서론 당뇨병환자의식사요법목표는적정수준으로혈당과혈중지질농도를유지하여합병증을예방하고, 적절한식사섭취를통해양호한영양상태를유지하는것이다. 일부당뇨병환자의경우식욕부진, 저작곤란등다양한원인으로인해일반적인식사로는영양요구량만큼에너지섭취가어려울수있는데이런경우경구영양보충음료 (oral

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1 J Korean Diabetes 2017;18: Vol.18, No.3, 2017 ISSN 당뇨병환자를위한경구영양보충음료의사용 강미라 CHA Use of Oral Nutritional Supplements for Patients with Diabetes Mi Ra Kang Department of Nutrition, CHA Bundang Medical Center, CHA University, Seongnam, Korea Abstract Dietary counseling and oral nutritional supplements (ONS) should be considered to increase the nutritional intake of people malnourished or at risk of malnutrition. These supplements are typically ready-made liquids and contain a balanced mix of energy,, and micronutrients. The diabetesspecific ONS are specifically designed for patients with hyperglycemia or diabetes mellitus in order to provide better glycemic control such as postprandial glucose and HbA1c compared to the standard ONS. These supplements are lower in carbohydrates and higher in fat than standard supplements and are rich in monounsaturated fats. Using diabetes-specific ONS in malnourished diabetic patients can allow increasing energy intake while maintaining glucose control and improving nutritional status and also providing economic benefits. However, inadequate intake of ONS that do not fit the patient's condition can be a problem. Therefore, when using ONS for patients with diabetes, it is necessary to clinically evaluate the nutritional status of the patient and to provide individualized education and management accordingly. Keywords: Diabetes mellitus, Glycemic index, Malnutrition, Oral nutritional supplements, Postprandial glucose Corresponding author: Mi Ra Kang Department of Nutrition, CHA Bundang Medical Center, CHA University, 5 Yatap-ro, Bundang-gu, Seongnam 1346, Korea, mirharoo@naver.com Received: Jul. 28, 2017; Accepted: Jul. 2, 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2017 Korean Diabetes Association The Journal of Korean Diabetes 181

