Journal of Health Informatics and Statistics Original Article J Health Info Stat 2019;44(2): pissn

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1 Original Article J Health Info Stat 2019;44(2): pissn eissn 제 2 형당뇨병으로새롭게진단받은성인의생활습관요인, 비만, C-peptide 분비, 대사증후군및심혈관질환발생위험과의관계 : 사례연구 권선영 1, 박혜자 2 1 차의과학대학교분당차병원수간호사, 2 차의과학대학교간호대학교수 Association among Lifestyle Factors, Obesity, C-peptide Secretion, Metabolic Syndrome, and Cardiovascular Risk in Adults with Newly Diagnosed Type 2 Diabetes Mellitus: A Case Study Sun-Young Kwon 1, Hye-Ja Park 2 1 Head Nurse, Diabetes Education Nurse, CHA Bundang Medical Center, Seongnam; 2 Professor, College of Nursing, CHA University, Pocheon, Korea Objectives: This study examined the association among lifestyle factors, obesity, and C-peptide secretion, metabolic syndrome (MS) and cardiovascular disease (CVD) risk in newly diagnosed type 2 diabetes mellitus (T2DM) adults. Methods: In this cross-sectional study, 99 participants completed measures of lifestyle factors and the anthropometric, metabolic, and glycemic indices. Obesity was classified by body mass index (BMI) of 25 kg/m 2. C-peptide secretion was classified into severe, moderate, and non-secretory defect. MS was defined by National Cholesterol Education Program Adult Treatment Panel III guidelines. The 10-year CVD risk score was calculated using Framingham equation. Results: The incidence of obesity, non-secretory defect of C-peptide, MS, and CVD risk > 20% were 49.5%, 52.5%, 65.7%, and 52.5%, respectively. New T2DM adults with MS had greater consumed alcohol, lower regular exercise rate, higher BMI, and greater fasting blood C-peptide. Male and usual T2DM onset age ( 40) had greater high CVD risk than female and the early T2DM onset age ( < 40). MS associated with greater consumed alcohol (odds ratio [OR]: 3.25, 95% confidence interval [95% CI]: ) and fasting C-peptide (OR: 1.99, 95% CI: ). CVD risk > 20% associated with more MS traits (OR: 1.84, 95% CI: ). Conclusions: An integrated educational program including more intensive and strict behavioral change, exercise, diet, and self monitoring may help newly diagnosed type 2 diabetes mellitus adults. Key words: Lifestyle, Obesity, C-peptide, Metabolic syndrome, Cardiovascular risk 서론 우리나라성인의당뇨병유병률은 2011 년 10.1% 에서 2014 년 13.7% 로 빠르게증가하고있고, 성인 4 명중 1 명이공복혈당장애에의한잠재적 당뇨병을보여제2형당뇨병발생률과질병부담은더욱증가될것으로예측된다 [1]. 