɞ ɪɚɯɢɬɢɫɚ (Kreiter, et al. 2000). Ɉɜɨ ɩɨɜɟʄɚʃɟ ɛɪɨʁɚ ɫɥɭɱɚʁɟɜɚ ɪɚɯɢɬɢɫɚ ɢɡ ɋɟɜɟɪɧɟ Ʉɚɪɨɥɢɧɟ ɨɞɝɨɜɚɪɚ ɩɨɪɚɫɬɭ ɫɬɨɩɟ ɞɨʁɟʃɚ ɨɞ 5,2 ɧɚ 34,7% ɭ ɩɟɪɢɨɞɭ ɨɞ 1988. ɢ 1998. ɝɨɞɢɧɟ ɭ ɠɟɧɚ ɢɡ ɋɟɜɟɪɧɟ Ʉɚɪɨɥɢɧɟ, ɤɚɤɨ ɨɞɨʁɱɚɞɢ, ɬɚɤɨ ɢ ɦɚɥɟ ɞɟɰɟ (ɩɪɨɞɭɠɟɧɨ, ɱɟɫɬɨ ɟɤɫɤɥɭɡɢɜɧɨɞɨʁɟʃɟ) (Kreiter, et al. 2000). ɉɪɢɛɥɢɠɧɢ ɧɚɥɚɡɢ ɩɪɟɬɯɨɞɧɢɦ ɩɨʁɚɜɢɥɢ ɫɭ ɫɟ ɭ ɱɥɚɧɤɭ ɤɨʁɢ ʁɟ ɩɪɢʁɚɜɢɨ 166 ɫɥɭɱɚʁɟɜɚ ɜɢɬɚɦɢɧ Ⱦ ɡɚɜɢɫɧɨɝ ɪɚɯɢɬɢɫɚ ɭ ɚɦɟɪɢɱɤɟ ɞɟɰɟ ɦɥɚђɟ ɨɞ 5 ɝɨɞɢɧɚ ɭ ɩɟɪɢɨɞɭ ɢɡɦɟђɭ 1986. ɢ 2003. ɝɨɞɢɧɟ (Weisberg, et al. 2004). ɋɥɭɱɚʁɟɜɢ ɪɚɯɢɬɢɫɚ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ʁɚɜɢɨ ɫɟ ɭ 83% Ⱥɮɪɨɚɦɟɪɢɤɚɧɚɰɚ, ɚ 96% ʃɢɯ ʁɟ ɛɢɥɨ ɧɚ ɩɨɞɨʁɭ (Weisberg, et al. 2004). Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ɍɨɤɨɦ ɢɫɬɪɚɠɢɜɚʃɚ ɭɬɢɰɚʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɧɚɲɥɢ ɫɦɨ ɞɚ ʁɟ 49 (32,7%) ɢɫɩɢɬɚɧɢɤɚ ɢɦɚɥɨ ɜɪɟɞɧɨɫɬ Hb<110 g/L. ɋɦɚɬɪɚɦɨ, ɞɚ ʁɟ ɜɟɥɢɤɚ ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɭ ɞɟɰɟ ɨɜɨɝ ɭɡɪɚɫɬɚ, ɩɨɫɥɟɞɢɰɚ ɦɧɨɝɨɛɪɨʁɧɢɯ ɟɬɢɨɥɨɲɤɢɯ ɮɚɤɬɨɪɚ, ɤɚɨ ɲɬɨ ɫɭ: ɩɨɞɨʁ, ɱɟɫɬɨ ɩɪɨɞɭɠɟɧ ɢ ɟɤɫɤɥɭɡɢɜɧɢ ɩɨɞɨʁ, ɧɟɚɞɟɤɜɚɬɧɚ ɞɨɩɭɧɫɤɚ (ɧɟɦɥɟɱɧɚ ɢɫɯɪɚɧɚ), ɤɨʁɚ ɩɨɞɪɚɡɭɦɟɜɚ, ɭ ɨɞɨʁɱɚɞɢ, ɤɚɫɧɨ ɭɜɨђɟʃɟ ɧɟɦɥɟɱɧɟ ɯɪɚɧɟ, ɧɟɚɞɟɤɜɚɬɚɧ ɭɧɨɫ ɜɨʄɚ ɤɚɨ ɡɧɚɱɚʁɧɨɝ ɢɡɜɨɪɚ ɜɢɬɚɦɢɧɚ ɐ ɤɨʁɢ ɭɱɟɫɬɜɭʁɟ ɭ ɩɪɟɬɜɚɪɚʃɭ ɮɟɪɢ ʁɨɧɚ ɢɡ ɯɪɚɧɟ ɭ ɮɟɪɨ ɨɛɥɢɤ (ʁɟɪ ɫɟ ʁɟɞɢɧɨ ɤɚɨ ɬɚɤɜɨ ɝɜɨɠђɟ ɪɟɫɨɪɛɭʁɟ), ɫɦɚʃɟɧ ɭɧɨɫ ɩɨɜɪʄɚ, ɡɟɥɟɧɨɝ ɥɢɫɧɚɬɨɝ ɩɨɜɪʄɚ, ɦɚɯɭɧɚɪɤɢ, ɦɟɫɚ ɢ ɠɭɦɚɧɰɟɬɚ, ɤɚɨ ɝɥɚɜɧɢɯ ɢɡɜɨɪɚ ɝɜɨɠђɚ ɭ ɯɪɚɧɢ. Ɇɚʁɤɟ ɫɭ ɱɟɫɬɨ ɫɥɚɛɨ ɢɧɮɨɪɦɢɫɚɧɟ ɨ ɩɪɚɜɢɥɧɨʁ ɢɫɯɪɚɧɢ ɭ ɩɟɪɢɨɞɭ ɨɞɨʁɱɟɬɚ ɢ ɦɚɥɨɝ ɞɟɬɟɬɚ. ɂɡ ɚɧɤɟɬɧɢɯ ɨɞɝɨɜɨɪɚ ɞɨɛɢɥɢ ɫɦɨ ɩɨɞɚɬɚɤ ɞɚ ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɦɚʁɤɢ ɤɨʁɟ ɞɨʁɟ ɫɜɨʁɭ ɞɟɰɭ, ɢ ɧɚɤɨɧ ɱɟɬɜɪɬɨɝ ɦɟɫɟɰɚ ɠɢɜɨɬɚ, ɩɪɟɜɚɫɯɨɞɧɨ ɞɨʁɟ. ɇɚʁɱɟɲʄɟ ɨɫɢɦ ɩɨɞɨʁɚ, ɞɟɰɢ ɞɚʁɭ ɢɧɞɭɫɬɪɢʁɫɤɢ ɧɚɩɪɚɜʂɟɧɟ ɫɨɤɨɜɟ, ɜɨʄɧɟ, ɢ ɤɚɲɢɰɟ ɨɞ ɩɨɜɪʄɚ (ɡɚ ɤɨʁɟ 78 ʁɟ ɞɨɤɚɡɚɧɨ ɞɚ ɫɚɞɪɠɟ ɦɚɥɢ ɩɪɨɰɟɧɚɬ ɜɨʄɚ ɢ ɩɨɜɪʄɚ, ɤɚɨ ɞɨɛɪɨɝ ɢɡɜɨɪɚ ɜɢɬɚɦɢɧɚ ɐ), ɤɚɨ ɢ ɢɧɞɭɫɬɪɢʁɫɤɢ ɧɚɩɪɚɜʂɟɧɟ ɤɚɲɢɰɟ ɫɚ ɦɟɫɨɦ, ɭ ɤɨʁɢɦɚ ɢɦɚ ɧɟɞɨɜɨʂɧɨ ɦɟɫɚ, ɚ ɫɚɦɢɦ ɬɢɦ ɢ ɝɜɨɠђɚ, ɞɨɤ ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɫɚɞɪɠɚʁɚ ɤɚɲɢɰɚ, ɱɢɧɢ ɫɤɪɨɛ, ɤɨʁɢ ɫɥɭɠɢ ɡɝɭɲʃɚɜɚʃɭ ɫɦɟɟ, ɤɚɤɨ ɛɢ ɫɟ ɫɚɦɨ ɩɨɜɟʄɚɥɚ ɡɚɩɪɟɦɢɧɚ ɯɪɚɧɟ. ɇɟɤɟ ɨɞ ɦɚʁɤɢ, ɠɭɦɚɧɚɰ, ɤɚɨ ɞɨɛɚɪ ɢɡɜɨɪ ɝɜɨɠђɚ, ɭ ɨɛɥɢɤɭ ɭ ɤɨɦɟ ɫɟ ɧɚʁɛɨʂɟ ɪɟɫɨɪɛɭʁɟ, ɱɟɫɬɨ ɧɢɫɭ ɞɚɜɚɥɟ ɞɟɰɢ ɞɨ ɤɪɚʁɚ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ ɞɟɬɟɬɚ. Ɇɟɫɨ, ɤɨʁɟ ɭ ɫɟɛɢ ɫɚɞɪɠɢ ɜɟɥɢɤɟ ɤɨɥɢɱɢɧɟ ɝɜɨɠђɚ ɭ ɯɟɦ ɨɛɥɢɤɭ ɤɨʁɟ ʁɟ ɢɫɤɨɪɢɫɬʂɢɜɢʁɟ ɧɟɝɨ ɨɧɨ ɢɡ ɛɢʂɧɢɯ ɢɡɜɨɪɚ ɢ ɜɚɠɚɧ ʁɟ ɢɡɜɨɪ ɜɢɬɚɦɢɧɚ Ȼ12, ɤɨɝɚ ɧɟɦɚ ɭ ɛɢʂɧɨʁ ɯɪɚɧɢ, ɚ ɤɨʁɢ ʁɟ ɩɨɬɪɟɛɚɧ ɭ ɟɪɢɬɪɨɩɨɟɡɢ, ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɦɚʁɤɢ ɤɨʁɢ ɧɢʁɟ ɩɪɚɜɢɥɧɨ ɢɧɮɨɪɦɢɫɚɧ ɨ ɢɫɯɪɚɧɢ ɞɟɬɟɬɚ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ, ɧɢʁɟ ɞɚɜɚɨ ɫɜɨɦ ɞɟɬɟɬɭ ɞɨ ɤɪɚʁɚ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ. Ɋɟɡɟɪɜɟ ɝɜɨɠђɚ ɤɨʁɟ ɞɟɰɚ ɧɚɫɥɟђɭʁɭ ɨɞ ɦɚʁɤɢ ɫɭ ɱɟɫɬɨ ɧɟɞɨɜɨʂɧɟ. ɇɚɪɨɱɢɬɨ ɫɭ ɚɧɟɦɢɱɧɚ ɛɢɥɚ ɨɞɨʁɱɚɞ ɦɚʁɤɢ ɤɨʁɟ ɫɭ ɛɢɥɟ ɚɧɟɦɢɱɧɟ ɭ ɬɨɤɭ ɬɪɭɞɧɨʄɟ, ɢ ɤɨʁɟ ɧɢɫɭ ɭɡɢɦɚɥɟ ɩɪɟɩɚɪɚɬɟ ɝɜɨɠђɚ ɭ ɬɨɤɭ ɬɪɭɞɧɨʄɟ. ɋɬɪɭɱʃɚɰɢ SГO ɩɪɟɩɨɪɭɱɭʁɭ ɞɚ ɫɜɟ ɬɪɭɞɧɢɰɟ, ɛɟɡ ɨɛɡɢɪɚ ɧɚ ɜɪɟɞɧɨɫɬɢ ɩɟɪɢɮɟɪɧɟ ɤɪɜɧɟ ɫɥɢɤɟ, ɫɨɰɢʁɚɥɧɨ-ɟɤɨɧɨɦɫɤɢ ɫɬɚɬɭɫ ɢ ɧɚɱɢɧ ɢɫɯɪɚɧɟ, ɞɨɛɢʁɚʁɭ ɝɜɨɠђɟ (pОr Шs), ɡɚ ɫɜɟ ɜɪɟɦɟ ɬɪɭɞɧɨʄɟ. ȼɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɬɪɭɞɧɢɰɚ ɝɚ ɬɟɲɤɨ ɩɨɞɧɨɫɢ, ɩɨɫɟɛɧɨ ɭ ɩɪɜɢɦ ɦɟɫɟɰɢɦɚ, ɬɚɤɨ ɞɚ ɜɟʄɢɧɚ ɩɟɪɢɧɚɬɨɥɨɝɚ ɩɪɟɞɥɚɠɟ ɞɚ ɫɟ ɩɪɟɩɚɪɚɬɢ ɝɜɨɠђɚ, ɡɚʁɟɞɧɨ ɫɚ ɩɪɟɩɚɪɚɬɢɦɚ ɮɨɥɧɟ ɤɢɫɟɥɢɧɟ, ɞɚʁɭ ɡɚ ɫɜɟ ɜɪɟɦɟ ɞɪɭɝɟ ɩɨɥɨɜɢɧɟ ɬɪɭɞɧɨʄɟ, ɢ ɩɨ GrООЧСТХu, ʁɨɲ ɬɪɢ ɦɟɫɟɰɚ ɧɚɤɨɧ ɩɨɪɨђɚʁɚ. Ɇɧɨɝɢ ɚɭɬɨɪɢ ɫɦɚɬɪɚʁɭ ɞɚ ʁɟ ɫɬɚʃɟ ɢɫɯɪɚʃɟɧɨɫɬɢ ɦɚʁɤɟ ɩɪɟ ɡɚɱɟʄɚ ɨɞ ɢɡɭɡɟɬɧɨɝ ɡɧɚɱɚʁɚ, ɚ BКТrН ɱɚɤ ɫɦɚɬɪɚ ɞɚ ʁɟ ɢɫɯɪɚɧɚ ɢ ɯɟɦɚɬɨɥɨɲɤɢ ɫɬɚɬɭɫ ɭ ɨɜɨɦ ɩɟɪɢɨɞɭ, ɡɧɚɱɚʁɧɢʁɢ ɨɞ ɢɫɯɪɚɧɟ ɭ ɬɨɤɭ ɬɪɭɞɧɨʄɟ (Baird, 1995). ɀɟɥɭɞɚɱɧɚ ɤɢɫɟɥɢɧɚ ɢ ɜɢɬɚɦɢɧ ɐ ɩɨɜɟʄɚɜɚʁɭ, ɚ ɮɨɫɮɚɬɢ, ɨɤɫɚɥɚɬɢ ɢ ɰɟɥɭɥɨɡɚ (ɜɥɚɤɧɚɫɬɟ ɦɚɬɟɪɢʁɟ) ɫɦɚʃɭʁɭ ɚɩɫɨɪɩɰɢʁɭ ɝɜɨɠђɚ ɢɡ ɰɪɟɜɚ. Ⱦɟɰɚ ɫɚ ɦɚɥɨɦ ɩɨɪɨђɚʁɧɨɦ ɦɚɫɨɦ, ɞɟɰɚ ɢɡ ɦɭɥɬɢɩɧɢɯ ɬɪɭɞɧɨʄɚ (ɤɨʁɚ ɧɢɫɭ ɞɨɛɢʁɚɥɚ ɩɪɟɩɨɪɭɱɟɧɟ ɩɪɨɮɢɥɚɤɬɢɱɤɟ ɞɨɡɟ ɩɪɟɩɚɪɚɬɚ ɝɜɨɠђɚ), ɫɚ ɤɪɚɬɤɢɦ ɪɚɡɦɚɤɨɦ ɢɡɦɟђɭ ɬɪɭɞɧɨʄɚ, ɩɨɬɯɪɚʃɟɧɚ ɞɟɰɚ, ɧɟɤɚɞ ɢ ɝɨʁɚɡɧɚ ɞɟɰɚ ɫɭ ɱɟɫɬɨ ɛɢɥɚ ɢ ɚɧɟɦɢɱɧɚ. ɍ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɭ ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ ɫɭ ɞɟɰɚ ɧɚɤɨɧ ɩɨɞɨʁɚ ɞɨɛɢʁɚɥɚ ɤɪɚɜʂɟ ɦɥɟɤɨ (ɤɨʁɟ ɧɢʁɟ ɨɛɨɝɚʄɟɧɨ ɝɜɨɠђɟɦ), ɢ ɤɨʁɟ ɤɚɨ ɯɪɚɧɚ ɬɪɟɛɚ ɞɚ ɛɭɞɟ ɫɬɪɨɝɨ ɧɟɩɪɟɩɨɪɭɱʂɢɜɨ ɤɚɨ ɨɫɧɨɜɧɚ ɯɪɚɧɚ ɩɪɟ 12 ɦɟɫɟɰɢ (Hopkins, et al. 2007). ɇɚ ɨɫɧɨɜɭ ɞɨɛɢʁɟɧɢɯ ɪɟɡɭɥɬɚɬɚ ɩɪɢɦɟʄɭʁɟɦɨ ɞɚ ʁɟ ɩɨɞɨʁ ɛɢɨ ɡɚɫɬɭɩʂɟɧ ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ (79%) ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ ɭ ɩɪɜɨʁ ɢ ɞɪɭɝɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ. ɂɫɯɪɚɧɚ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ 13 ɞɨ 24 ɦɟɫɟɰɚ ɠɢɜɨɬɚ ʁɟ ɭ ɜɟʄɟɦ ɩɪɨɰɟɧɬɭ ɫɩɪɨɜɟɞɟɧɚ ɦɢɦɨ ɩɪɟɩɨɪɭɤɚ ɨ ɩɪɚɜɢɥɧɨʁ ɢɫɯɪɚɧɢ ɞɟɰɟ ɢɡɧɚɞ ɩɪɜɟ ɝɨɞɢɧɟ ɠɢɜɨɬɚ. 79 Ⱥɧɟɦɢʁɚ ʁɟ ɛɢɥɚ ɩɪɢɫɭɬɧɚ ɭ ɜɟʄɢɧɢ ɞɟɰɟ ɤɨʁɚ ɫɭ ɫɟ ɧɟɩɪɚɜɢɥɧɨ ɯɪɚɧɢɥɚ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɢ ɤɨɞ ɤɨʁɢɯ ɧɢʁɟ ɩɪɟɩɨɡɧɚɬ ɞɟɮɢɰɢɬ ɝɜɨɠђɚ ɢ ɧɢʁɟ ɫɩɪɨɜɟɞɟɧɚ ɚɞɟɤɜɚɬɧɚ ɬɟɪɚɩɢʁɚ. Ɇɚɥɚ ɞɟɰɚ ɤɨʁɚ ɫɭ ɭɡɢɦɚɥɚ ɜɟɥɢɤɟ ɤɨɥɢɱɢɧɟ ɦɥɟɤɚ (>500 ml/ɞɚɧ) ɭ ɞɪɭɝɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɫɭ ɩɪɟɬɟɠɧɨ ɛɢɥɚ ɚɧɟɦɢɱɧɚ. Ⱦɧɟɜɧɟ ɤɨɥɢɱɢɧɟ ɦɥɟɤɚ ɨɞɨʁɱɚɞɢ ɫɬɚɪɢʁɨʁ ɨɞ ɲɟɫɬ ɦɟɫɟɰɢ ɬɪɟɛɚ ɨɝɪɚɧɢɱɢɬɢ ɧɚ ɥɢɬɚɪ, ɚ ɫɬɚɪɢʁɨʁ ɨɞ ɝɨɞɢɧɭ ɞɚɧɚ ɧɚ ɩɨɥɚ ɥɢɬɪɚ (Schwarts, 2000). Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɩɪɟɞɫɬɚɜʂɟɧɢ ɧɚ ɝɪɚɮɢɤɨɧɭ ɢ ɬɚɛɟɥɢ ɩɨɤɚɡɭʁɭ ɞɚ ʁɟ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ ɢɦɚɥɨ 39%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ 25%, ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɢ ɚɧɟɦɢʁɭ 16% ɢɫɩɢɬɚɧɢɤɚ Ɉɩɬɢɦɚɥɧɭ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɚɧɟɦɢʁɭ ʁɟ ɢɦɚɥɨ 20% ɢɫɩɢɬɚɧɢɤɚ, ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɜɟʄɢɧɨɦ ɢɫɬɪɚɠɢɜɚʃɚ ɨ ɭɞɪɭɠɟɧɨɫɬɢ ɝɜɨɠђɟ ɞɟɮɢɰɢɬɚɪɧɟ ɚɧɟɦɢʁɟ (ɋȺ) ɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ). ɍ ɧɚɲɟɦ ɢɫɬɪɚɠɢɜɚʃɭ, ɭɬɜɪɞɢɥɢ ɫɦɨ, ɞɚ 5% ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 23% ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɢ 21% ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, (49% ɫɚ ȼȾȾ), ɧɢʁɟ ɛɢɥɨ ɚɧɟɦɢɱɧɨ. KШɞ 51% ɢɫɩɢɬɚɧɢɤɚ ɫɭ ɧɚђɟɧɟ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɚ HЛ≥110 Р/L. Ⱦɨɛɢʁɟɧɢ ɪɟɡɭɥɬɚɬɢ ɭɤɚɡɭʁɭ ɧɚ ɩɨɜɟʄɚɧɭ ɭɞɪɭɠɟɧɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɢ ɫɢɞɟɪɨɩɟɧɢʁɫɤɟ ɚɧɟɦɢʁɟ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɧɚ ɲɬɚ ɭɤɚɡɭʁɟ ɞɨɛɢʁɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ=0,0091). ɂɫɩɢɬɢɜɚʃɟɦ ɤɨɪɟɥɚɰɢʁɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɢ ɯɟɦɨɝɥɨɛɢɧɚ (Hb) ɞɨɛɢʁɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ (r=0,3189). Ⱦɨɛɢʁɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ (ɪ=0,0001) ɢɡɦɟђɭ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D ɢ ɜɪɟɞɧɨɫɬɢ HЛ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɢ ɭ ɝɪɭɩɢ ɨɞɨʁɱɚɞɢ (r=0,315; p=0,0066), ɢ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ (r=0,420, p=0,0001). ɍɩɨɪɟђɭʁɭʄɢ ɪɟɡɭɥɬɚɬɟ ɧɚɲɢɯ ɢɫɬɪɚɠɢɜɚʃɚ ɨ ɭɞɪɭɠɟɧɨɫɬɢ ɚɧɟɦɢʁɟ ɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ, ɧɚɢɲɥɢ ɫɦɨ ɧɚ ɦɧɨɝɨɛɪɨʁɧɚ ɢɫɬɪɚɠɢɜɚʃɚ ɤɨʁɚ ɭɤɚɡɭʁɭ ɧɚ ɩɨɜɟʄɚɧɭ ɭɱɟɫɬɚɥɨɫɬ ɮɟɪɨɞɟɮɢɰɢɬɚɪɧɟ (ɧɭɬɪɢɬɢɜɧɟ) ɚɧɟɦɢʁɟ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ. ɏɨɩɤɢɧɫ-Ʌɟɞ ɫɬɭɞɢʁɚ ɭ ɤɨʁɨʁ ʁɟ ɩɪɚʄɟɧ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɯɟɦɨɝɥɨɛɢɧɚ ɭ 10400 ɞɟɰɟ ɭɤɚɡɭʁɟ ɞɚ ɫɭ ɧɢɜɨɢ ɜɢɬɚɦɢɧɚ Ⱦ ɫɬɚɥɧɨ ɧɢɠɢ ɤɨɞ ɞɟɰɟ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɯɟɦɨɝɥɨɛɢɧɚ. ȼɪɟɞɧɨɫɬɢ HРЛ<110Р/L ɤɨʁɟ ɭɤɚɡɭʁɭ ɧɚ ɚɧɟɦɢʁɭ, ɛɢɥɟ ɫɭ ɩɪɢɫɭɬɧɟ ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ, ɱɚɤ ɢ ɭ ɞɟɰɟ ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ (ɛɥɚɝɢɦ ɧɟɞɨɫɬɚɬɤɨɦ, ɫɭɛɨɩɬɢɦɚɥɧɢɦ) ɜɢɬɚɦɢɧɨɦ Ⱦ ɭ ɫɟɪɭɦɭ, 25(Ɉɇ)D<30 ЧР/ЦХ (ɪ=0.006). ɍ ɞɟɰɟ ɫɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ʁɟ ɛɢɥɚ ɫɤɨɪɨ ɞɜɨɫɬɪɭɤɚ (ɪ=0,004). Ɋɟɡɭɥɬɚɬɢ ɢɫɬɪɚɠɢɜɚʃɚ ɧɚ ɩɟɞɢʁɚɬɪɢʁɫɤɨɦ ɨɞɟʂɟʃɭ ɭ ɛɨɥɧɢɰɢ ɭ Јɨɪɞɚɧɭ, ɨɤɬɨɛɪɚ ɦɟɫɟɰɚ 2012. ɝɨɞɢɧɟ, ɨɞɪɟђɢɜɚɧ ʁɟ ɧɢɜɨ HЛ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ 80 ɡɞɪɚɜɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 6-36 ɦɟɫɟɰɢ ɠɢɜɨɬɚ. ɍɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɭ 204 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɢɡɧɨɫɢɥɚ ʁɟ 40 (4%). ɍɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɭ ɨɞɨʁɱɚɞɢ (ɇ=110) ʁɟ ɛɢɥɚ 51 (8%), ɞɨɤ ʁɟ ɭɱɟɫɬɚɥɨɫɬ ɚɧɟɦɢʁɟ ɭ ɦɚɥɟ ɞɟɰɟ (ɇ=93) ɛɢɥɚ 26 (9%). ɇɢʁɟ ɧɚђɟɧɚ ɜɟɡɚ ɢɡɦɟђɭ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɚɧɟɦɢʁɟ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɬɚɤɨ ɞɚ ʁɟ ɩɨɫɬɚɜʂɟɧ ɡɚɤʂɭɱɚɤ ɞɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɧɢʁɟ ɮɚɤɬɨɪ ɪɢɡɢɤɚ ɡɚ ɚɧɟɦɢʁɭ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (Abdul-Razzak, et al. 2012). Ɂɚ ɫɢɧɬɟɡɭ ɝɜɨɠђɚ ɧɟɨɩɯɨɞɚɧ ʁɟ ɜɢɬɚɦɢɧ Ⱦ, ɚ ʃɢɯɨɜ ɡɚʁɟɞɧɢɱɤɢ ɧɟɞɨɫɬɚɬɚɤ ɭ ɞɟɰɟ ʁɟ ʁɚɤɨ ɱɟɫɬ (ɦɚʁ 2012.). ɋɦɚɬɪɚ ɫɟ, ɞɚ ɫɟ ɤɨɧɜɟɪɡɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ʁɟɬɪɢ ɫɦɚʃɭʁɟ ɚɤɨ ɧɟɦɚ ɞɨɜɨʂɧɨ ɝɜɨɠђɚ ɭ ɨɪɝɚɧɢɡɦɭ. Ɉɞ 13 ɧɨɜɨɪɨђɟɧɱɚɞɢ ɫɚ ɚɧɟɦɢʁɨɦ, 9 ʁɟ ɢɦɚɥɨ ɧɢɡɚɤ ɧɢɜɨ 25(OH)D<10 ЧР/ЦХ. Ɉɜɚ ɞɟɰɚ ɫɭ ɭ ɬɟɪɚɩɢʁɢ ɞɨɛɢʁɚɥɚ ɝɜɨɠђɟ, ɧɚɤɨɧ ɱɟɝɚ ɫɭ ɫɟ ɜɪɟɞɧɨɫɬɢ ɫɟɪɭɦɫɤɨɝ ɝɜɨɠђɚ ɢ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɜɟʄɚɥɟ (Meredith, et al. 2013). ɉɪɟɦɚ ɢɫɩɢɬɢɜɚɧɢɦ ɫɬɭɞɢʁɚɦɚ, ɟɪɢɬɪɨɰɢɬɢ ɫɟ ɛɪɠɟ ɨɛɧɨɜɟ ɤɨɞ ɨɫɨɛɚ ɫɚ ɜɢɲɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (Gaweda, et al. 2009). Ⱦɚ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ ɢɦɚʁɭ ɜɟɡɭ ɫɚ ɚɧɟɦɢʁɨɦ ɭ ɞɟɰɟ ɞɨɤɚɡɚɧɨ ʁɟ ɭ ɫɬɭɞɢʁɢ 9400 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 2-18 ɝɨɞɢɧɚ, ɝɞɟ ɫɭ ɜɪɟɞɧɨɫɬɢ 25(Ɉɇ)D <20 ЧР/ЦХ ɡɚ 50% ɩɨɜɟʄɚɜɚɥɟ ɪɢɡɢɤ ɡɚ ɚɧɟɦɢʁɭ. ɉɨɜɟʄɚʃɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɡɚ ɫɜɚɤɢ ЧР/ЦХ, ɞɨɜɨɞɢɨ ʁɟ ɞɨ ɫɦɚʃɟʃɚ ɪɢɡɢɤɚ ɡɚ ɚɧɟɦɢʁɭ ɨɞ ɨɤɨ 3%. ɋɚɦɨ 1% ɞɟɰɟ ʁɟ ɢɦɚɥɨ ɫɢɞɟɪɨɩɟɧɢʁɫɤɭ ɚɧɟɦɢʁɭ (CȺ), ɞɨɤ ʁɟ 9% ɰɪɧɟ ɞɟɰɟ ɢɦɚɥɨ CA. ȼɟʄɚ ʁɟ ɲɚɧɫɚ ɞɚ ɫɭ ɞɟɰɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɬɧɚ (ȼȾȾ), ɚɤɨ ɫɭ ɚɧɟɦɢɱɧɚ (Јɚɧɭɚɪ 2012.). ɉɨɫɬɚɜʂɚ ɫɟ ɩɢɬɚʃɟ ɞɚ ɥɢ ʁɟ ɧɟɨɩɯɨɞɧɨ ɞɚɜɚʃɟ ɫɭɩɥɟɦɟɧɚɬɚ ɝɜɨɠђɚ ɤɚɤɨ ɛɢ ɫɟ ɥɟɱɢɨ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ (ȼȾȾ). ȼɢɬɚɦɢɧ Ⱦ ʁɟ ɧɟɨɩɯɨɞɚɧ ɞɚ ɩɨɦɨɝɧɟ ɬɟɥɭ ɞɚ ɮɭɧɤɰɢɨɧɢɲɟ ɧɨɪɦɚɥɧɨ. ȼɚɠɚɧ ɭɬɢɰɚʁ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɞɚ ɩɨɦɨɝɧɟ ɟɪɢɬɪɨɰɢɬɢɦɚ ɞɚ ɤɨɪɢɫɬɟ ɝɜɨɠђɟ, ɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɪɝɚɧɢɡɦɭ ʁɟ ɩɨɜɟɡɚɧ ɫɚ ɝɜɨɠђɟ ɞɟɮɢɰɢɬɚɪɧɨɦ ɚɧɟɦɢʁɨɦ. ɑɚɤ ɢ ɫɪɟɞʃɟ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ ɭ ɞɟɱʁɟɦ ɨɪɝɚɧɢɡɦɭ ɦɨɝɭ ɭɫɥɨɜɢɬɢ ɨɡɛɢʂɧɟ ɩɨɪɟɦɟʄɚʁɟ ɭ ɨɪɝɚɧɢɡɦɭ (Hall, 2010). Ʉɚɨ ɞɨɤɚɡ ɤɨɦɩɥɟɤɫɧɨɫɬɢ ɢɡɦɟђɭ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɯɟɦɨɝɥɨɛɢɧɚ, ɨɤɫɢɝɟɧɢɫɚɧɨɝ ɩɪɨɬɟɢɧɚ ɭ ɰɪɜɟɧɢɦ ɤɪɜɧɢɦ ɡɪɧɰɢɦɚ, ɭɤɚɡɭʁɟ ɧɟɤɨɥɢɤɨ ɦɟɯɚɧɢɡɚɦɚ ɤɨʁɢ ɦɨɝɭ ɞɚ ɨɛʁɚɫɧɟ ɜɟɡɭ ɢɡɦɟђɭ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɚɧɟɦɢʁɟ, ɭɤʂɭɱɭʁɭʄɢ ɟɮɟɤɚɬ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɩɪɨɢɡɜɨɞʃɭ ɰɪɜɟɧɢɯ ɤɪɜɧɢɯ ɡɪɧɚɰɚ ɭ ɤɨɲɬɚɧɨʁ ɫɪɠɢ, ɤɚɨ ɢ ɫɩɨɫɨɛɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɪɟɝɭɥɚɰɢʁɢ ɢɦɭɧɨɥɨɲɤɢɯ ɭɩɚɥɚ, ɤɨʁɟ ɫɭ ɩɨɡɧɚɬɟ ɤɚɨ ɤɚɬɚɥɢɡɚɬɨɪɢ ɚɧɟɦɢʁɟ. Ɏɚɤɬɨɪɢ ɪɢɡɢɤɚ ɡɚ ɚɧɟɦɢʁɟ ɭɤʂɭɱɭʁɭ: ɢɫɯɪɚɧɭ ɫɢɪɨɦɚɲɧɭ ɝɜɨɠђɟɦ ɢ ɮɨɥɚɬɢɦɚ, ɬɟɲɤɟ ɛɨɥɟɫɬɢ ɤɚɨ ɲɬɨ ɫɭ ɭɧɭɬɪɚɲʃɟ ɤɪɜɚɪɟʃɟ, ɛɨɥɟɫɬɢ ɛɭɛɪɟɝɚ, ɪɚɤ, ɞɢʁɚɛɟɬɟɫ, ɏɂȼ, ɛɨɥɟɫɬɢ ʁɟɬɪɟ ɢ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ (Heldenberg, et al. 1992). 