2 서론 당뇨병환자의식사요법목표는적정수준으로혈당과혈중지질농도를유지하여합병증을예방하고, 적절한식사섭취를통해양호한영양상태를유지하는것이다. 일부당뇨병환자의경우식욕부진, 저작곤란등다양한원인으로인해일반적인식사로는영양요구량만큼에너지섭취가어려울수있는데이런경우경구영양보충음료 (oral nutritional supplement, ONS) 를활용할수있다. 본논문에서는 ONS 중당뇨병환자에게적절한영양소를공급하고혈당조절을최적화할수있도록영양성분을조정한당뇨병환자용 ONS (diabetes-specific ONS) 에대해소개하고자한다. 본론 1. ONS의정의 ONS는필수적인영양소의대부분을함유한제품이다. 이는식품공전상특수의료용도식품으로정상적으로영양을섭취, 소화, 흡수, 대사할수있는능력이제한되거나손상된환자및질병이나임상적상태로인하여일반인과생리적으로특별히다른영양요구량을가진사람에게식사의일부또는전부를대신할목적으로제조ㆍ가공한식품이다 [1]. 식사섭취가부족한영양불량상태의노인 [2-5], 암환자 [6,7], 수술후환자 [8,] 를대상으로 ONS를영양중재한연구결과들은환자들의경구섭취량을증가시키고영양상태를개선하는데기여한다고보고하였다. 영국국립임상보건연구원 (National Institute for Care Excellence) 은영양불량상태이거나영양불량위험이있는사람들의영양섭취를개선하기위해영양상담과 ONS를고려해야한다고권고하고있다 []. 일반환자용 ONS (standard ONS) 가상용화된이후에혈당관리가중요한당뇨병환자들을위해당질함량은감소시키고지방함량은증가시키는등혈당조절을최적화하기위한당뇨병환자용 ONS를 [11] 개발하였다. 따라서당뇨병환자또는고혈당환자에게는일반환자용 ONS보다당뇨병환자용 ONS를사용할것을권장하고있다 [12]. 2. 당뇨병환자용 ONS의영양적특성당뇨병환자용 ONS의특성을일반환자용 ONS와비교하여각영양소별로알아보면다음과같다. 국내당뇨병환자용 ONS의자세한영양성분에대해서는 Table 1에제시하였다. 1) 당질당뇨병환자용 ONS의가장큰특징은당질함량을감소시키고식이섬유소함량을증가시킨것이다. 당질이혈당에미치는영향은당질의종류나형태보다총당질의함량이가장크다 [13]. 그러므로당뇨병환자용 ONS는혈당조절을위해총당질함량을가능한최소화하여제조한다. 일반환자용 ONS의당질함량 ( 총에너지의 55~65%) 에비해당뇨병환자용 ONS의당질함량 ( 총에너지의 37~45%) 이적다. 당질함량이같다면다음으로혈당지수 (glycemic index, GI) 가낮은당질을활용하면혈당조절에부가적인도움을줄수있다 [13]. 당뇨병환자용 ONS는단순당을최소한으로하고, 천천히소화ㆍ흡수되는팔라티노스 (, isomaltose) 등의 GI가낮은당을사용하여식후고혈당을예방하도록고안한제품이다 [12,14]. Wolever 등 [15] 은제2형당뇨병환자에게당질의함량과 GI가다른당뇨병환자용 ONS와일반환자용 ONS를영양중재한연구결과당질함량이적고 GI가낮은당뇨병환자용 ONS가식후혈당이유의적으로낮아임상적으로유용한효과를나타내었다 [16,17]. 수용성식이섬유소는인슐린감수성을증가시키고위내용물배출속도를지연시켜혈당조절에효과적이다 [12,13]. 당뇨병환자용 ONS는일반환자용 ONS보다섬유소함량이많고, 식약처에서혈당상승억제기능성원료로인정한난소화성말토덱스트린, 대두식이섬유소, 치커리식이섬유 182

3 Table 1. Composition of oral nutritional supplements for patients with diabetes/glucose intolerance Product (company) Greenbia DM R (Dr. Chung's Food) Greenbia DM Solution R (Dr. Chung's Food) Greenbia Plus Care DM R (Dr. Chung's Food) Nucare DM R (Daesang Wellife) Nucare Diabetes Plan R (Daesang Wellife) Mediwell DM R (MDwell) Medifood Glutrol R (Korea Medical Foods) Medifood Glutrol R (Korea Medical Foods) EN DM R (Korea Medical Foods) Care Well DM R (Korea Enteral Foods) kcal /ml g/can (%kcal) (45) (3) (42) (37) Carbohydrate Protein Fat Fiber Source crystalline fructose, high