제2형당뇨병에서복부비만, 체질량지수 (body mass index, BMI) 25 kg/m 2 이상, 고지질혈증, 비정상인슐린대사는심혈관질환발생에핵심적인위험요인으로간주된다 [2,3] 년대한당뇨병학회의 Corresponding author: Hye-Ja Park 120 Haeryong-ro, Pocheon 11160, Korea clara@cha.ac.kr Received: January 31, 2019 Revised: April 12, 2019 Accepted: April 16, 2019 *This article is an addition based on the first author s master s thesis from CHA University. No potential conflict of interest relevant to this article was reported. How to cite this article: Kwon SY, Park HJ. Association among lifestyle factors, obesity, C-peptide secretion, metabolic syndrome, and cardiovascular risk in adults with newly diagnosed type 2 diabetes mellitus: a case study. J Health Info Stat 2019;44(2): Doi: It is identical to the Creative Commons Attribution Non-Commercial License ( whichpermit sunrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited

2 Sun-Young Kwon and Hye-Ja Park 보고에의하면당뇨병성인의 48.6% 가비만하며 58.9% 가고혈압을동반하고 31.6% 에서이상지질혈증의심혈관질환발생위험요인을가지고있다 [1]. 반면혈당, 혈압, 콜레스테롤의통합적관리는당뇨병성인의 9.4% 만이수행하며흡연, 음주, 운동부족과같은불건강한건강행위로당뇨병성인의심혈관질환발생위험은더욱높아지고있다 [1,4]. 제2형당뇨병은특별한증상이없어당뇨병성인의 10명중 3명은당뇨병임을인지하지못하고 [1], 새로운제2형당뇨병성인의심장동맥질환과뇌혈관질환유병률은 8.7% 와 5.5% 로심장동맥질환이발생한후당뇨병이발견되는경우가 30% 에달한다 [5]. 심혈관질환발생은당뇨병기간이경과되면서더욱증가되기때문에당뇨병진단시점부터적극적인혈당조절뿐만아니라다양한심혈관질환위험요인의평가가우선적으로이루어져야한다 [2,4,5]. 심혈관질환발생위험을평가하는유용한지표인 National Cholesterol Education Program Adult Treatment Panal III (NCEP-ATP III) 의대사증후군은당뇨병, 인슐린저항성, 복부비만을중점으로대사성심혈관질환위험여부를당뇨병진단시점에서판단하고 [2,6], 성별에따른나이, 수축기혈압, 흡연, 당뇨병, 총콜레스테롤, 고밀도지질단백콜레스테롤로점수화한프래밍험심혈관질환발생위험 (Framingham Cardiovascular Risk, CVD Risk) 으로향후 10년동안심혈관질환발생위험정도를낮은위험에서고위험까지예측하며치료및자가관리의기준으로활용된다 [2,3]. 제2형당뇨병성인의심혈관질환발생위험단계모형에의하면, 과도한식이, 운동부족, 흡연과같은생활습관위험요인이일차적으로형성되면다음단계에서비만, 고지질혈증, 고혈압, 당뇨병을동반한대사장애가나타나며이후혈관내피세포염증과초기혈관질환이심혈관질환으로진행되어사망까지이른다 [4]. 선행연구에서성인의흡연과음주, 신체활동, 섭취에너지는대사증후군발생과관련되고 [7] 새로운제2형당뇨병성인의체질량지수가높을수록인슐린저항성이높았다 [8]. 인슐린저항성은심장동맥석회화와좌심실비대발생의위험요인이며 [9] 과도한체중증가를보였던새로운당뇨병환자에서임상전단계의심장동맥협착과석회화, 플라크 (plaque) 가이미형성되어있었고 [10], 대사증후군위험요인이많을수록심혈관질환발생의위험이높았다 [9]. 그러나선행연구대상이기존의당뇨병성인이나비당뇨병성인이었고 [1,7], 후향적이차자료를이용한보고이므로직접교육을제공하기위해대상자에게접근하는데한계가있다 [1,3,5,7,11]. 새로운당뇨병성인은적절한당뇨병관리의 70% 까지도달하는데 5년이소요되고 [12] 진단시점에서먹고싶은것을못먹고평생자가관리를한다는점에서실망을느끼고, 당뇨병을심각한질병이아니라고과소평가하여신체증상이나합병증을경험하기전까지자가관리 를무시하는문제를보인다 [13]. 이에임상실무에서당뇨병성인의심혈관질환발생위험요인을매년반복적으로평가하는것을권고하고있고대사증후군과심혈관질환위험요인을낮추도록생활습관행위변화를돕는건강관리자의역할이강조되고있다 [2,4,12,13]. 그러나제 2형당뇨병검진자에게서검진직후대사증후군발생과심혈관질환발생위험에대한연구가부족하므로제2형당뇨병으로새롭게진단받은성인의대사증후군발생과심혈관질환발생위험요인을평가하기위한탐색연구가필요하다. 따라서본연구는제2형당뇨병으로새롭게진단받은성인을대상으로생활습관요인, 비만, C-peptide 분비, 대사증후군, 심혈관질환발생위험정도를확인하고대사증후군발생및고위험심혈관질환발생과관련되는요인을탐색하고자한다. 연구방법 연구대상본연구는 2014년 1월부터 2015년 2월까지차의과학대학교분당차병원건강검진센터에서공복혈당검사결과 100 mg/dl 이상또는급격한체중감소를보여당뇨병환자로선별된후 [2] 내분비내과에서제2 형당뇨병으로처음진단을받은성인전체를대상으로하였다. 대상자선정조건은내분비내과전문의가공복혈당 126 mg/dl 이상또는식후 2시간혈당 200 mg/dl 이상또는당화혈색소를 6.5% 이상을기준으로제2형당뇨병으로확진한 [2] 18세이상의성인과경구혈당강하제복용이나인슐린치료를시작하기전인자이다 [8]. 본연구기간동안건강검진을받고내분비내과에등록되었던 120명의환자중검사항목누락이있었던 6명과경구혈당강하제를이미복용중인 15명의자료를제외한후 [8] 최종 99명의자료를분석하였다. 건강검진을통해당뇨병으로선별된후당뇨병진단을위해내분비내과외래를방문한대상자에게차의과학대학교분당차병원의당뇨병표준진료지침을근거로당뇨병교육간호사인본연구자가설문조사를면대면으로완료하였다. 안정상태에서혈압을 2회측정하여평균값을이용하였으며신장과체중을측정한후줄자로허리둘레는서있는상태에서허리가노출되게한다음줄자가배꼽을지나가도록 cm 단위로 2회측정하여평균값을사용하였다. 설문조사와신체계측은 20-30분정도소요되었고측정한자료는전자의무기록에스캔하여입력하였다. 내분비내과전문의가처방한공복혈당, 당화혈색소, C- peptide, 혈청지질검사를위해검사예약일전날부터 8시간이상금식을한후임상병리과에서채혈하도록교육하였다. 검사당일공복채혈후환자에게식사를하도록교육하였고환자는식사시작시간을기준으로 2시간후에혈당과 C-peptide 를임상병리과에서검사하였다

3 Type 2 Diabetes Mellitus 영양사가측정한식이조사자료와공복혈당, C-peptide, 당화혈색소, 지질검사자료는의무기록에서수집하였다. 본연구는연구자가속한차의과학대학교분당차병원의연구윤리심의위원회의승인 (IRB No. BD ) 을받은후수행하였다. 연구도구대상자의특성일반적특성과생활습관요인으로성별과나이를조사하였고당뇨병발병나이는 40세미만 ( 조기발병 ) 과 40세이상 ( 호발나이 ) 으로구분하였으며 [14] 1일흡연담배개비수, 주 2회를기준으로한음주유무, 1회음주량 ( 병 ), 주당운동회수항목으로구성되었다 [1]. 혈당, 당화혈색소, C-peptide, 총콜레스테롤 (total cholesterol, TC), 중성지방 (triglyceride, TG), 고밀도지질단백콜레스테롤 (high density lipoprotain cholesterol, HDL-C), 저밀도지질단백콜레스테롤 (low density lipoprotain cholesterol, LDL-C) 을전자의무기록에서수집하였다. 1일섭취에너지, 3대영양소섭취비율, 1일권장에너지는영양사가식품섭취빈도법으로컴퓨터지원자동화프로그램을이용하여산출한자료를전자의무기록에서수집하였다. 비만비만은자동신장체중계 (DS-103, Jenix, Seoul, Korea) 를이용하여신장과체중을측정한후체중을신장의제곱으로나누어 BMI를산출하였다 ( 비만 : BMI >25 kg/m 2, 비비만 : < 25 kg/m 2 ) [1]. C-peptide 분비공복 C-peptide 분비는분비결함 ( 심한, 중등도 ) 과분비결함없음으로분류하였다 ( 심한분비결함 : <1.10 ng/ml, 중등도분비결함 : ng/ml, 분비결함없음 : 1.70 ng/ml) [15]. 대사증후군대사증후군은 NCEP-ATP III에의해복부비만 ( 허리둘레 : 남자 >90 cm, 여자 > 80 cm), 중성지방 (TG 150 mg/dl), HDL-C ( 남자 <40 mg/ dl, 여자 < 50 mg/dl), 혈압 ( 130/85 mmhg 또는항고혈압제복용 ) 및공복혈당 ( 110 mg/dl) 중 3개이상의항목에해당되는경우이다 [6]. 