81 ɉɨɫɬɨʁɢ ɜɟɥɢɤɢ ɛɪɨʁ ɫɬɭɞɢʁɚ ɤɨʁɟ ɩɨɜɟɡɭʁɭ ɧɢɠɢ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɜɟʄɢ ɪɢɡɢɤ ɨɞ ɚɧɟɦɢʁɟ: - ɍ ɚɭɫɬɪɚɥɢʁɫɤɨʁ ɫɬɭɞɢʁɢ ɨɫɨɛɟ ɫɚ ɧɟɯɨɥɟɫɬɚɡɧɢɦ ɯɪɨɧɢɱɧɢɦ ɛɨɥɟɫɬɢɦɚ ʁɟɬɪɟ ɢɦɚʁɭ ɧɢɠɢ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɜɟɡɚɧ ɡɚ ɚɧɟɦɢʁɭ. - Ɍɪɭɞɧɢɰɟ ɭ Ɍɚɧɡɚɧɢʁɢ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɧɨɫɭ ɧɚ ɨɧɟ ɫɚ ɨɞɝɨɜɚɪɚʁɭʄɢɦ ɧɢɜɨɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɀɟɧɟ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɢɦɚɥɟ ɦɧɨɝɨ ɜɟʄɢ ɪɢɡɢɤ ɨɞ ɚɧɟɦɢʁɟ. - ɍ ɋʁɟɞɢʃɟɧɢɦ ɞɪɠɚɜɚɦɚ, 41% ɩɚɰɢʁɟɧɚɬɚ ɫɚ ɯɪɨɧɢɱɧɨɦ ɛɨɥɟɲʄɭ ɛɭɛɪɟɝɚ ʁɟ ɢɦɚɥɨ ɚɧɟɦɢʁɭ. ɇɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɩɨɜɟɡɚɧ ɫɚ ɧɢɠɢɦ ɧɢɜɨɢɦɚ ɯɟɦɨɝɥɨɛɢɧɚ ɢ ɚɧɟɦɢʁɨɦ. - ɋɬɭɞɢʁɚ ɭ Ʌɨɫ Ⱥɧђɟɥɟɫɭ ɩɪɨɧɚɲɥɚ ʁɟ ɜɟɡɭ ɢɡɦɟђɭ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɚɧɟɦɢʁɟ. - Ⱥɦɟɪɢɱɤɚ ɫɬɭɞɢʁɚ ɭ ɨɞɧɨɫɭ ʂɭɞɢ ɫɚ, ɢ ɛɟɡ ɚɧɟɦɢʁɟ, ɩɨɤɚɡɚɥɚ ʁɟ ɞɚ ɨɫɨɛɟ ɫɚ ɚɧɟɦɢʁɨɦ ɢɦɚʁɭ ɜɟʄɟ ɲɚɧɫɟ ɞɚ ɢɦɚʁɭ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ. - Ⱦɪɭɝɚ ɫɬɭɞɢʁɚ ɭ Ⱥɦɟɪɢɰɢ ɩɨɤɚɡɭʁɟ ɞɢɪɟɤɬɧɭ ɜɟɡɭ ɢɡɦɟђɭ ɧɢɜɨɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɦɚɤɫɢɦɚɥɧɟ ɩɨɬɪɨɲʃɟ ɤɢɫɟɨɧɢɤɚ. ɍ ɫɬɭɞɢʁɢ ɭ Ⱦɟɧɜɟɪɭ 2011. ɝɨɞɢɧɟ, ɤɨʁɚ ʁɟ ɪɚɡɦɚɬɪɚɥɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɯɟɦɨɝɥɨɛɢɧɚ ɢ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɭ 10410 ɞɟɰɟ ɭɡɪɚɫɬɚ ɨɞ 1-21 ɝɨɞɢɧɟ, ɡɚɤʂɭɱɟɧɨ ʁɟ ɞɚ ʁɟ ȼȾȾ ɩɨɜɟɡɚɧɚ ɫɚ ɜɟʄɢɦ ɪɢɡɢɤɨɦ ɨɞ ɚɧɟɦɢʁɟ ɤɨɞ ɧɚɨɤɨ ɡɞɪɚɜɟ ɞɟɰɟ, ɞɨɤ ʁɟ ȼȾȾ ɛɢɥɚ ɜɢɲɟ ɩɨɜɟɡɚɧɚ ɫɚ ɧɢɠɢɦ ɜɪɟɞɧɨɫɬɢɦɚ Hb ɭ ɰɪɧɟ ɞɟɰɟ, ɭ ɨɞɧɨɫɭ ɧɚ ɞɟɰɭ ɛɟɥɟ ɪɚɫɟ (Ɇɟredith A. Atkinson, et al 2011). ɐɪɧɚ ɞɟɰɚ ɫɭ ɢɦɚɥɚ ɜɟʄɭ ɫɬɨɩɭ ɚɧɟɦɢʁɟ ɢ ȼȾȾ ɭ ɨɞɧɨɫɭ ɧɚ ɞɟɰɭ ɛɟɥɟ ɪɚɫɟ (14% ɩɪɟɦɚ 2%) ɢ ɧɢɠɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D, ɚɥɢ ɫɟ ɪɢɡɢɤ ɡɚ ɚɧɟɦɢʁɭ ɭ ɰɪɧɟ ɞɟɰɟ ɧɢʁɟ ɩɨɜɟʄɚɨ, ɞɨɤ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɰɪɧɟ ɞɟɰɟ ɞɚɥɟɤɨ ɦɚʃɟ ɩɚɥɟ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ 25(Ɉɇ)D ɞɟɰɟ ɛɟɥɟ ɪɚɫɟ (ɆɟrОНТtС A. AtФТЧsШЧ, et al 2013). Ⱥɦɟɪɢɱɤɨ ɭɞɪɭɠɟʃɟ ɡɚ ɤɥɢɧɢɱɤɭ ɢɫɯɪɚɧɭ ʁɟ ɭ ɫɜɨɦ ɢɫɬɪɚɠɢɜɚʃɭ ɭ 9 ɨɞ 17 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ (ɭɡɪɚɫɬɚ 10.5 +/- 4.3) ɫɚ ɚɧɟɦɢʁɨɦ ɧɚɲɥɨ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɢɫɩɨɞ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ, 25(OH)D<10 ЧР/ЦХ, ɢɚɤɨ ɫɭ ɫɜɚ ɨɞɨʁɱɚɞ ɞɨɛɢУКɥɚ 10 ɦɢɤɪɨɝɪɚɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɞɧɟɜɧɨ ɨɞ ɧɚɜɪɲɟɧɢɯ ɦɟɫɟɰ ɞɚɧɚ ɠɢɜɨɬɚ. ɇɨɜɨɪɨђɟɧɱɚɞ ɫɭ ɞɨɛɢɥɚ ɝɜɨɠђɟ - ɞɟɤɫɬɪɚɧ (ɂɦɮɟɪɨɧ) ɢɧɬɪɚɦɭɫɤɭɥɚɪɧɨ. ɍɫɥɟɞ ɤɨɪɢɲʄɟʃɚ ɝɜɨɠђɚ ɞɟɤɫɬɪɚɧ, ɞɨɲɥɨ ʁɟ ɞɨ ɩɨɜɟʄɚʃɚ ɯɟɦɨɝɥɨɛɢɧɚ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɝɜɨɠђɚ ɭ ɫɟɪɭɦɭ, ɤɚɨ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɢ 24,25(OH)2D. Ɂɧɚɦɨ ɞɚ ɧɟɞɨɫɬɚɬɚɤ ɝɜɨɠђɚ ɫɦɚʃɭʁɟ ɚɩɫɨɪɩɰɢʁɭ ɦɚɫɬɢ ɢ ɜɢɬɚɦɢɧɚ Ⱥ ɢɡ ɰɪɟɜɚ. Ɂɛɨɝ ɬɨɝɚ ɫɟ ɫɦɚɬɪɚ ɞɚ ʄɟ ɢ ɚɩɫɨɪɩɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɬɚɤɨђɟ ɛɢɬɢ ɫɦɚʃɟɧɚ. Ɍɨ ɦɨɠɟ ɭɡɪɨɤɨɜɚɬɢ ɪɚɡɜɨʁɭ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. 82 Ɉɜɢɦ ɫɟ ɨɛʁɚɲʃɚɜɚ ɞɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɚ ɝɜɨɠђɚ ɭ ɞɟɰɟ ɦɨɠɟ ɞɨɜɟɫɬɢ ɞɨ ɛɨʂɟ ɚɩɫɨɪɩɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɬɚɧɤɨɦ ɰɪɟɜɭ, ɢ ɧɚ ɬɚʁ ɧɚɱɢɧ ɩɨɜɟʄɚɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɥɚɡɦɢ (Heldenberg, et al. 1992). ɂɚɤɨ ɞɨ ɫɚɞɚ ɧɟɦɚ ɩɪɢʁɚɜʂɟɧɢɯ ɫɬɭɞɢʁɚ ɞɚ ɜɢɬɚɦɢɧ Ⱦ ɫɩɪɟɱɚɜɚ ɚɧɟɦɢʁɭ, ɧɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɡɚ ɦɧɨɝɟ ɞɪɭɝɟ ɛɨɥɟɫɬɢ, ɤɚɨ ɲɬɨ ɫɭ ɯɪɨɧɢɱɧɟ ɛɨɥɟɫɬɢ ɛɭɛɪɟɝɚ, ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɧɚɞ 30-40 ng/ml ɦɨɠɟ ɩɨɜɟʄɚɬɢ ɛɪɨʁ ɟɪɢɬɪɨɰɢɬɚ ɭ ɫɟɪɭɦɭ ɢ ɨɤɫɢɝɟɧɚɰɢʁɭ ɤɪɜɢ (William, et al.; Lac, et al. 2010). ɉɪɟɦɚ ɢɫɩɢɬɢɜɚɧɢɦ ɫɬɭɞɢʁɚɦɚ, ɟɪɢɬɪɨɰɢɬɢ ɫɟ ɛɪɠɟ ɨɛɧɨɜɟ ɤɨɞ ɨɫɨɛɚ ɫɚ ɜɢɲɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (Gaweda, et al. 2009). Jeffrey Fadrowski, M.D., M.H.S., ɞɟɱʁɢ ɧɟɮɪɨɥɨɝ ɭ JШСЧs HШpФТЧs CСТХНrОЧ,s Centru ɬɜɪɞɢ, ɞɚ ɚɤɨ ɞɚʂɚ ɢɫɬɪɚɠɢɜɚʃɚ ɭɤɚɡɭʁɭ ɧɚ ɭɬɢɰɚʁ ɧɢɫɤɢɯ ɜɪɟɞɧɨɫɬɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɞɟɰɟ, ɢɡɦɟђɭ ɨɫɬɚɥɨɝ, ɤɚɨ ɮɚɤɬɨɪ ɪɢɡɢɤɚ ɡɚ ɚɧɟɦɢʁɭ, ɨɧɞɚ ʄɟ ɫɟ ɥɚɤɲɟ "ɧɨɫɢɬɢ" ɫɚ ɫɭɩɥɟɦɟɧɬɚɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ (Atkinson, et al. 2013). Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɛɢɨɯɟɦɢјɫɤɟ ɜɚɪɢјɚɛɥɟ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢјɭɦɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɂɫɩɢɬɭʁɭʄɢ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫ ɭ ɨɞɧɨɫɭ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ (<1,9 mmol/L) ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɧɚђɟɧɟ ɫɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɋɚ<1,9 mmol/L ɭ ɨɫɦɨɪɨ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɍɪɨʁɟ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ʁɟɞɧɨ ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ʁɟɞɧɨ ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɢ ɞɜɨʁɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɟɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ʁɟ ɢɦɚɥɨ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ < 1,9 ЦЦШХ/L. Ʉɚɨ ɲɬɨ ɡɧɚɦɨ, ɧɚʁɜɚɠɧɢʁɢ ɟɮɟɤɚɬ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɚɩɫɨɪɩɰɢʁɚ ɤɚɥɰɢʁɭɦɚ. ɍ ȼȾȾ, ɫɚ ɫɦɚʃɟʃɟɦ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ, ɩɪɟɦɚ ɬɪɟɧɭɬɧɨʁ ɬɟɨɪɢʁɢ, ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɭ ɫɢɧɬɟɡɢ ɊɌɇ ɭɫɥɟɞ ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ. Ɉɧ ɩɨɜɟʄɚɜɚ ɤɚɥɰɢʁɭɦ ɭ ɫɟɪɭɦɭ ɚɤɭɬɧɨɦ ɦɨɛɢɥɢɡɚɰɢʁɨɦ ɤɚɥɰɢʁɭɦɚ ɢɡ ɤɨɫɬɢʁɭ. Ɂɛɨɝ ɪɚɫɩɪɨɫɬɪɚʃɟɧɨɫɬɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɞɟɰɟ, ɜɚɠɧɨ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɧɚʁɛɨʂɟ ɜɪɟɦɟ ɞɟɬɟɤɰɢʁɟ ɤɨɥɢɱɢɧɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ. ɋɬɪɭɱʃɚɰɢ ɫɦɚɬɪɚʁɭ ɞɚ ɫɟ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɩɪɨɜɟɪɚɜɚ ɭ ɫɥɭɱɚʁɭ ɯɢɩɨɤɚɥɰɢɟɦɢʁɟ, ɢɥɢ, 83 ɚɤɨ ɫɭ ɩɪɢɫɭɬɧɢ ɧɟɤɢ ɫɢɦɩɬɨɦɢ ɢɥɢ ɡɧɚɰɢ ɪɚɯɢɬɢɫɚ, ɤɚɨ ɢ ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɮɪɚɤɬɭɪɚ ɭ ɨɞɫɭɫɬɜɭ ɩɨɜɪɟɞɟ ʁɚɱɟɝ ɢɧɬɟɧɡɢɬɟɬɚ (Munns, et al. 2006). Ɇɨɝɭʄɟ ʁɟ ɞɚ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɢɡɚɡɨɜɟ ɧɟɲɬɨ ɦɚɥɨ ɩɨɜɢɲɟɧɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɊɌɇ, ɞɨɤ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɧɢɤɚɞɚ ɧɟʄɟ ɩɨɜɟʄɚɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɋɚ ɭ ɤɪɜɢ. Ɉɫɨɛɟ ɫɚ ɧɢɫɤɢɦ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɤɪɜɢ ɦɨɝɭ ɪɚɡɜɢɬɢ ɧɢɡɚɤ ɧɢɜɨ ɋɚ ɭ ɤɪɜɢ, ɚɥɢ ɫɭ ɪɟɡɟɪɜɟ ɭ ɤɨɫɬɢɦɚ ɬɨɥɢɤɟ, ɞɚ ɫɤɨɪɨ ɫɜɟ ɨɫɨɛɟ ɫɚ ɧɢɫɤɢɦ ɤɨɧɰɟɧɬɪɚɰɢʁɚɦɚ 25(OH)D ɡɛɨɝ ɱɢʃɟɧɢɰɟ ɞɚ ɧɟ ɞɨɛɢʁɚʁɭ ɞɨɜɨʂɧɨ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɯɪɚɧɢ ɢɥɢ ɫɟ ɧɟ ɢɡɥɚɠɭ ɫɭɧɱɟɜɢɦ ɡɪɚɰɢɦɚ ʄɟ ɢɦɚɬɢ ɧɨɪɦɚɥɧɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɋɚ ɭ ɤɪɜɢ. ɇɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɞɨɜɨɞɢ ɞɨ ɫɦɚʃɟɧɟ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ ɢɡ ɯɪɚɧɟ, ɛɟɡ ɨɛɡɢɪɚ ɧɚ ɤɨɥɢɱɢɧɭ ɤɚɥɰɢʁɭɦɚ ɤɨʁɭ ɭɧɨɫɢɦɨ. ɍɤɨɥɢɤɨ ɨɪɝɚɧɢɡɚɦ ɧɟ ɞɨɛɢʁɚ ɞɨɜɨʂɧɭ ɤɨɥɢɱɢɧɭ ɤɚɥɰɢʁɭɦɚ ɨɜɢɦ ɩɭɬɟɦ, ɧɟɨɩɯɨɞɧɚ ɤɨɥɢɱɢɧɚ ɤɚɥɰɢʁɭɦɚ ɫɟ ɨɛɟɡɛɟђɭʁɟ ʃɟɝɨɜɢɦ ɩɨɜɥɚɱɟʃɟɦ ɢɡ ɤɨɫɬɢʁɭ. Ʉɚɨ ɩɨɫɥɟɞɢɰɚ ɨɜɨɝ ɩɪɨɰɟɫɚ ʁɚɜʂɚ ɫɟ ɫɦɚʃɟʃɟ ɝɭɫɬɢɧɟ ɤɨɲɬɚɧɨɝ ɬɤɢɜɚ (ɨɫɬɟɨɩɟɧɢʁɚ), ɚ ɡɚɬɢɦ ɢ ɨɫɬɟɨɩɨɪɨɡɚ. Ɉɪɝɚɧɢɡɚɦ ɧɚɫɬɨʁɢ ɞɚ ɨɞɪɠɢ ɜɪɟɞɧɨɫɬɢ ɤɚɥɰɢʁɭɦɚ ɭ ɤɪɜɢ ɭ ɨɤɜɢɪɭ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ ɧɚ ɛɢɥɨ ɤɨʁɢ ɧɚɱɢɧ, ʁɟɪ ʁɟ ɤɚɥɰɢʁɭɦ ɧɟɨɩɯɨɞɚɧ ɡɚ ɮɭɧɤɰɢɨɧɢɫɚʃɟ ɩɥɭʄɚ, ɦɢɲɢʄɚ, ɦɨɡɝɚ, ɫɪɰɚ. ɂɚɤɨ ʁɟ ɫɭɧɰɟ ɭɨɛɢɱɚʁɟɧɢ ɢɡɜɨɪ ɜɢɬɚɦɢɧɚ Ⱦ, ɢɫɯɪɚɧɚ ʁɟ ɧɚɪɚɜɧɨ ɢɡɜɨɪ ɤɚɥɰɢʁɭɦɚ. ɉɨɫɟɛɧɨ ʁɟ ɜɚɠɧɨ ɞɚ ɫɟ ɫɩɪɟɱɢ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ ɫɚ ɨɝɪɚɧɢɱɟɧɢɦ ɭɧɨɫɨɦ ɤɚɥɰɢʁɭɦɚ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɍ ɧɚɲɟɦ ɢɫɬɪɚɠɢɜɚʃɭ ɨ ɭɬɢɰɚʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ, ɞɨɛɢʁɟɧɟ ɜɪɟɞɧɨɫɬɢ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɫɭ ɫɟ ɭ ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɧɚɥɚɡɢɥɟ ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ. ɏɢɩɨɮɨɫɮɚɬɟɦɢʁɚ (<1,1 mmol/L) ʁɟ ɧɚђɟɧɚ ɫɚɦɨ ɭ 6 ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, 5 ɭ ɝɪɭɩɢ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ, ɢ 1 ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɲɬɨ ɫɟ ɫɥɚɠɟ ɫɚ ɪɟɡɭɥɬɚɬɢɦɚ ɦɧɨɝɨɛɪɨʁɧɢɯ ɢɫɬɪɚɠɢɜɚʃɚ. Ɇɨɝɭ ɫɟ ɭɨɱɢɬɢ ɦɧɨɝɟ ɜɚɪɢʁɚɰɢʁɟ ɭ ɬɨɤɭ ɥɚɛɨɪɚɬɨɪɢʁɫɤɢɯ ɩɪɟɬɪɚɝɚ. ɇɟ ɪɟɬɤɨ, ɞɟɰɚ ɫɚ ɢɡɪɚɡɢɬɨɦ ɯɢɩɨɤɚɥɰɢɟɦɢʁɨɦ ɢ ɫɟɤɭɧɞɚɪɧɢɦ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɨɦ, ɢɦɚʁɭ ɧɨɪɦɚɥɚɧ ɢɥɢ ɩɨɜɢɲɟɧ ɧɢɜɨ ɮɨɫɮɚɬɚ, ɲɬɨ ʁɟ ɦɨɝɭʄɟ ɭɫɥɟɞ ɭɬɢɰɚʁɚ ɩɚɪɚɬɢɪɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ), ɤɚɤɨ ɧɚ ɤɨɫɬɢ, ɬɚɤɨ ɢ ɧɚ ɛɭɛɪɟɝɟ ɭɫɥɟɞ ɩɪɨɞɭɠɟɧɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ (Robinson, et al. 2006; Ladhani, et al. 2004). 84 Ɍɨ ɦɨɠɟ ɞɨɜɟɫɬɢ ɞɨ ɡɚɛɭɧɟ ɫɚ ɯɢɩɨɩɚɪɚɬɢɪɨɢɞɢɡɦɨɦ ɢɥɢ ɩɫɟɭɞɨɯɢɩɨɩɚɪɚɬɢɪɨɢɞɢɡɦɨɦ, ɤɚɞɚ ɫɭ ɜɪɟɞɧɨɫɬɢ ɤɚɥɰɢʁɭɦɚ ɢ ɮɨɫɮɚɬɚ ɭ ɫɟɪɭɦɭ ɪɚɧɢʁɟ ɞɨɫɬɭɩɧɢ, ɩɪɟ ɪɟɡɭɥɬɚɬɚ 25(Ɉɇ)D ɢ ɊɌɇ ɭ ɫɟɪɭɦɭ (Robinson, et al. 2006). Ʉɨɧɰɟɧɬɪɚɰɢʁɚ ɤɚɥɰɢɬɪɢɨɥɚ (1,25(Ɉɇ)2D) ɦɨɠɟ ɛɢɬɢ ɧɢɫɤɚ, ɧɨɪɦɚɥɧɚ ɢɥɢ ɜɢɫɨɤɚ ɭ ɜɪɟɦɟ ɩɨɫɬɚɜʂɚʃɚ ɞɢʁɚɝɧɨɡɟ, ɢ ɧɟɦɚʁɭ ɡɧɚɱɚʁɚ ɭ ɩɨɫɬɚɜʂɚʃɭ ɞɢʁɚɝɧɨɡɟ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALЈ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ Ɋɚɡɦɚɬɪɚʁɭʄɢ ɪɟɡɭɥɬɚɬɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ȺLP ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɞɧɨɫɭ ɧɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ ɭɬɜɪɞɢɥɢ ɫɦɨ ɩɨɜɢɲɟɧɭ ɜɪɟɞɧɨɫɬ ALP, ɭ 45% ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 20% ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, 20% ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ ɢ ɭ 15% ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ɇɚʁɜɟʄɢ ɩɪɨɰɟɧɚɬ ɞɟɰɟ ɫɚ ɩɨɜɢɲɟɧɨɦ ȺLP ʁɟ ɛɢɨ ɩɪɢɫɭɬɚɧ ɭ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ (45%). ɍ 3 ɫɥɭɱɚʁɚ ɫɭ ɜɪɟɞɧɨɫɬɢ ALP ɛɢɥɟ ɩɨɜɢɲɟɧɟ ɭ ɞɟɰɟ ɫɚ ɨɩɬɢɦɚɥɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ. ɇɢʁɟ ɧɚђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ȺLP ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (ɪ=0,07) ɋɬɭɞɢʁɚ ɜɢɲɟ ɰɟɧɬɚɪɚ, ɫɩɪɨɜɟɞɟɧɚ ʁɟ ɭ ɇɚɰɢɨɧɚɥɧɨʁ ɛɨɥɧɢɰɢ Ɇɟɞɢɰɢɧɫɤɨɝ ɮɚɤɭɥɬɟɬɚ, ɤɚɨ ɢ ɭ ɇɚɰɢɨɧɚɥɧɨɦ ɦɟɞɢɰɢɧɫɤɨɦ ɰɟɧɬɪɭ Ɇɟɞɢɤɚɪɟ ɛɨɥɧɢɰɟ, Ʉɚɪɚɱɢ, ɭ ɜɪɟɦɟɧɫɤɨɦ ɩɟɪɢɨɞɭ ɨɞ ʁɚɧɭɚɪɚ ɞɨ ɨɤɬɨɛɪɚ 2009. ɝɨɞɢɧɟ, ɤɨʁɨɦ ɫɭ ɨɛɪɚђɟɧɢ ɩɚɰɢʁɟɧɬɢ ɫɚ ɛɥɚɝɢɦ ɧɟɞɨɫɬɚɬɤɨɦ (ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ) ɜɢɬɚɦɢɧɚ Ⱦ (25(Ɉɇ)D=20-29 ng/ml), ɩɚɰɢʁɟɧɬɢ ɫɚ ɭɦɟɪɟɧɢɦ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (25(Ɉɇ)D=5-19 ЧР/ЦХ) ɢ ɬɟɲɤɢɦ ɧɟɞɨɫɬɚɬɤɨɦ ɜɢɬɚɦɢɧɚ Ⱦ (25(Ɉɇ)D<5 ЧР/ЦХ). Ɂɚ ɬɟɫɬɢɪɚʃɟ ɤɨɪɟɥɚɰɢʁɟ ɫɟɪɭɦɫɤɢɯ ɧɢɜɨɚ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɫɚ ɧɢɜɨɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɤɨɪɢɲʄɟɧ ʁɟ ɉɢɪɫɨɧɨɜ ɬɟɫɬ. Ʉɚɨ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭɡɢɦɚɧɟ ɫɭ ɜɪɟɞɧɨɫɬɢ <0.05. Ɉɞ 110 ɭɡɨɪɚɤɚ, 23% ʁɟ ɢɦɚɥɨ ɛɥɚɝɢ ɧɟɞɨɫɬɚɬɚɤ, ɨɞɧɨɫɧɨ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ, 55% ɭɦɟɪɟɧɢ, ɚ 19,1% ʁɟ ɢɦɚɥɨ ɬɟɠɚɤ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɋɜɢ ɢɫɩɢɬɚɧɢɰɢ, ɢɡ ɫɜɟ ɬɪɢ ɝɪɭɩɟ ɫɭ ɢɦɚɥɢ ɜɪɟɞɧɨɫɬɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɧɨɪɦɚɥɧɢɦ ɝɪɚɧɢɰɚɦɚ, ɚ ɭɤɭɩɧɚ ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɟɧɡɢɦɚ ALP ʁɟ ɢɡɧɨɫɢɥɚ 135,97 ± 68,141 IJ/L. ɇɚʁɜɢɲɟ ɜɪɟɞɧɨɫɬɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ (ALP) ɫɭ ɧɚђɟɧɟ ɭ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɭɦɟɪɟɧɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. Ʉɨɟɮɢɰɢʁɟɧɬ ɤɨɪɟɥɚɰɢʁɟ ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ ɢ ɧɢɜɨɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ʁɟ r=0,05 (p=0,593). 