fructose corn syrup, high fructose corn syrup, g/can (%kcal) (20) (20) (20) (18) (18) (20) Maltodextrin (17) Maltodextrin 13 (17) Maltodextrin (17) crystalline fructose, DM, diabetes mellitus; MCT, medium chain triglyceride. (18) Source whey concentrate, g/can (%kcal) 8 (35).6 (43) Casein.5 (43) Casein 14 (43) whey concentrate,.6 (43) (45) Source Sunflower oil, soybean oil g/can (%kcal) Source 5 Soybean Canola oil 3 Soybean Canola oil, soybean oil 5 Soybean Canola oil 5 Soybean Canola oil, MCT oil, sunflower oil Canola oil, MCT oil, sunflower oil 5 Soybean fiber gel 5 Soybean Canola oil 7 Soybean dietary fiber, chicory Canola oil 7 Soybean dietary fiber, chicory Canola oil 3 Soybean Canola oil, MCT oil, sunflower oil 3 Soybean 183

4 소등의수용성식이섬유소를함유하고있다 [18]. 2) 단백질당뇨병환자는혈당조절이잘되지않아체단백질의이화작용으로인해소변으로많은양의질소를배출하며단백질로부터포도당신생합성작용이증가하므로총에너지의 15~20% (1~1.5 g/kg) 로충분한단백질을섭취할것을권장한다. 그러나단백질섭취량에대해서는충분한과학적근거가부족하므로환자의혈당조절과대사목표에따라개별화하는것을권장한다 [13]. 당뇨병환자용 ONS는단백질요구량이높은당뇨병환자에게양질의단백질을공급할수있어야하므로우리나라대부분의당뇨병환자용 ONS의단백질원료는대부분카제인단백질과분리대두단백을혼합하여제조한다. 카제인은우유에서유래한단백질중하나로단백질함량이 0% 이상으로가장많고, 열안정성과유화력이우수하여지방원료와함께사용해야하는액상형태인 ONS의단백질주원료로가장많이사용하며 [1], 식물성콩단백질보다생물학적가치가높다 [20]. 콩에서유래한분리대두단백 ( ) 은식물성단백질이지만단백질함량이많고, 우유유래단백질과섞어사용할경우아미노산조합이보다풍부해지며포만감의시간을증가시킬수있는등다양한이점을보고하고있다 [14,21]. 3) 지방당뇨병환자용 ONS는당질함량이적은대신지방함량이총에너지의 35~45% 로일반환자용 ONS ( 총에너지의 20~30%) 보다많다. 동일한에너지로영양소조성을다르게하여영양중재한메타분석연구에서당질을불포화지방산으로대체했을경우당화혈색소와인슐린저항성이유의하게낮았다고보고하였다 [22]. 지방산조성은단일불포화지방산 (monounsaturated fatty acids, MUFA) 의함량을증가시켜혈당을조절하고, 혈중중성지방을감소시키고 HDL 콜레스테롤수치를증가시켜혈중지질을개선하는데유용하도록구성하여제조한다. 반면포화지방은총에너지 의 % 미만, 콜레스테롤은 1,000 kcal당 0 mg 이하로제한한다 [1]. 지방섭취와혈당조절과의관련성을규명한많은연구에서지방의총섭취량보다지방산조성이더중요하고 [13], 포화지방산대신불포화지방산을사용하는것이인슐린감수성과혈중지질, 지단백질구성에유익하다고보고하였다 [1]. 또한당뇨병환자에게 MUFA 함량이다른 ONS를영양중재한연구결과 MUFA 함량이많은당뇨병환자용 ONS를섭취한환자들의식후혈당과당화혈색소가유의적으로낮아혈당개선효과를보고하였다 [23-25]. 4) 비타민과무기질당뇨병환자용 ONS 제조시제품 1,000 kcal당비타민 A, B1, B2, B6, C, D, E, 나이아신, 엽산, 단백질, 칼슘, 철, 아연을영양성분기준치의 50% 이상함유하도록하며 [1]. 당뇨병환자에게필요한항산화영양소인베타카로틴, 비타민 C, 비타민 E와지방대사에필수적인 L-카르니틴등을보강하기도한다. 크롬 (chromium) 은탄수화물과지방대사에중요한필수미량영양소로크롬보충이혈당조절과인슐린대사를개선시키는데도움을주는것으로알려져있다 [12]. 