심혈관질환발생위험 Framingham 공식에의해성별에따라나이, TC, HDL-C, 혈압, 당뇨병, 흡연항목으로향후 10년동안심혈관질환발생위험 (%) 으로산출하였다 ( 위험정도는저위험 CVD <10%, 중간위험 CVD 10-20%, 고위험 CVD >20% 로분류하 고, 고위험유무는 CVD >20% 와 CVD 20% 로분류하였다 [2,3]. 자료분석자료는 SPSS 23.0 (IBM Corp., Armonk, NY, USA) 프로그램을사용하여분석하였다. 1) 대상자의특성과생활습관요인, 비만, C-peptide, 대사증후군, 심혈관질환발생위험은빈도와백분율또는평균과표준편차의기술통계로분석하였다. 2) 대사증후군발생과고위험심혈관질환발생위험에따른생활습관요인, 비만, C-peptide는 t-test 또는 χ 2 -test, Fisher s exact test로분석하였다. 3) 대사증후군발생과고위험심혈관질환발생관련요인은로지스틱회귀분석을사용하였다. 연구결과 대상자의특성대상자의 54.5% 가남성이었고평균나이는 ±12.14 세이었으며 27.3% 가 40세미만이었다. 흡연과음주빈도는각각 53.5% 와 56.6% 이었고 59.6% 가규칙적인운동을하였다. 1일흡연담배개비수와 1회음주량 ( 병 ) 은 7.81±9.96 개비와 0.71± 0.84병이었고주당운동회수는 2.04 ± 2.22회이었으며권장에너지의 % ± 33.25% 를섭취하였다. 대상자의 49.5% 가비만이었고공복 C-peptide 는 1.89± 0.91 ng/ml 이었으며 C- peptide 분비결함이없는대상자는 52.5% 이었다 (Table 1). 대사증후군에따른대상자특성, 생활습관요인, 비만및 C-peptide 분비대사증후군발생빈도는 65.7% 이었고대사증후군성인의 1회음주량 ( 병 ) 은 0.82 ± 0.90병으로대사증후군이없는성인의 0.50 ± 0.67병보다많았다 (p = 0.047). 대사증후군성인의규칙적인운동수행빈도는 52.3% 로대사증후군이없는성인의 73.5% 보다낮았다 (p = 0.041). 대사증후군성인의흡연, 음주, 비운동의생활습관빈도는 24.6% 로대사증후군이없는성인의 5.6% 보다높았다 (p = 0.027). 대사증후군성인의비만빈도는 64.6% 로대사증후군이없는대상자의 20.6% 보다높았고 (p < 0.001) 대사증후군성인의공복 C-peptide 는 2.03± 0.92 ng/ml 로대사증후군이없는환자의 1.61 ± 0.86 ng/ml 보다높았다 (p = 0.031) (Table 1). 심혈관질환발생위험에따른생활습관요인, 비만, C-peptide 분비및대사증후군심혈관질환발생위험 >20% 는 52.5% 이었으며남성의심혈관질환발 127

4 Sun-Young Kwon and Hye-Ja Park Table 1. Characteristics, lifestyle factors, obesity, and C-peptide according to metabolic syndrome in newly diagnosed type 2 diabetes mellitus patients (n=99) Variables Categories Total Yes (n=65) Metabolic syndrome No (n=34) n (%) or M ± SD n (%) or M ± SD n (%) or M ± SD Characteristics Sex Male 54 (54.5) 34 (52.3) 20 (58.8) Female 45 (45.5) 31 (47.7) 14 (41.2) Age (y) 49.01± ± ± < (27.3) 22 (33.8) 5 (14.7) (72.7) 43 (66.2) 29 (85.3) Lifestyle factors Smoking Yes 53 (53.5) 36 (55.4) 29 (44.6) Number of cigarettes a day 7.81± ± ± Alcohol drinking Yes 56 (56.6) 39 (68.5) 17 (50.0) Consumed alcohol (bottle/one time) 0.71± ± ± Regular exercise Yes 59 (59.6) 34 (52.3) 25 (73.5) Exercise times/week 2.04± ± ± Current dietary calories (kcal) 2,153.11± ,167.06± ,116.67± Carbohydrate (%) 62.38± ± ± Protein (%) 15.45± ± ± Lipid (%) 23.02± ± ± Current dietary calories (%) ± ± ± Smoking+Alcohol Yes 37 (37.4) 27 (41.5) 10 (29.4) Smoking+No exercise Yes 27 (27.3) 21 (32.3) 6 (17.6) Alcohol+No exercise Yes 27 (27.3) 21 (32.3) 6 (17.6) Somking+Alcohol+No exercise Yes 18 (18.2) 16 (24.6) 2 (5.6) Anthropometric measurements Current BMI (kg/m 2 ) ± ± ± < (49.5) 42 (64.6) 7 (20.6) <0.001 <25 50 (50.5) 23 (35.4) 27 (79.4) Previous BMI (kg/m 2 ) ± ± ± < (58.6) 48 (73.8) 10 (29.4) <0.001 <25 41 (41.4) 17 (26.2) 24 (70.6) Recent weight loss Yes 31 (31.3) 18 (27.7) 13 (38.2) Glycemic control HbA1c (%) 9.32± ± ± C-peptide (ng/ml) Fasting 1.89± ± ± Secretory defect Severe 12 (12.1) 6 (9.2) 6 (17.6) Moderate 35 (35.4) 19 (29.2) 14 (47.1) None 52 (52.5) 40 (61.5) 12 (35.3) Metabolic syndrome traits 1 8 (8.1) 2 26 (26.2) 3 38 (38.4) 4 19 (19.2) 5 8 (8.1) M±SD, mean±standard deviation; BMI, body mass index; HbA1c, glycated hemoglobin. 1 Fisher s exact test. t or χ 2 p 생위험 >20% 는 69.2% 로여성의 30.8% 보다높았으며 (p = 0.002), 40 세미 만에서심혈관질환발생위험 >20% 는 9.6% 로 40 세이상의 90.4% 보다 낮았다 (p < 0.001). 심혈관질환발생위험 >20% 에서흡연율은 73.1% 로 심혈관질환발생위험 20% 의 31.9% 보다높았고 (p < 0.001) 심혈관질환 발생위험 >20% 의 1 일흡연담배개비 ±10.38 은심혈관질환발생 위험 20% 의 4.78±8.60 보다높았다 (p = 0.004) (Table 2)

5 Type 2 Diabetes Mellitus Table 2. Characteristics, lifestyle factors, obesity, and C-peptide according to cardiovascular risk in newly diagnosed type 2 diabetes mellitus patients (n=99) CVD risk Variables Categories > 20% (n = 52) 20% (n = 47) t or χ 2 p n (%) or M ± SD n (%) or M ± SD Characteristics Sex Male 36 (69.2) 18 (38.3) Female 16 (30.8) 29 (61.7) Age (y) 55.58± ± <0.001 < 40 5 (9.6) 22 (46.8) < (90.4) 25 (53.2) Lifestyle factors Smoking Yes 38 (73.1) 15 (31.9) <0.001 Number of cigarettes a day 11.06± ± Alcohol drinking Yes 30 (57.7) 26 (55.3) Consumed alcohol (bottle/one time) 0.72± ± Regular exercise Yes 29 (55.8) 30 (63.8) Exercise times/week 1.82± ± Current dietary calories (kcal) 2,116.63± ,188.48± Carbohydrate (%) 62.19± ± Protein (%) 14.09± ± Lipid (%) 22.25± ± Current dietary calories (%) ± ± Smoking+Alcohol Yes 23 (44.2) 14 (29.8) Smoking+No exercise Yes 18 (34.6) 9 (19.1) Alcohol+No exercise Yes 18 (34.6) 9 (19.1) Smoking+Alcohol+No exercise Yes 10 (24.6) 8 (5.6) Anthropometric measurements Current BMI (kg/m 2 ) ± ± (48.1) 24 (51.1) <25 27 (51.9) 23 (48.9) Previous BMI (kg/m 2 ) ± ± (59.6) 27 (57.4) <25 21 (40.4) 20 (42.6) Recent