85 Ɍɟɫɬɢɪɚʃɟɦ, ɭ ʁɟɞɧɨʁ ɫɬɭɞɢʁɢ ɬɨɤɨɦ 2012. ɝɨɞɢɧɟ, ɩɨɤɚɡɚɧɨ ʁɟ ɞɚ ɧɟɦɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɟ ɪɚɡɥɢɤɟ (ɪ=0,07) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ȺLP ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɉɜɚ ɫɬɭɞɢʁɚ ʁɟ ɞɨɲɥɚ ɞɨ ɡɚɤʂɭɱɤɚ, ɞɚ ɜɪɟɞɧɨɫɬɢ ɫɟɪɭɦɫɤɨɝ ɜɢɬɚɦɢɧɚ Ⱦ3 (25(OH)D), ɧɢɫɭ ɭɜɟɤ ɭ ɤɨɪɟɥɚɰɢʁɢ ɫɚ ɩɨɜɟʄɚɧɢɦ ɫɟɪɭɦɫɤɢɦ ɚɥɤɚɥɧɢɦ ɮɨɫɮɚɬɚɡɚɦɚ (Shaheen, et al. 2012). ɋɚɦɢɦ ɬɢɦ, ɚɥɤɚɥɧɚ ɮɨɫɮɚɬɚɡɚ ɫɟ ɧɟ ɦɨɠɟ ɤɨɪɢɫɬɢɬɢ ɤɚɨ ɫɤɪɢɧɢɧɝ ɬɟɫɬ ɤɚɤɨ ɛɢ ɫɟ ɢɫɤʂɭɱɢɨ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɟɤɟ ɫɬɭɞɢʁɟ ɭɤɚɡɭʁɭ ɧɚ ɬɨ, ɞɚ ɢɚɤɨ ɫɜɚ ɞɟɰɚ ɫɚ ɪɚɞɢɨɝɪɚɮɫɤɢɦ ɞɨɤɚɡɨɦ ɪɚɯɢɬɢɫɚ ɢɦɚʁɭ ɧɢɡɚɤ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ, ɧɟɦɚʁɭ ɫɜɚ ɞɟɰɚ ɢ ɜɢɫɨɤɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ȺLP, ɬɚɤɨ ɞɚ ʁɟ ɪɚɞɢɨɝɪɚɮɢʁɚ ɡɝɥɨɛɚ (ɞɢɫɬɚɥɧɢɯ ɤɪɚʁɟɜɚ ɪɚɞɢʁɭɫɚ ɢ ɭɥɧɟ, ɨɞɧɨɫɧɨ, ɬɢɛɢʁɟ ɢ ɮɟɦɭɪɚ), ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɭɡɪɚɫɬɚ, ɧɚʁɩɨɭɡɞɚɧɢʁɢ ɬɟɫɬ ɡɚ ɨɬɤɪɢɜɚʃɟ ɫɭɛɤɥɢɧɢɱɤɨɝ ɪɚɯɢɬɢɫɚ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɍ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɫɪɟɞʃɚ ɜɪɟɞɧɨɫɬ ɊɌɇ ʁɟ ɛɢɥɚ 87,6 pg/ml, ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ - 39,4 pР/ЦХ, ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ - 16,5 pР/ЦХ, ɭ ɞɟɰɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D<40 ЧР/ЦХ - 13 pg/ml, <50 ng/ml - 10,5 pg/ml, <60 ng/ml - 8,1 pg/ml ɢ ɭ ɞɟɰɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D <70 ЧР/ЦХ - 7,4 pg/ml. ɍ ɬɨɤɭ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ ɩɪɢɦɟʄɭʁɟɦɨ ɞɚ ɫɭ ɞɨɛɢʁɟɧɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɭ ɪɟɰɢɩɪɨɱɧɨɦ ɨɞɧɨɫɭ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɉɛɪɧɭɬɢ ɨɞɧɨɫ ɢɡɦɟђɭ ɊɌɇ ɢ 25(Ɉɇ)D УО ɛɢɨ ɩɪɢʁɚɜʂɟɧ ɭ ɦɧɨɝɢɦ ɩɨɩɪɟɱɧɢɦ ɩɪɟɫɟɰɢɦɚ ɢ ɫɬɭɞɢʁɚɦɚ ɭ ɪɚɡɥɢɱɢɬɢɦ ɫɬɚɪɨɫɧɢɦ ɝɪɭɩɚɦɚ (Schoenmakers, et al. 2010). ɂɡ ɞɨɛɢʁɟɧɢɯ ɪɟɡɭɥɬɚɬɚ ɜɢɞʂɢɜɨ ʁɟ, ɞɚ ɫɭ ɭ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ, ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɢ ɩɨɪɟɞ ʁɚɤɨ ɧɢɫɤɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɚɧɢɤɚ, ɭ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɛɢɥɟ ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɧɢɯ ɜɪɟɞɧɨɫɬɢ (<50 pР/ЦХ). ɍ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɫɭ ɛɢɥɟ ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɧɢɯ, ɢɡɭɡɟɜ 2 ɫɥɭɱɚʁɚ, ɚ ɭ ɝɪɭɩɢ ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɨɦ (ɫɭɛɨɩɬɢɦɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɜɢɬɚɦɢɧɚ Ⱦ) ɢ ɨɩɬɢɦɚɥɧɢɦ ɫɬɚɬɭɫɨɦ ɧɢɫɭ ɩɪɨɧɚђɟɧɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ>50 pg/ml (r=-0,5999, p<0,0001). ɍɩɨɪɟђɭʁɭʄɢ ɫɚ ɫɬɭɞɢʁɨɦ ɭ ɭɪɛɚɧɨʁ ɚɦɛɭɥɚɧɬɢ ɭ ɋȺȾ-ɭ ɝɞɟ ʁɟ ɢɫɩɢɬɚɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ 380 ɡɞɪɚɜɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ, ɝɞɟ ʁɟ ɧɚђɟɧɨ ɞɚ ɫɭ ɨɛɟ ɝɪɭɩɟ ɢɫɩɢɬɚɧɢɤɚ ɢɦɚɥɟ ɩɪɢɛɥɢɠɧɭ ɭɱɟɫɬɚɥɨɫɬ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɢɜɨɢ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɫɭ ɛɢɥɢ ɭ ɪɟɰɢɩɪɨɱɧɨɦ ɨɞɧɨɫɭ ɫɚ ɧɢɜɨɨɦ ɊɌɇ (ɭ ɨɞɨʁɱɚɞɢ: r = - 0,27; ɪ<0,001; ɭ ɦɚɥɟ ɞɟɰɟ r = -0,20; ɪ= 0,02) (Gordon, et al. 2008). 86 Ʉɨɧɰɟɧɬɪɚɰɢʁɚ 25(OH)D ɭ ɩɥɚɡɦɢ ʁɟ ɧɚʁɱɟɲʄɢ ɛɢɨɦɚɪɤɟɪ ɡɚ ɫɬɚɬɭɫ ɜɢɬɚɦɢɧɚ Ⱦ, ʁɟɪ ʁɟ ʃɟɝɨɜ ɩɨɥɭɠɢɜɨɬ ɪɟɥɚɬɢɜɧɨ ɞɭɝ. Ⱥɥɢ, ɜɪɟɞɧɨɫɬɢ 25(OH)D ɭ ɩɥɚɡɦɢ ɧɟ ɩɪɭɠɚʁɭ ɢɧɮɨɪɦɚɰɢʁɟ ɨ ɦɟɪɢ ɭ ɤɨʁɨʁ ɜɢɬɚɦɢɧ Ⱦ ɡɚɞɨɜɨʂɚɜɚ ɮɭɧɤɰɢɨɧɚɥɧɟ ɡɚɯɬɟɜɟ. ɉɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ʁɟ ɩɪɟɞɥɨɠɟɧ ɤɚɨ ɮɭɧɤɰɢɨɧɚɥɧɢ ɦɚɪɤɟɪ ɜɢɬɚɦɢɧ Ⱦ ɫɬɚɬɭɫɚ, ʁɟɪ ʁɟ ɩɨɜɢɲɟɧ ɊɌɇ ɪɢɡɢɤ ɡɚ ɨɫɬɟɨɩɨɪɨɡɭ ɢ ɦɨɠɟ ɫɦɚʃɢɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɂɫɬɪɚɠɢɜɚɱɢ ɫɭ ɩɨɤɭɲɚɥɢ ɞɚ ɤɚɬɟɝɨɪɢɡɭʁɭ 25(Ɉɇ)D ɤɚɨ ɞɨɜɨʂɧɭ ɤɨɞ ɨɞɪɚɫɥɢɯ ɧɚ ɨɫɧɨɜɭ ɮɭɧɤɰɢɨɧɚɥɧɢɯ ɪɟɡɭɥɬɚɬɚ ɜɟɡɚɧɢɯ ɡɚ ɡɞɪɚɜʂɟ ɤɨɫɬɢʁɭ (ɨɫɬɟɨɦɚɥɚɰɢʁɚ, ɨɫɬɟɨɩɨɪɨɡɚ, ɦɢɧɟɪɚɥɧɢ ɫɚɞɪɠɚʁ ɤɨɫɬɢ, ɮɪɚɤɬɭɪɟ, ɩɚɞɨɜɢ). ɉɨɲɬɨ ɧɢʁɟ ɩɨɫɬɢɝɧɭɬ ɤɨɧɫɟɧɡɭɫ ɧɚ ɨɫɧɨɜɭ ɨɜɢɯ ɩɚɪɚɦɟɬɚɪɚ, ɩɨɤɭɲɚɥɢ ɫɭ ɞɚ ɤɨɪɢɫɬɟʄɢ ɨɛɪɧɭɬɭ ɤɨɪɟɥɚɰɢʁɭ ɢɡɦɟђɭ 25(Ɉɇ)D ɢ ɊɌɇ ɤɨɧɰɟɧɬɪɚɰɢʁɟ, ɞɟɮɢɧɢɲɭ ɧɨɪɦɚɥɧɭ ɤɨɧɰɟɧɬɪɚɰɢʁɭ 25(Ɉɇ)D ɤɨɞ ɨɞɪɚɫɥɢɯ, ʁɟɪ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɊɌɇ ɧɟ ɡɚɜɢɫɢ ɞɢɪɟɤɬɧɨ ɨɞ ɫɟɡɨɧɟ, ɢɫɯɪɚɧɟ, ɢɥɢ ɭɡɢɦɚʃɚ ɜɢɬɚɦɢɧɚ Ⱦ (Greer, 2008). ɂɡɜɟɲɬɚʁɢ ɢɫɩɢɬɢɜɚʃɚ ɢɡ ɋɟɜɟɪɧɟ Ⱥɦɟɪɢɤɟ ɭ ɤɨʁɢɦɚ ʁɟ ɦɟɪɟɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ɭ 9 ɞɟɰɟ ɭɡɪɚɫɬɚ 2-42 ɦɟɫɟɰɚ ɫɚ ɪɚɯɢɬɢɫɨɦ ɭ Ʉɚɧɚɞɢ (Arnaud, 1976). ɍ 3 ɞɟɰɟ ɫɚ ɛɥɚɝɢɦ ɪɚɯɢɬɢɫɨɦ, ɩɪɨɫɟɱɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ʁɟ ɢɡɧɨɫɢɥɚ 45,7±17,5 nmol/L, ɞɨɤ ʁɟ ɭ 5 ɞɟɰɟ ɫɚ ɭɦɟɪɟɧɢɦ ɪɚɯɢɬɢɫɨɦ, 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɡɧɨɫɢɥɚ 29,9±12,5 ЧЦШХ/L. ɉɪɟɨɫɬɚɥɨ (1) ɨɞɨʁɱɟ ʁɟ ɢɦɚɥɨ ɨɡɛɢʂɚɧ ɪɚɯɢɬɢɫ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ 25(Ɉɇ)D <20 ЧЦШХ/L (<8 ЧР/ЦХ). ɇɢʁɟ ɢɡɧɟɧɚђɭʁɭʄɟ ɲɬɨ ɫɭ ɚɭɬɨɪɢ ɧɚɲɥɢ ɧɟɝɚɬɢɜɧɭ ɤɨɪɟɥɚɰɢʁɭ (r = - 0,7) ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɊɌɇ (Arnaud, 1976). ɉɨɲɬɨ ɞɨɫɬɭɩɧɚ ɥɢɬɟɪɚɬɭɪɚ ɩɨɤɚɡɭʁɟ ɞɚ ɫɟ ɜɢɬɚɦɢɧ Ⱦ ɡɚɜɢɫɧɢ ɪɚɯɢɬɢɫ ʁɚɜʂɚ, ɢ ɭ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ɤɨɧɰɟɧɬɪɚɰɢʁɨɦ ɭ ɫɟɪɭɦɭ 25(Ɉɇ)D>27,5 ЧЦШХ/L (>11 ЧР/ЦХ), ɞɨɤɚɡɢ ɧɟ ɩɨɞɪɠɚɜɚʁɭ ɤɨɪɢɲʄɟʃɟ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɤɚɨ ɦɟɪɨɞɚɜɧɭ ɚɧɚɥɢɡɭ ɭ ɩɪɟɜɟɧɰɢʁɢ ɤɥɢɧɢɱɤɨɝ ɪɚɯɢɬɢɫɚ (Greer, 2008; Arnaud, et al. 1976). Ʉɚɨ ɲɬɨ ʁɟ ɭ ɭɜɨɞɭ ɨɛʁɚɲʃɟɧɨ, ɧɚʁɜɚɠɧɢʁɢ ɟɮɟɤɚɬ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɚɩɫɨɪɩɰɢʁɚ ɤɚɥɰɢʁɭɦɚ. ɍ ȼȾȾ, ɫɚ ɫɦɚʃɟʃɟɦ ɚɩɫɨɪɩɰɢʁɟ ɤɚɥɰɢʁɭɦɚ, ɩɪɟɦɚ ɬɪɟɧɭɬɧɨʁ ɬɟɨɪɢʁɢ, ɞɨɥɚɡɢ ɞɨ ɩɨɜɟʄɚʃɚ ɭ ɫɢɧɬɟɡɟ ɊɌɇ ɭɫɥɟɞ ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ. Ɉɧ ɩɨɜɟʄɚɜɚ ɤɚɥɰɢʁɭɦ ɭ ɫɟɪɭɦɭ ɚɤɭɬɧɨɦ ɦɨɛɢɥɢɡɚɰɢʁɨɦ ɤɚɥɰɢʁɭɦɚ ɢɡ ɤɨɫɬɢʁɭ. Ɉɜɨ ɫɟ ɞɟɲɚɜɚ ɢɧɞɢɪɟɤɬɧɨ ɩɨɞ ɞɟʁɫɬɜɨɦ ɊɌɇ, ɚɥɢ ɪɚɧɨ, ɢ ɫɦɚɬɪɚ ɫɟ ɞɚ ɤɚɨ ɢɧɞɢɤɚɬɨɪ ȼȾȾ, ɩɨ ɧɚʁɧɨɜɢʁɢɦ ɞɨɤɚɡɢɦɚ ɧɢʁɟ ɞɢɪɟɤɬɧɨ ɭɤʂɭɱɟɧ ɭ ɚɩɫɨɪɩɰɢʁɭ ɤɚɥɰɢʁɭɦɚ (Garg and Mahalle, 2013). Ɇɨɪɚɦɨ ɛɢɬɢ ɫɜɟɫɧɢ ɨɝɪɚɱɢʃɟʃɚ ɊɌɇ, ʁɟɪ ʁɟ ɨɧ ɩɨɥɢɩɟɩɬɢɞ ɤɨʁɢ ɫɟ ɛɪɡɨ ɪɚɡɝɪɚђɭʁɟ ɩɟɩɬɢɞɚɡɚɦɚ ɩɪɢɫɭɬɧɢɦ ɭ ɤɪɜɢ. ȼɪɟɦɟ ɩɨɥɭɪɚɫɩɚɞɚ ɦɭ ʁɟ ʁɚɤɨ ɤɪɚɬɤɨ ɢ ɢɡɧɨɫɢ ɫɚɦɨ 3-5 ɦɢɧɭɬɚ (Yamashita, et al. 2003). Ɂɛɨɝ ɬɨɝɚ, ɩɪɢ ɭɡɢɦɚʃɭ ɤɪɜɢ ɧɟɨɩɯɨɞɚɧ ʁɟ 87 ɯɥɚɞɚɧ ɲɩɪɢɰ, ɚ ɤɪɜ ɨɞɦɚɯ ɢɡɰɟɧɬɪɢɮɭɝɢɪɚɧɚ ɢ ɡɚɦɪɡɧɭɬɚ ɧɚ -200ɋ ɞɨ ɬɪɟɧɭɬɤɚ ɦɟɪɟʃɚ (Endres, 1989). ɂɩɚɤ, ɭɡ ɨɞɝɨɜɚɪɚʁɭʄɟ ɦɟɪɟ ɨɩɪɟɡɚ, ɊɌɇ ɫɟ ɦɨɠɟ ɤɨɪɢɫɬɢɬɢ ɤɚɨ ɢɧɞɢɤɚɬɨɪ ȼȾȾ. Ⱦɪɭɝɢ ɩɪɨɛɥɟɦ ɩɪɟɞɫɬɚɜʂɚ ɝɨɪʃɚ ɝɪɚɧɢɰɚ ɤɨʁɚ ɨɡɧɚɱɚɜɚ ɫɟɤɭɧɞɚɪɧɢ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɚɦ, ɚ ɭ ɜɟɡɢ ʁɟ ɫɚ ȼȾȾ. Ɇɢ ɫɦɨ ɤɚɨ ɝɨɪʃɭ ɝɪɚɧɢɰɭ ɧɨɪɦɚɥɧɟ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɭɡɟɥɢ ɜɪɟɞɧɨɫɬ з 65 pР/ЦХ. ɉɪɨɢɡɜɨђɚɱɢ ɫɦɚɬɪɚʁɭ ɞɚ ʁɟ ɨɧɚ ɩɪɟɜɢɫɨɤɚ ɞɚ ɛɢ ɭɤɚɡɚɥɚ ɧɚ ȼȾȾ. Ƚɨɪʃɚ ɪɟɮɟɪɟɧɬɧɚ ɜɪɟɞɧɨɫɬ ɊɌɇ ɫɦɚʃɟɧɚ ʁɟ ɫɚ 65 pР/ЦХ ɧɚ 46 pР/ЦХ, ɩɪɢ ɱɟɦɭ ɫɭ ɢɫɩɢɬɚɧɢɰɢ ɫɚ ȼȾȾ ɡɛɨɝ ɬɨɝɚ ɢɫɤʂɭɱɟɧɢ ɭ ʁɟɞɧɨʁ ɫɬɭɞɢʁɢ (Souberbielle, et al. 2001). Ɍɪɟʄɚ ɝɟɧɟɪɚɰɢʁɚ, ɤɨʁɚ ɫɟ ɬɪɟɧɭɬɧɨ ɛɚɜɢ ɢɫɬɪɚɠɢɜɚʃɟɦ ɜɪɟɞɧɨɫɬɢ ɊɌɇ, ɫɧɢɡɢɥɚ ʁɟ ɪɟɮɟɪɟɧɬɧɟ ɜɪɟɞɧɨɫɬɢ ɧɚ 7-36 pР/ЦХ ɭ ɧɨɪɦɨɤɚɥɰɟɦɢʁɫɤɢɯ ɨɫɨɛɚ (John, et al. 1999). ɇɟɞɚɜɧɨ, ɚɧɚɥɢɡɚ ɥɚɛɨɪɚɬɨɪɢʁɫɤɨ ɢɫɩɢɬɢɜɚʃɟ ɡɚɫɧɨɜɚɧɨ ɧɚ ɜɢɲɟ ɨɞ 300 000 ɫɟɪɭɦɫɤɢɯ 25(OH)D ɢ PTH ɩɚɪɨɜК, ɨɬɤɪɢɥɨ ʁɟ ɩɨɪɚɫɬ ɜɪɟɞɧɨɫɬɢ ɊɌɇ ɤɨɞ ɩɪɢɛɥɢɠɧɢɯ ɜɪɟɞɧɨɫɬɢ 25(OH)D ɭ ɫɟɪɭɦɭ (Valcour, et al. 2012). ɍ ɧɟɞɚɜɧɨɦ ɢɫɬɪɚɠɢɜɚʃɭ ɫɩɪɨɜɟɞɟɧɨɦ ɭɩɨɪɟђɢɜɚʃɟɦ ɢɡɦɟђɭ 25(OH)D, ɊɌɇ ɢ ɝɭɫɬɢɧɭ ɤɨɫɬɢʁɭ ɭ ɢɧɞɢʁɫɤɢɯ ɚɞɨɥɟɫɰɟɧɚɬɚ ɢ ɨɞɪɚɫɥɢɯ (> 50 ɝɨɞɢɧɚ), ɞɨɲɥɨ ɫɟ ɞɨ ɩɨɞɚɬɤɚ ɞɚ ʁɟ ɞɨ ɡɧɚɱɚʁɧɨɝ ɩɨɝɨɪɲɚʃɚ ɧɚ ɤɨɫɬɢɦɚ ɞɨɲɥɨ ɩɪɢ ɜɪɟɞɧɨɫɬɢɦɚ ɊɌɇ ɨɞ 35 pР/ЦХ ɡɚ ɨɦɥɚɞɢɧɭ ɢ 55 pР/ЦХ ɡɚ ɨɞɪɚɫɥɟ (Garg, et al. 2013). ɋɚɦɢɦ ɬɢɦ, ɥɨɲɚ ɦɢɧɟɪɚɥɢɡɚɰɢʁɚ ɤɨɫɬɢʁɭ, ɦɨɠɟ ɫɟ ɭɡɟɬɢ ɤɚɨ ɩɨɤɚɡɚɬɟʂ ȼȾȾ, ɚɥɢ ɨɞɫɭɫɬɜɨ ɞɟɦɢɧɟɪɚɥɢɡɚɰɢʁɟ ɤɨɫɬɢʁɭ, ɧɟ ɦɨɠɟ ɞɚ ɢɫɤʂɭɱɢ ɩɪɢɫɭɫɬɜɨ ȼȾȾ. Ɉɜɢ ɩɨɞɚɰɢ ɭɤɚɡɭʁɭ ɞɚ ɩɨɜɟʄɚɧɢ ɧɢɜɨɢ ɦɚɪɤɟɪɚ ɤɚɨ ɲɬɨ ɫɭ ALP, PTH, ɢ ɧɢɫɤɟ ɜɪɟɞɧɨɫɬɢ CК ɢ ɧɟɨɪɝɚɧɫɤɨɝɮɨɫɮɚɬɚ, ɫɭ ɞɨɛɚɪ ɩɨɤɚɡɚɬɟʂ ȼȾȾ, ɚɥɢ ɧɨɪɦɚɥɧɢ ɧɢɜɨɢ ɧɟ ɢɫɤʂɭɱɭʁɭ ɩɪɢɫɭɫɬɜɨ ȼȾȾ (Garg, et al. 2013). Ɍɪɟɧɭɬɧɢ ɞɨɤɚɡɢ ɩɨʁɚɲʃɚɜɚʁɭ ɞɚ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ ɊɌɇ ʁɟ ɭ ɨɜɨɦ ɬɪɟɧɭɬɤɭ, ɧɚʁɛɨʂɢ ɢɧɞɢɪɟɤɬɧɢ ɩɨɤɚɡɚɬɟʂ ɫɢɫɬɟɦɫɤɢɯ ɟɮɟɤɚɬɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ). ɇɟɨɩɯɨɞɧɨ ʁɟ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɬɭɦɚɱɢɬɢ ɡɚʁɟɞɧɨ ɫɚ ɧɢɜɨɨɦ ɊɌɇ, ɚ ɧɟ ɢɡɨɥɨɜɚɧɨ ʁɟɞɚɧ ɨɞ ɞɪɭɝɨɝ ɩɚɪɚɦɟɬɪɚ. Ɍɨ ʄɟ ɬɚɤɨђɟ ɫɦɚʃɢɬɢ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ɡɚ 50% ɧɚ ɝɥɨɛɚɥɧɨɦ ɧɢɜɨɭ, ʁɟɪ ʁɟ ɫɚɦɨ 50% ɢɫɩɢɬɚɧɢɤɚ ɫɚ ɧɢɜɨɨɦ 25(ɈH)D<10 ЧР/ЦХ ɩɨɤɚɡɚɥШ ɩɪɢɫɭɫɬɜɨ ɫɟɤɭɧɞɚɪɧɨɝ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ (Valcour, et al. 2012; Cusano, et al. 2013; Garg, et al. 2013; Yoshida and Stern, 2012; Nordin, 2010; Seibel, 2006; Lu, et al. 2012; Kuchuk, et al. 2009; Vanderschueren, et al. 2013; Hill, et al. 2012; Smith, et al. 2005; Khashayar, et al. 2011; Hashemipour, et al. 2006; Marwaha, et al. 2011). Ɍɪɟɧɭɬɧɟ ɫɦɟɪɧɢɰɟ ɤɨɪɢɫɬɟ ɪɚɡɥɢɱɢɬɟ ɞɟɮɢɧɢɰɢʁɟ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɨɫɧɨɜɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ, ɲɬɨ ɤɨɦɩɥɢɤɭʁɟ ɤɥɢɧɢɱɤɭ ɨɞɥɭɤɭ ɨ ɞɨɡɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɟɜɟɧɰɢʁɢ ɢ ɬɟɪɚɩɢʁɢ. ɋɬɭɞɢʁɚ ɤɨʁɚ ʁɟ ɞɟɰɟɦɛɪɚ 2012. ɝɨɞɢɧɟ ɩɪɨɭɱɚɜɚɥɚ ɨɞɧɨɫ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɩɨɬɪɚɡɢ ɡɚ ɛɢɨɯɟɦɢʁɫɤɭ ɞɟɮɢɧɢɰɢʁɭ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨɞ ɞɟɰɟ, ʁɟ ɭɨɱɢɥɚ, ɞɚ ɞɨ ɩɨɜɟʄɚʃɚ ɧɢɜɨɚ ɊɌɇ ɞɨɥɚɡɢ, ɤɚɞɚ ʁɟ ɧɢɜɨ 25(Ɉɇ)D 34 nmol/L (13,6 ЧР/ЦХ) ɢɥɢ ɭ 95% ɭ 27-41 88 nmol/L (10 - 16 ng/ml). ɍ 73 (86%) ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɫɚ ɜɪɟɞɧɨɫɬɢɦɚ 10 - 16 ЧР/ЦХ ɫɭ ɧɚђɟɧɟ ɧɟɤɟ ɛɢɨɯɟɦɢʁɫɤɟ ɚɛɧɨɪɦɚɥɧɨɫɬɢ. ɋɜɢ ɩɚɰɢʁɟɧɬɢ ɫɚ ɪɚɯɢɬɢɫɨɦ ɫɭ ɢɦɚɥɨ ɧɢɜɨ 25(Ɉɇ)D < 34 ɧɦɨɥ/Ʌ (<13,6 ЧР/ЦХ) ɢ ɧɢɜɨ ɊɌɇ>50 pР/ЦХ. ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ʁɟ ɞɨɤɚɡɚɧɨ ɞɚ ʁɟ 95,2% ɩɚɰɢʁɟɧɚɬɚ ɢɦɚɥɨ ɯɢɩɨɤɚɥɰɢɟɦɢʁɭ, 70,4% ɯɢɩɨɮɨɫɮɚɬɟɦɢʁɭ, ɚ 69,5% ɩɨɜɢɲɟɧɭ ALP ɫɚ ɧɢɜɨɨɦ 25(Ɉɇ)D<34 ЧЦШХ/L ɢ PTH>50 pg/ml. ɋɚɦɢɦ ɬɢɦ ɫɟ ɡɚɤʂɭɱɭʁɟ ɞɚ ɩɪɚɝ ɡɚ ɪɚɯɢɬɢɫ ɧɟ ɦɨɠɟ ɞɚ ɫɟ ɡɚɫɧɢɜɚ ɧɚ ɢɡɨɥɨɜɚɧɢɦ ɜɪɟɞɧɨɫɬɢɦɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ. Ƚɪɭɩɚ ɞɟɰɟ ɤШУК УО ɢɦɚɥɚ ɧɨɪɦɚɥɚɧ ɭɧɨɫ ɤɚɥɰɢʁɭɦɚ, ɡɚɞɪɠɚɥɚ ʁɟ ɧɢɜɨ ɊɌɇ ɭ ɝɪɚɧɢɰɚɦɚ ɧɨɪɦɚɥɟ (Steingrimsdottir, et al. 2005; Aggarwal, et al. 2012). ɍ ɨɜɨʁ ɫɬɭɞɢʁɢ ɞɨɛɢʁɟɧɢ ɫɭ ɢ ɫɭɩɪɨɬɧɢ ɪɟɡɭɥɬɚɬɢ, ɩɨɜɢɲɟɧɢ ɧɢɜɨ ɊɌɇ ɤɨɞ ɞɟɰɟ ɫɚ "ɧɨɪɦɚɥɧɢɦ" ɧɢɜɨɢɦɚ 25(Ɉɇ)D, ɜɟɪɨɜɚɬɧɨ ɡɛɨɝ ɧɢɫɤɨɝ ɭɧɨɫɚ ɤɚɥɰɢʁɭɦɚ. ɍɫɥɟɞ ɜɟɥɢɤɟ ɭɱɟɫɬɚɥɨɫɬɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɢ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɧɢɫɤɨɝ ɭɧɨɫɚ ɤɚɥɰɢʁɭɦɚ ɭ ɫɜɟɬɭ, ɨɫɬɚʁɭ ɜɚɠɧɚ ɩɢɬɚʃɚ ɤɨʁɚ ɫɟ ɨɞɧɨɫɟ ɧɚ ɩɪɟɜɟɧɰɢʁɭ ɢ ɞɨɩɭɧɭ. Ɂɚ ɪɚɡɥɢɤɭ ɨɞ ɧɢɜɨɚ ɊɌɇ, ɧɢɜɨ ɋɚ, ɮɨɫɮɚɬɚ, ɚ ɧɚɪɨɱɢɬɨ ȺLP ɜɚɪɢɪɚʁɭ ɭ ɡɚɜɢɫɧɨɫɬɢ ɨɞ ɭɡɪɚɫɬɚ ɢ ɩɪɨɰɟɫɚ ɪɚɫɬɚ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɤɨɧɰɟɧɬɪɚɰɢјɭ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ ɢ ɚɥɛɭɦɢɧɚ ɭ ɨɞɨјɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɇɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɧɚɲɟɝ ɢɫɬɪɚɠɢɜɚʃɚ, ɡɚɤʂɭɱɢɥɢ ɫɦɨ ɞɚ ɧɟ ɩɨɫɬɨʁɢ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɜɪɟɞɧɨɫɬɢ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ ɢ ɚɥɛɭɦɢɧɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɢ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɢɫɤɟ ɜɪɟɞɧɨɫɬɢ ɭɤɭɩɧɢɯ ɩɪɨɬɟɢɧɚ ɢ ɚɥɛɭɦɢɧɚ ɧɚђɟɧɟ ɫɭ ɫɚɦɨ ɭ ɩɨɬɯɪɚʃɟɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɇɟɭɯɪɚʃɟɧɨɫɬ ɢ ɧɟɞɨɫɬɚɬɚɤ ɩɪɨɬɟɢɧɚ ɦɨɠɟ ɞɚ ɞɨɜɟɞɟ ɞɨ ȼȾȾ ɫɦɚʃɟʃɟɦ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ- ɜɟɡɭʁɭʄɟ ɩɪɨɬɟɢɧɟ ɭ ɤɪɜɢ. Ɂɚɬɨ ɫɭ ɩɪɟɰɢɡɧɚ ɚɧɬɪɨɩɨɦɟɬɪɢʁɫɤɚ ɦɟɪɟʃɚ ɜɢɫɢɧɟ/ɞɭɠɢɧɟ ɢ ɬɟɥɟɫɧɟ ɦɚɫɟ ɧɟɨɩɯɨɞɧɚ ɩɪɢ ɩɪɨɰɟɧɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ. Ⱦɢɫɤɭɫɢјɚ ɪɟɡɭɥɬɚɬɚ ɢɫɬɪɚɠɢɜɚњɚ ɭɬɢɰɚјɚ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɫɩɟɰɢɮɢɱɧɟ ɛɢɨɦɚɪɤɟɪɟ ɦɟɬɚɛɨɥɢɡɦɚ ɤɨɫɬɢјɭ ɇɚ ɨɫɧɨɜɭ ɪɟɡɭɥɬɚɬɚ ɧɚɲɢɯ ɢɫɬɪɚɠɢɜɚʃɚ, ɢ ɦɧɨɝɨɛɪɨʁɧɢɯ ɫɬɭɞɢʁɚ ɭ ɫɜɟɬɭ, ɡɚɤʂɭɱɭʁɟɦɨ, ɞɚ ʁɟ ɨɩɬɢɦɚɥɧɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɤɨɧɬɪɚɜɟɪɡɧɚ, ɢ ʁɨɲ ɭɜɟɤ ɧɟɞɨɜɨʂɧɨ ɩɪɨɭɱɟɧɚ, ɧɚɪɨɱɢɬɨ ɭɩɟɞɢʁɚɬɪɢʁɫɤɨʁ ɩɨɩɭɥɚɰɢʁɢ. 89 ɉɪɨɰɟɧɚ ɧɢɜɨɚ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D, ɝɥɚɜɧɨɝ ɰɢɪɤɭɥɢɲɭʄɟɝ ɨɛɥɢɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɧɚʁɛɨʂɢ ɞɨɫɬɭɩɧɢ ɩɨɤɚɡɚɬɟʂ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ. Ɇɟђɭɬɢɦ, ɪɟɚɝɟɧɫɢ ɡɚ ɨɞɪɟђɢɜɚʃɟ ɜɢɬɚɦɢɧɚ Ⱦ ɫɭ ɫɤɭɩɢ ɢ ɧɢɫɭ ɲɢɪɨɤɨ ɞɨɫɬɭɩɧɢ. Ɂɛɨɝ ɢɡɪɚɡɢɬɨ ɜɢɫɨɤɟ ɩɪɟɜɚɥɟɧɰɢʁɟ ɫɭɛɤɥɢɧɢɱɤɨɝ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ, ɩɨɬɪɟɛɚɧ ʁɟ ʁɟɞɧɨɫɬɚɜɚɧ ɢ ʁɟɮɬɢɧ ɧɚɱɢɧ ɨɬɤɪɢɜɚʃɚ ɯɢɩɨɜɢɬɚɦɢɧɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ. ɇɟɨɩɯɨɞɧɨ ʁɟ ɞɚ ɫɟ ɧɚɩɪɚɜɢ ɜɟɥɢɤɢ ɛɪɨʁ ɢɫɬɪɚɠɢɜɚʃɚ ɤɚɤɨ ɛɢ ɦɨɝɥɢ ɬɚɱɧɨ ɞɚ ɤɚɠɟɦɨ ɤɨɥɢɤɨ ʁɟ ɜɢɬɚɦɢɧɚ Ⱦ ɩɨɬɪɟɛɧɨ ɞɚ ɛɢ ɫɟ ɫɩɪɟɱɢɨ ɪɚɯɢɬɢɫ. Ɇɟђɭɬɢɦ, ɬɨ ʁɟ ɬɟɠɚɤ ɡɚɞɚɬɚɤ, ɢ ɢɫɬɪɚɠɢɜɚʃɢɦɚ ɧɟʄɟɦɨ ɦɨʄɢ ɧɢɤɚɞɚ ɞɚ ɩɪɨɰɟɧɢɦɨ ɬɚɱɧɭ ɞɨɡɭ ɧɟɨɩɯɨɞɧɨɝ ɜɢɬɚɦɢɧɚ Ⱦ. ȼɚɠɧɚ ʁɟ ɞɪɭɝɚ ɫɬɜɚɪ ɤɨʁɭ ɬɪɟɛɚ ɢɫɬɪɚɠɢɜɚɱɢ ɢ ɥɟɤɚɪɢ ɞɚ ɭɡɦɭ ɭ ɨɛɡɢɪ, ɚ ɬɨ ʁɟ ɱɢʃɟɧɢɰɚ ɞɚ ɥɢ ʁɟ ɨɞɪɟђɟɧɚ ɤɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɞɟɰɢ ɞɨɜɨʂɧɚ ɞɚ ɡɚɞɨɜɨʂɢ ɞɪɭɝɟ ɡɞɪɚɜɫɬɜɟɧɟ ɩɨɬɪɟɛɟ, ɤɚɨ ɢ ɞɚ ɫɩɪɟɱɢ ɪɚɯɢɬɢɫ. Ʉɨɥɢɱɢɧɚ ɜɢɬɚɦɢɧɚ Ⱦ ɤɨʁɚ ʁɟ ɧɟɨɩɯɨɞɧɚ ɞɟɰɢ ɡɚ ɨɱɭɜɚʃɟ ɡɞɪɚɜʂɚ ɢ ɩɪɟɜɟɧɰɢʁɭ ɞɪɭɝɢɯ ɛɨɥɟɫɬɢ ɦɨɠɟ ɛɢɬɢ ɱɚɤ ɢ ɜɟʄɚ, ɧɟɝɨ ɲɬɨ ʁɟ ɩɨɬɪɟɛɧɨ ɞɚ ɛɢ ɫɟ ɫɩɪɟɱɢɨ ɪɚɯɢɬɢɫ. ɂɩɚɤ ʁɟ ɧɟɨɩɯɨɞɧɨ ʁɨɲ ɩɭɧɨ ɢɫɬɪɚɠɢɜɚʃɚ ɤɚɤɨ ɛɢ ɫɟ ɤɨɧɚɱɧɨ ɞɨɧɟɥɚ ɨɞɥɭɤɚ ɨ ɚɞɟɤɜɚɬɧɨʁ ɫɭɩɥɟɦɟɧɬɚɰɢʁɢ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɞɟɰɟ. Ɂɛɨɝ ɪɚɫɩɪɨɫɬɪɚʃɟɧɨɫɬɢ ɧɟɞɨɫɬɚɬɤɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ ɤɨɞ ɨɞɨʁɱɚɞɢ ɢ ɞɟɰɟ, ɜɚɠɧɨ ʁɟ ɞɚ ɫɟ ɭɬɜɪɞɢ ɧɚʁɛɨʂɟ ɜɪɟɦɟ ɞɟɬɟɤɰɢʁɟ ɤɨɥɢɱɢɧɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ. Ɂɛɨɝ ɱɟɲʄɟɝ ɜɢɬɚɦɢɧ Ⱦ ɧɟɞɨɫɬɚɬɤɚ ɭɡɪɚɫɬɚ ɢɡɦɟђɭ 1-5 ɝɨɞɢɧɚ, ɧɟɝɨ ɭ ɫɬɚɪɢʁɟ ɞɟɰɟ, ɧɟɨɩɯɨɞɧɨ ʁɟ ɦɟɪɢɬɢ ɧɢɜɨ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɞɟɰɟ ɭ ɪɚɡɥɢɱɢɬɢɦ ɟɬɧɢɱɤɢɦ ɝɪɭɩɚɦɚ, ɢ ɪɚɡɥɢɱɢɬɢɦ ɩɟɪɢɨɞɢɦɚ ɭ ɝɨɞɢɧɢ, ʁɟɪ ɫɟ ɡɧɚɱɚʁɚɧ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɞɟɰɟ ʁɚɜʂɚ ɧɟɤɨɥɢɤɨ ɦɟɫɟɰɢ ɪɚɧɢʁɟ ɩɪɟ ɧɟɝɨ ɫɟ ɢɫɩɨʂɟ ɫɢɦɩɬɨɦɢ ɢ ɡɧɚɰɢ ɛɨɥɟɫɬɢ. Јɨɲ ɭɜɟɤ ɫɭ ɧɟɨɩɯɨɞɧɚ ɦɧɨɝɨɛɪɨʁɧɚ ɨɩɫɟɠɧɢʁɚ ɢɫɬɪɚɠɢɜɚʃɚ ɢ ɫɬɭɞɢʁɟ ɤɨʁɟ ɛɢ ɩɨɬɜɪɞɢɥɟ ɬɚɱɧɟ ɤɨɥɢɱɢɧɟ ɜɢɬɚɦɢɧɚ Ⱦ ɧɟɨɩɯɨɞɧɟ ɩɪɢ ɪɚɡɥɢɱɢɬɢɦ ɜɪɟɞɧɨɫɬɢɦɚ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ (Pramyothin and Holick, 2012). ɋɦɟɪɧɢɰɟ ȿɧɞɨɤɪɢɧɨɝ ɞɪɭɲɬɜɚ ɋȺȾ-ɚ ɩɪɟɩɨɪɭɱɭʁɭ ɫɤɪɢɧɢɧɝ ɫɚɦɨ ɭ ɩɨɩɭɥɚɰɢʁɢ ɭ ɪɢɡɢɤɭ. ɇɚ ɨɫɧɨɜɭ ɧɚɲɢɯ ɢɫɩɢɬɢɜɚʃɚ ɢ ɢɫɬɪɚɠɢɜɚʃɚ ɭ ɫɜɟɬɭ, ɫɦɚɬɪɚɦɨ ɞɚ ɜɪɟɞɧɨɫɬ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ, ɤɚɨ ɚɧɚɥɢɡɭ ɤɨʁɚ ʁɟ ɫɤɭɩɚ ɢ ɧɟ ɫɩɚɞɚ ɭ ɪɭɬɢɧɫɤɟ ɚɧɚɥɢɡɟ, ɬɪɟɛɚ ɪɚɞɢɬɢ ɭ ɞɟɰɟ ɫɚ: ɪɚɯɢɬɢɫɨɦ, ɨɫɬɟɨɦɚɥɚɰɢʁɨɦ, ɨɫɬɟɨɩɨɪɨɡɨɦ, ɛɨɥɟɫɬɢɦɚ ʁɟɬɪɟ, ɯɪɨɧɢɱɧɢɦ ɛɨɥɟɫɬɢɦɚ ɛɭɛɪɟɝɚ, ɦɚɥɚɩɫɨɪɩɰɢʁɨɦ, ɰɢɫɬɢɱɧɨɦ ɮɢɛɪɨɡɨɦ, ɡɚɩɚʂɟɧɫɤɢɦ ɛɨɥɟɫɬɢɦɚ ɰɪɟɜɚ, ʁɟɬɪɟ, ɤɨɞ ɯɢɩɟɪɩɚɪɚɬɢɪɟɨɢɞɢɡɦɚ, ɢ ɭ ɞɟɰɟ ɤɨʁɚ ɭɡɢɦɚʁɭ ɚɧɬɢɤɨɧɜɭɥɡɢɜɟ, ɚɧɬɢɟɩɢɥɟɩɬɢɤɟ, ɝɥɢɤɨɤɨɪɬɢɤɨɢɞɟ, ɚɧɬɢɦɢɤɨɬɢɤɟ ɢ ɯɨɥɟɫɬɢɪɚɦɢɧ, ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ ɢ ɞɟɰɟ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢɬɚɪɧɢɯ ɦɚʁɤɢ, ɝɨʁɚɡɧɟ (>Ɋ97 ɢɥɢ ɫɚ BMI>30 ФР/Ц2) ɢ ɩɨɬɯɪɚʃɟɧɟ ɞɟɰɟ (<Ɋ3), ɤɚɨ ɢ ɭ ɞɟɰɟ ɫɚ ɤɥɢɧɢɱɤɢɦ ɡɧɚɰɢɦɚ ɤɨʁɢ ɭɤɚɡɭʁɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ, ɟɜɟɧɬɭɚɥɧɨ ɩɪɢɫɭɫɬɜɨ ɧɟɫɩɟɰɢɮɢɱɧɢɯ ɫɢɦɩɬɨɦɚ, ɤɚɨ 90 ɲɬɨ ɫɭ ɭɫɩɨɪɟɧ ɪɚɫɬ, ɡɚɫɬɨʁ ɭ ɦɨɬɨɪɧɨɦ ɪɚɡɜɨʁɭ ɢ ɧɟɨɛɢɱɧɚ ɪɚɡɞɪɚɠʂɢɜɨɫɬ. ȼɚɠɧɨ ʁɟ ɨɞɪɟђɢɜɚɬɢ ɧɢɜɨ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɤɨɞ ɬɪɭɞɧɢɰɚ ɢ ɞɨʁɢʂɚ ɤɚɤɨ ɛɢ ɫɟ ɧɚ ɜɪɟɦɟ ɩɪɟɩɨɡɧɚɥɟ ɫɦɚʃɟɧɟ ɪɟɡɟɪɜɟ ɜɢɬɚɦɢɧɚ Ⱦ ɧɚ ɪɨђɟʃɭ. ɇɢɜɨ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɫɟ ɤɨɪɢɫɬɢ ɢ ɡɚ ɩɪɚʄɟʃɟ ɟɮɢɤɚɫɧɨɫɬɢ ɬɟɪɚɩɢʁɟ ɜɢɬɚɦɢɧɨɦ Ⱦ, ɤɚɨ ɢ ɡɚ ɨɬɤɪɢɜɚʃɟ ɧɟɞɨɫɬɚɬɤɚ ɢɥɢ ɬɨɤɫɢɱɧɢɯ ɞɨɡɚ ɨɜɨɝ ɜɢɬɚɦɢɧɚ. ɋɬɪɭɱʃɚɰɢ ɫɦɚɬɪɚʁɭ ɞɚ ɫɟ ɧɢɜɨ ɜɢɬɚɦɢɧɚ Ⱦ ɩɪɨɜɟɪɚɜɚ ɭ ɫɥɭɱɚʁɭ ɯɢɩɨɤɚɥɰɢɟɦɢʁɟ ɢɥɢ ɚɤɨ ɫɭ ɩɪɢɫɭɬɧɢ ɧɟɤɢ ɫɢɦɩɬɨɦɢ ɢɥɢ ɡɧɚɰɢ ɪɚɯɢɬɢɫɚ, ɤɚɨ ɢ ɭ ɫɥɭɱɚʁɟɜɢɦɚ ɮɪɚɤɬɭɪɚ ɭ ɨɞɫɭɫɬɜɭ ɩɨɜɪɟɞɟ ʁɚɱɟɝ ɢɧɬɟɧɡɢɬɟɬɚ (Craig, et al. 2006). Ʉɨɞ ɞɟɰɟ ɫɚ ʁɟɞɧɢɦ ɢɥɢ ɜɢɲɟ ɮɚɤɬɨɪɚ ɪɢɡɢɤɚ ɡɚ ɧɢɫɤɭ ɜɪɟɞɧɨɫɬ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɫɟɪɭɦɭ ɧɟɨɩɯɨɞɧɨ ʁɟ ɭɬɜɪɞɢɬɢ ɤɨɧɰɟɧɬɪɚɰɢʁɭ: - ɜɢɬɚɦɢɧɚ Ⱦ (25(Ɉɇ)D), ɤɚɥɰɢʁɭɦ (ɋɚ), ɧɟɨɪɝɚɧɫɤɢ ɮɨɫɮɚɬ (ɊɈ4) ɢ ɚɥɤɚɥɧɭ ɮɨɫɮɚɬɚɡɭ (ALP) ɭ ɫɟɪɭɦɭ, - ɤɨɞ ɨɧɢɯ ɫɚ ɫɢɦɩɬɨɦɢɦɚ/ɡɧɚɰɢɦɚ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɜɢɬɚɦɢɧɚ Ⱦ, ɨɛɚɜɟɡɧɨ ɢɡɦɟɪɢɬɢ ɢ ɩɚɪɚɬɢɪɟɨɢɞɧɢ ɯɨɪɦɨɧ (ɊɌɇ) ɭɡ ɫɟɪɭɦɭ, - ɤɨɞ ɞɟɰɟ ɫɚ ɡɧɚɰɢɦɚ ɪɚɯɢɬɢɫɚ ɨɛɚɜɟɡɧɚ ʁɟ Ɋɬɝ ɡɝɥɨɛɚ. 91 ɁȺɄȴɍɑɐɂ ɇɚ ɨɫɧɨɜɭ ɞɨɛɢʁɟɧɢɯ ɪɟɡɭɥɬɚɬɚ ɢ ʃɢɯɨɜɢɦ ɭɩɨɪɟђɢɜɚʃɟɦ ɫɚ ɧɚɥɚɡɢɦɚ ɞɪɭɝɢɯ ɚɭɬɨɪɚ, ɦɨɝɭ ɫɟ ɞɨɧɟɬɢ ɫɥɟɞɟʄɢ ɡɚɤʂɭɱɰɢ: 1. ɍɱɟɫɬɚɥɨɫɬ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ) ɭ ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɜɟɥɢɤɚ. ȼɢɲɟ ɨɞ ɩɨɥɨɜɢɧɟ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ (58%) ʁɟ ɢɦɚɥɨ ɞɟɮɢɰɢɬ ɜɢɬɚɦɢɧɚ Ⱦ. Ɍɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ ʁɟ ɢɦɚɥɨ 16%, ɞɟɮɢɰɢʁɟɧɰɢʁɭ 23% ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ 19% ɢɫɩɢɬɚɧɢɤɚ. 2. ȼɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɭ (ȼȾȾ) ʁɟ ɢɦɚɥɨ 48% ɨɞɨʁɱɚɞɢ ɢ 69% ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ. ɍɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɛɪɨʁɚ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɫɚ ȼȾȾ. ȼɟʄɚ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ʁɟ ɧɚђɟɧɚ ɭ ɭɡɪɚɫɬɭ ɦɚɥɟ ɞɟɰɟ. 3. ɍ ɜɟɥɢɤɨɦ ɩɪɨɰɟɧɬɭ ɢɫɩɢɬɚɧɢɤɚ ɭɨɱɟɧɚ ʁɟ ɭɞɪɭɠɟɧɨɫɬ ȼȾȾ ɢ ɤɥɢɧɢɱɤɢɯ ɡɧɚɤɨɜɚ ɤɨʁɢ ɦɨɝɭ ɞɚ ɭɤɚɠɭ ɧɚ ɧɟɞɨɫɬɚɬɚɤ ɜɢɬɚɦɢɧɚ Ⱦ. ɂ ɭ ɝɪɭɩɢ ɧɚɢɡɝɥɟɞ ɡɞɪɚɜɟ ɞɟɰɟ (49% ɢɫɩɢɬɚɧɢɤɚ) ɭɬɜɪђɟɧɚ ʁɟ ȼȾȾ. 4. Ɂɧɚɬɧɨ ɜɟʄɚ ɭɱɟɫɬɚɥɨɫɬ ȼȾȾ ɛɢɥɚ ʁɟ ɩɪɢɫɭɬɧɚ ɭ ɢɫɩɢɬɢɜɚɧɟ ɞɟɰɟ ɫɚ ɬɚɦɧɨ ɩɪɟɛɨʁɟɧɨɦ ɤɨɠɨɦ, ɭ ɨɞɧɨɫɭ ɧɚ ɞɟɰɭ ɛɟɥɟ ɪɚɫɟ. ɍ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɧɢʁɟ ɭɬɜɪђɟɧɚ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɨɞɧɨɫɭ ɧɚ ɛɨʁɭ ɤɨɠɟ, ɞɨɤ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɢ ɛɨʁɟ ɤɨɠɟ ɭɬɜɪђɟɧɚ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɦɚɥɟ ɞɟɰɟ. 5. ɂɡɦɟђɭ ɝɪɭɩɟ ɨɞɨʁɱɚɞɢ ɫɚ ɚɞɟɤɜɚɬɧɨɦ (ɞɧɟɜɧɨɦ ɩɪɟɩɨɪɭɱɟɧɨɦ ɞɨɡɨɦ) ɢ ɧɟɚɞɟɤɜɚɬɧɨɦ ɫɭɩɥɟɦɟɧɬɚɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɭɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɭɱɟɫɬɚɥɨɫɬɢ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɟ. ɇɢʁɟɞɧɨ ɨɞ ɨɞɨʁɱɚɞɢ ɤɨʁɚ ɫɭ ɞɨɛɢʁɚɥɚ ɚɞɟɤɜɚɬɧɭ ɩɪɨɮɢɥɚɤɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɩɪɜɨʁ ɝɨɞɢɧɢ ɠɢɜɨɬɚ, ɧɢʁɟ ɢɦɚɥɨ ɬɟɲɤɭ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. ɂ ɩɨɪɟɞ ɚɞɟɤɜɚɬɧɟ ɩɪɨɮɢɥɚɤɫɟ, ɜɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ʁɟ ɢɦɚɥɨ ɞɟɮɢɰɢʁɟɧɰɢʁɭ ɢ ɢɧɫɭɮɢɰɢʁɟɧɰɢʁɭ ɜɢɬɚɦɢɧɚ Ⱦ. 6. ɂɫɩɢɬɢɜɚʃɟɦ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ ɭɡɪɚɫɬɚ ɞɨ 24 ɦɟɫɟɰɚ ɭ ɨɞɧɨɫɭ ɧɚ ɜɪɫɬɭ ɦɥɟɱɧɟ ɢɫɯɪɚɧɟ, ɞɨɛɢɥɢ ɫɦɨ ɩɨɞɚɬɚɤ ɞɚ ʁɟ ɜɟɥɢɤɢ ɛɪɨʁ ɧɚɲɢɯ ɢɫɩɢɬɚɧɢɤɚ ɭ ɨɜɨɦ ɭɡɪɚɫɬɭ (79%) 92 ɛɢɨ ɧɚ ɩɨɞɨʁɭ. ɍ ɝɪɭɩɢ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ, 55% ʁɟ ɢɦɚɥɨ ȼȾȾ. ȼɟɥɢɤɢ ɩɪɨɰɟɧɚɬ ɢɫɩɢɬɚɧɢɤɚ ʁɟ ɛɢɨ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ, ɢɥɢ ʁɟ ɩɪɨɞɭɠɟɧɨ ɫɢɫɚɥɨ, ɭɡ ɱɟɫɬɨ ɧɟɚɞɟɤɜɚɬɧɭ ɧɟɦɥɟɱɧɭ ɢɫɯɪɚɧɭ (ɢɫɯɪɚɧɭ ɫɢɪɨɦɚɲɧɭ ɜɢɬɚɦɢɧɨɦ Ⱦ ɢ ɤɚɥɰɢʁɭɦɨɦ). ɋɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɞɨɛɢʁɟɧɚ ʁɟ ɢɡɦɟђɭ ɝɪɭɩɟ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɩɨɞɨʁɭ ɢ ɞɟɰɟ ɧɚ ɢɫɯɪɚɧɢ ɚɞɚɩɬɢɪɚɧɢɦ ɮɨɪɦɭɥɚɦɚ ɤɪɚɜʂɟɝ ɦɥɟɤɚ. ɋɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɭ ɫɬɚɬɭɫɭ ɜɢɬɚɦɢɧɚ Ⱦ ɧɢʁɟ ɭɬɜɪђɟɧɚ ɢɡɦɟђɭ ɝɪɭɩɟ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɢ ɞɟɰɟ ɧɚ ɜɟɲɬɚɱɤɨʁ ɢɫɯɪɚɧɢ, ɢ ɢɡɦɟђɭ ɞɟɰɟ ɧɚ ɩɨɞɨʁɭ ɢ ɞɟɰɟ ɧɚ ɟɤɫɤɥɭɡɢɜɧɨɦ ɢɥɢ ɩɪɨɞɭɠɟɧɨɦ ɩɨɞɨʁɭ. 7. ȼɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɭ (ȼȾȾ) ɢ ɚɧɟɦɢʁɭ ʁɟ ɢɦɚɥɨ 80% ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. ɍɬɜɪɞɢɥɢ ɫɦɨ ɜɢɫɨɤɨ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɭ ɪɚɡɥɢɤɭ ɢɡɦɟђɭ ɝɪɭɩɟ ɞɟɰɟ ɫɚ ɚɧɟɦɢʁɨɦ ɢ ɩɪɢɫɭɬɧɨɦ ȼȾȾ ɢ ɞɟɰɟ ɛɟɡ ɚɧɟɦɢʁɟ ɢ ɩɪɢɫɭɬɧɨɦ ȼȾȾ. ɇɚʁɜɟʄɢ ɩɪɨɰɟɧɚɬ ɚɧɟɦɢʁɟ ʁɟ ɧɚђɟɧ ɭ ɝɪɭɩɢ ɞɟɰɟ ɫɚ ɬɟɲɤɨɦ ɞɟɮɢɰɢʁɟɧɰɢʁɨɦ ɜɢɬɚɦɢɧɚ Ⱦ. ɂ ɭ ɝɪɭɩɢ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ, ɢ ɭ ɝɪɭɩɢ ɦɚɥɟ ɞɟɰɟ ɭɨɱɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɢ ɤɨɧɰɟɬɪɚɰɢʁɟ HЛ ɭ ɫɟɪɭɦɭ. 8. ɍɬɜɪђɟɧɚ ʁɟ ɫɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɭɤɭɩɧɨɝ ɤɚɥɰɢʁɭɦɚ ɭ ɫɟɪɭɦɭ ɢ ɫɬɚɬɭɫɚ ɜɢɬɚɦɢɧɚ Ⱦ ɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. 9. ɋɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɞɨɛɢʁɟɧɚ ʁɟ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ ɧɟɨɪɝɚɧɫɤɨɝ ɮɨɫɮɚɬɚ ɢ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(Ɉɇ)D ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. 10. ɋɬɚɬɢɫɬɢɱɤɢ ɡɧɚɱɚʁɧɚ ɤɨɪɟɥɚɰɢʁɚ ɧɢʁɟ ɭɬɜɪђɟɧɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɢ ɚɥɤɚɥɧɟ ɮɨɫɮɚɬɚɡɟ ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ. Ɉɜɢɦ ɢɫɩɢɬɢɜɚʃɟɦ ɡɚɤʂɭɱɢɥɢ ɫɦɨ ɞɚ ɤɨɧɰɟɧɬɪɚɰɢʁɚ ȺLP ɭ ɫɟɪɭɦɭ ɧɢʁɟ ɤɨɪɢɫɬɚɧ ɩɚɪɚɦɟɬɚɪ ɡɚ ɫɤɪɢɧɢɧɝ ɯɢɩɨɜɢɬɚɦɢɧɨɡɟ ɜɢɬɚɦɢɧɚ Ⱦ. 11. ɍɬɜɪђɟɧɚ ʁɟ ɜɢɫɨɤɨ ɫɬɚɬɢɫɬɢɱɤɚ ɡɧɚɱɚʁɧɚ ɪɚɡɥɢɤɚ ɢɡɦɟђɭ ɤɨɧɰɟɧɬɪɚɰɢʁɟ 25(OH)D ɢ ɩɚɪɚɬɢɪɟɨɢɞɧɨɝ ɯɨɪɦɨɧɚ (ɊɌɇ) ɭ ɫɟɪɭɦɭ ɢɫɩɢɬɢɜɚɧɟ ɨɞɨʁɱɚɞɢ ɢ ɦɚɥɟ ɞɟɰɟ 12. Ɍɪɟɧɭɬɧɢ ɞɨɤɚɡɢ ɩɨʁɚɲʃɚɜɚʁɭ ɞɚ ʁɟ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ ɊɌɇ ɧɚʁɛɨʂɢ ɢɧɞɢɪɟɤɬɧɢ ɩɨɤɚɡɚɬɟʂ ɫɢɫɬɟɦɫɤɢɯ ɟɮɟɤɚɬɚ ɜɢɬɚɦɢɧ Ⱦ ɞɟɮɢɰɢʁɟɧɰɢʁɟ (ȼȾȾ). ɇɟɨɩɯɨɞɧɨ ʁɟ ɧɢɜɨ ɫɟɪɭɦɫɤɨɝ 25(Ɉɇ)D ɬɭɦɚɱɢɬɢ ɡɚʁɟɞɧɨ ɫɚ ɧɢɜɨɨɦ ɊɌɇ, ɚ ɧɟ ɢɡɨɥɨɜɚɧɨ ʁɟɞɚɧ ɨɞ ɞɪɭɝɨɝ ɩɚɪɚɦɟɬɪɚ. ALP, PTH ɢ ɜɪɟɞɧɨɫɬ CК ɢ ɧɟɨɪɝɚɧɫɤɢ ɮɨɫɮɚɬ ɫɭ ɞɨɛɚɪ ɩɨɤɚɡɚɬɟʂ ȼȾȾ, ɚɥɢ ɧɨɪɦɚɥɧɢ ɧɢɜɨɢ ɧɟ ɢɫɤʂɭɱɭʁɭ ɩɪɢɫɭɫɬɜɨ ȼȾȾ. 93 ɅɂɌȿɊȺɌɍɊȺ 1. Abdul-Razzak KK1, Ajlony MJ, Khoursheed AM, Obeidat B. Vitamin D deficiency among healthy infants and toddlers: a prospective study from Irbid, Jordan. Pediatr Int. 2011 Dec;53(6):839-45 2. Abdul-Razzak KK1, Khoursheed AM, Altawalbeh SM, Obeidat BA, Ajlony MJ. Hb level in relation to vitamin D status in healthy infants and toddlers. 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KRAVLJE MLEKO NEMLEČNA HЊANA ЛoРКtК vТtКЦТЧoЦ D Riba (morska) KШХТčТЧКИИИИИИИИИ Broj dana u nedelji________ ŽuЦКЧКМ KШХТčТЧКИИИИИИИИИ Broj dana u nedelji________ Meso KШХТčТЧКИИИИИИИИИ Broj dana u nedelji________ DžТРОrТМК KШХТčТЧКИИИИИИИИИ Broj dana u nedelji________ HEMATOLOŠKE I BIOHEMIJSKE ANALIГE 1. Eritrociti______________ 6. Proteini uk.____________ 11. Fosfor_______________ 2. Hemoglobin___________ 7. Albumini______________ 12. Alkalna fosfataza______ 3. Hematokrit____________ 8. Urea_________________ 13. Paratir. hormon________ 4. Leukociti_____________ 9. Kreatinin______________ 102 103