특히미국당뇨병환자용 ONS (Diabetishield R, Glucerna R 등, 약 85~340 μg/l) 에함유하여제조하고, 미국제품보다함유량은적지만국내일부당뇨병환자용 ONS ( 약 40~60 μg/l) 도한국인영양섭취기준 (2015년) 충분섭취량 ( 남자 1~64 세기준 35 μg/ 일 ) 을충족하는크롬을함유하고있다. 3. 당뇨병환자용 ONS의혈당조절효과당뇨병환자용 ONS가일반환자용 ONS에비해혈당관리에유용한지비교한임상연구결과들을살펴보면다음과같다. 당뇨병환자에게당뇨병환자용 ONS 와일반환자용 ONS를영양중재한결과당질함량이적고 MUFA 함량이많은당뇨병환자용 ONS가식후혈당 [16,24,26-31] 과당 184

5 화혈색소 [32-34] 가유의적으로낮아단기간및장기간의혈당개선효과를보고하였다. 체중감소가있는당뇨병환자에게 MUFA 함량이많은당뇨병환자용 ONS를하루 2캔씩 주간영양중재한연구에서식후혈당과당화혈색소는유의적으로감소하고, 체중, 알부민수준은유의적으로증가하여혈당조절과함께영양상태를향상시키는효과를나타내었고 [23,35], 하루 2 캔보다 3캔을보충했을때더욱효과적이었다고보고하였다 [35]. 또한중환자실에입실한환자에게당뇨병환자용 ONS를사용했을때, 일반환자용 ONS보다식후혈당이유의적으로낮았고 [24], 사망률과인슐린사용량이유의적으로감소하여경제적개선효과도있음을보고하였다 [36]. 4. 당뇨병환자용 ONS 섭취시주의사항 결론 앞에서살펴본것과같이당뇨병환자용 ONS는당질함량이적고, 지방과섬유소함량이많은영양적특성을지니고있어일반환자용 ONS에비해당뇨병환자의혈당조절에보다효과적이다. 특히영양불량상태이거나식사섭취가저조한당뇨병환자에서당뇨병환자용 ONS 섭취시혈당조절을최적화하고에너지섭취량을증가시켜영양상태를개선하는효과를기대할수있겠다. 그러나환자의상태에맞지않는부적절한섭취는에너지및단백질과다공급으로인해혈당상승및합병증증상악화등의문제가발생할수있다. 따라서당뇨병환자의 ONS 섭취시임상영양사에의한환자영양상태및식사섭취평가등개별화된영양관리하에서적절히사용해야할것이다. 당뇨병환자용 ONS를적절히사용하면환자의혈당조절을최적화하고영양상태를개선하는데도움을줄수있겠다. 그러나합병증등환자개인별상태에따라사용시주의해야한다. 당뇨병환자용 ONS는에너지와단백질을농축한제품이므로환자가영양요구량이상섭취할경우혈당상승및합병증위험을증가시킬수있으므로환자의식사량을면밀히평가하여당뇨병환자용 ONS 사용에의해에너지를과도하게공급하지않도록주의해야하겠다. 또한과다한단백질섭취를피해야하는신장합병증을동반한당뇨병환자 [25] 의경우단백질함량이많은당뇨병환자용 ONS의사용은문제가될수있으므로반드시개별적으로환자의적절한단백질섭취량을평가한후주의하여사용해야한다. 또한당뇨병성위마비 (gastroparesis) 합병증을지닌당뇨병환자의경우지방및식이섬유소함량이많은당뇨병환자용 ONS의사용이메스꺼움, 구토, 조기포만감, 복부통증등의증상을악화시킬수있으므로 [37] 특히주의해야한다. REFERENCES 1. Ministry of Food and Drug Safety. Korean Food Standards Codex. Available from: go.kr/foodcode/01_03.jsp?idx=51 (updated 2016 Dec 1). 2. Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr 20;2: Capitini N, Montanari L, Marotta GG, Morucci R. Elderly nursing home residents, risk of malnutrition, and nutritional supplements: our experience. Nutr Ther Metab 2011;2: Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high oral nutritional supplements. Ageing Res Rev 2012;11: Mayr P, Kuhn KS, Klein P, Stover JF, Pestana EA. A diabetes-specific oral nutritional supplement improves glycaemic control in type 2 diabetes patients. Exp Clin 185

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R