weight loss Yes 17 (32.7) 134 (29.8) Glycemic control HbA1c (%) 8.82± ± C-peptide (ng/ml) Fasting 1.98± ± Metabolic syndrome Yes 37 (71.2) 28 (59.6) Number of MS traits (1-5) 3.00± ± M ± SD, mean ± standard deviation; BMI, body mass index; HbA1c, glycated hemoglobin; CVD, cardiovascular disease; CVD risk, probability of developing cardiovascular disease in next 10 years calculated using Framingham equation; MS, metabolic syndrome. 1 Fisher s exact test. 대사증후군발생관련요인성별과나이의영향을통제한후 [2,5,14] 생활습관요인과공복 C- peptide를후진단계선택 ( 조건 ) 을이용하여로지스틱회귀분석을하였다. 1회음주량이 1병늘어날때대사증후군이발생할승산비는 3.25배 (p = 0.009, 95% 신뢰구간 : ) 이었고공복 C-peptide가 1 ng/ml 증가할때마다대사증후군이발생할승산비는 1.99배 (p = 0.041, 95% 신뢰구간 : ) 이었다. 독립변수의분산팽창요인 ( 모형 1: 1.002, 모형 2: ) 은다중공선성이없다는기준에적합하였다. 회귀모형은유의하였고 (χ 2 = 17.61, p = 0.001), Nagelkerke 결정계수설명력은 26.2% 이었다. 분류정확도는 74.7% 이었으며관측값과예측값에차이가없다는 Hosmer-Lemeshow 모형적합도는적절하였다 (χ 2 =3.69, p = 0.884) (Table 3)

6 Sun-Young Kwon and Hye-Ja Park Table 3. Associated factors of metabolic syndrome and high cardiovascular risk in adults with newly diagnosed type 2 diabetes mellitus (n=99) Variables B SE Wald df p Exp (B) Model 1 Model 2 95% CI 95% CI B SE Wald df p Exp (B) Lower Upper Lower Upper Metabolic syndrome Constant Gender (female) Age ( <40 y) Alcohol consumption (bottle/one time) Fasting C-peptide Omnibus tests of model coefficient χ 2 = 4.64, p = χ 2 = 17.61, p = Log Likelihood Nagelkerke R Hosmer and Lemeshow test χ 2 = 0.01, p = χ 2 = 3.69, p = Framingham CVD risk Constant < Gender (female) < Age ( <40 y) < < Alcohol consumption (bottle/one time) Exercise frequency (wk) Fasting C-peptide Number of metabolic syndrome traits Omnibus tests of model coefficient χ 2 = 30.47, p < χ 2 = 39.26, p < Log Likelihood Nagelkerke R Hosmer and Lemeshow test χ 2 = 0.06, p = χ 2 = 4.18, p = SE, standard errors; df, degree of freedom; EXP, exponentiated coefficients; CI, confidence interval. Metabolic syndrome (Yes); Cardiovascular disease risk ( >20%); Range of number of metabolic syndrome traits=1-5. Logistic regression adjusted by covariates (gender and age)

7 Type 2 Diabetes Mellitus 고위험심혈관질환발생관련요인성별과나이의영향을통제하고 [2,5,14], 1회음주량, 주당운동회수, 공복 C-peptide, 대사증후군항목수의독립변수를후진단계선택 ( 조건 ) 을이용하여로지스틱회귀분석을하였다. 대사증후군항목수가 1 개증가할때 CVD >20% 고위험군에속할승산비는 1.84배 (p = 0.028, 95% 신뢰구간 : ) 이었다. 분산팽창요인 ( 모형 1: 1.000, 모형 2: ) 은다중공선성이없다는기준에적합하였다. 회귀모형은유의하였고 (χ 2 =39.26, p < 0.001), Nagelkerke 결정계수설명력은 43.7% 이었다. 분류정확도는 74.7% 이었으며 Hosmer-Lemeshow 모형적합도는적절하였다 (χ 2 = 4.18, p = 0.840) (Table 3). 고찰 본연구는제2형당뇨병으로새롭게진단받은성인에서대사증후군과고위험심혈관질환발생위험과관련되는요인을탐색하기위해시도되었다. 그결과음주량과공복 C-peptide가높을수록대사증후군발생위험이높았고대사증후군의항목이증가할수록고위험심혈관질환발생이높아지는것을확인하였다. 흡연, 과음, 식습관, 신체활동부족은대사증후군발생과심혈관질환발생위험의 4대생활습관요인으로 [2,4] 본연구대상자의흡연, 음주, 운동수행빈도는 53.5%, 56.6%, 59.6% 이었고섭취에너지는권장량의 % 인 2,153 kcal로자가관리를수행하고있는당뇨병성인의흡연율 27.4% 와고위험음주율 21.9% [1] 섭취에너지 1,887 kcal보다높았다 [16]. 이러한결과는표본크기나조사지역에따른차이를배제할수없으나선행보고에서지적한바와같이 [17] 제2형당뇨병성인에서낮은운동수행과함께높은섭취에너지의문제를보이므로진단시점부터제2형당뇨병성인의식사조절인식과식습관개선및생활습관에대한개별적인목표설정과실천이시급하다. 본연구대상자에서 BMI 25 kg/m 2 에의한비만발생률은 49.5% 로 2014년국민건강영양조사에의한당뇨병환자의 48.6% 와유사하였으나 [1] 당뇨병발병시점에서나타나는체중감소를감안할때 [15] 비만성인은 58.6% 에달하였다. 또한 C-peptide 분비결함없이인슐린저항성을보이는새로운당뇨병성인은 52.5% 로평균 9.6년의질병기간을보이는제2형당뇨병성인 1,601명의 54% 와유사하였다 [15]. 당뇨병성인은비당뇨병성인보다빠르게비만과최대복부비만에도달하므로당뇨병으로진단받은시점부터비만에대한인식을높이고체중감소실천을높이는효과적인교육이병행되어야한다 [18]. 본연구에서대사증후군발생빈도는 65.7% 로혈당장애환자의대사증후군발생률 % 보다높았다 [11]. 음주와신체활동이대사증후군발생위험을높였다는선행보고 [7] 와같이본연구에서대사 증후군이발생한성인은음주량이많았고규칙적인운동수행빈도가낮았다. 불건강한생활습관은하나에국한되는것이아니라여러개의요인이함께대사증후군발생에영향을미치는데 [19] 흡연, 음주, 운동미수행 3가지의불건강한생활습관이동반된경우대사증후군발생과관련되었다. 따라서당뇨병성인에서군집형태로나타나는생활습관평가를근거로통합적인행동변화교육이필요하다 [19]. 본연구에서남성, 정상당뇨병호발나이와흡연이고위험심혈관질환발생과관련되었으나이는프래밍험심혈관질환발생위험이나이와흡연을포함하여점수화하였기때문에나타난결과로생각된다. 그러나당뇨병치료와자가관리를시작하지않은상태인본연구대상자의심혈관질환발생위험 >20% 는 52.5% 로혈당조절이불량한당뇨병성인은 CVD >20% 발생률이더욱높아지므로 [20] 본연구대상자가제2형당뇨병으로진단받은즉시엄격하고집중적인혈당관리를수행하는것이필요하다 [2,4,20]. 본연구에서제2형당뇨병성인의심혈관질환발생위험단계모형을근거로 [4] 대사증후군발생에생활습관요인과비만및공복 C-peptide 가관련되는지와고위험심혈관질환발생에생활습관요인, 비만, 공복 C-peptide 및대사증후군항목수가관련되는지확인하였다. 그결과 1회음주량이 1병늘어날때대사증후군이발생할승산비는 3.25배이었고공복 C-peptide가 1 ng/ml 증가할때마다대사증후군이발생할승산비는 1.99배이었다. Cullmann et al. [21] 의종단적선행연구에서는술의종류에따라잔, 캔, 병단위와도수를기준으로 1일섭취알코올 (g) 로환산한후당뇨병발병위험을보고하였는데본연구에서는대한당뇨병학회의기준에따라술의종류에관계없이 1주일에 2회이상술을마실때음주를하는것으로간주하였다 [1]. 국민건강영양조사자료에의한 2,469명의성인에서흡연과과도한음주가동반될때대사증후군위험은남자에서 1.86배이었고여자에서 4.46배이었다 [19]. 또한음주량이많을수록폭음을할수록제2형당뇨병발병위험은 1.67 배와 1.42배이었고맥주를많이마시는남자의제2형당뇨병발병위험은 2.03배이며남성의양주과음은당뇨병전단계의위험을 2.41배높인다는보고와일치하였다 [21]. 본연구에서공복 C-peptide가새로운당뇨병성인의대사증후군발생과관련됨을확인하였다. 인슐린저항성은인슐린부족보다혈당조절을어렵게하고비만과관련되며혈압과지질조절을방해하므로 [15] 당뇨병진단시점부터비만감소와인슐린저항성을낮출수있는생활습관행동수정이선행되어야함을시사하고있다 [8,15]. 또한본연구에서대사증후군항목수가 1개증가할때 CVD >20% 고위험군에속할승산비는 1.84배이었는데내당능장애가있는성인에서대사증후군항목이 2개이상발생하면심혈관질환발생위험이 배이었고 [9] 대사성증후군이있는성인에서 CVD >20% 고위험프래밍험심혈관질환발생위험은 6.77배이었다는 131

8 Sun-Young Kwon and Hye-Ja Park 보고를근거로 [21] 본연구결과는지지될수있을것이다. 본연구는당뇨병교육간호사가새로운당뇨병성인을직접접촉하고전향적자료를수집하여정확성이높고, 제2형당뇨병으로진단받은시점에서심혈관질환발생위험에영향을미치는요인을통합적으로평가하였다는점에서의의가있다. 임상실무와교육적인측면에서국민건강영양조사대상자에게당뇨병교육을위해접근하는데한계가있는반면, 본연구의결과를당뇨병교육팀과공유하여집중적인체중감소, 운동증진, 적절한식사, 금주, 금연프로그램을재수립하여당뇨병자가관리와생활습관중재를통합한프로그램개발과적용을고려할수있을것이다 [2,19]. 생활습관중재는대상자의특성을고려하여도달목표를설정하고사회적지지와행위변화기술을이용하며, 자기통제의행위변화는건강관리자와의접촉횟수를높일때효과적이므로 [23] 본연구결과는일회성당뇨병교육에국한된건강보건정책의수정과새로운당뇨병교육정책수립근거로활용할수있을것이다. 본연구는 1개대학병원의내분비내과외래에등록된새로운제2 형당뇨병환자를대상으로수행하였으므로연구결과를일반화하는데제한점을보였다. 또한대규모표본에서수행한연구와생활습관발생률이차이를보였으므로다기관으로확대하여표본수를늘린후새로운제2형당뇨병성인을대상으로반복연구를통해확인할필요가있다. 결론 본연구결과제2형당뇨병으로새롭게진단받은성인의과반수이상이흡연과음주, 비만및 C-peptide 분비결함이없었다. 새로운제2형당뇨병성인의 65.7% 가대사증후군을보였고 52.5% 에서심혈관질환발생고위험을보였다. 제2형당뇨병으로새롭게진단받은성인의 1회음주량이 1병증가할수록대사증후군발생할승산비는 3.25배이었고공복 C-peptide가 1 ng/ml 증가할때마다대사증후군이발생할승산비는 1.99배이었으며대사증후군항목수가 1개증가할때 CVD >20% 고위험군에속할승산비는 1.84배이었다. 본연구결과를토대로제2형당뇨병으로새롭게진단받은성인을위한집중적인체중감소, 운동증진, 식사, 금주, 금연프로그램을재수립하여당뇨병자가관리와생활습관중재를통합한프로그램개발과적용의기초자료로활용할수있을것이다. 추후연구에서는표본수를확대하여새로운제2형당뇨병성인의생활습관요인, 인슐린저항성, 대사증후군이심혈관질환발생영향에대한종단적연구와통합적인자가관리프로그램개발및그효과를확인하는연구수행을제언하고자한다. ORCID Sun-Young Kwon Hye-Ja Park REFERENCES 1. Korean Diabetes Association. Diabetes fact sheet in Korea Available at ode=admin&number=1428&mode=view [accessed on July 1, 2018]. 2. Korean Diabetes Association Treatment guidelines for diabetes. Available at guide&mode=list&year_v=2015 [accessed on January 6, 2018]. 3. Wilson PW, D Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97(18): Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation 2008;117(23): Koo BK, Lee CH, Yang BR, Hwang SS, Choi NK. The incidence and prevalence of diabetes mellitus and related atherosclerotic complications in Korea: a national health insurance database study. PLoS One 2014;9(10):e Doi: /journal.pone National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106(25): Tran BT, Jeong BY, Oh JK. The prevalence trend of metabolic syndrome and its components and risk factors in Korean adults: results from the Korean National Health and Nutrition Examination Survey BMC Public Health 2017;17(1):71. Doi: /s Chung JO, Cho DH, Chung DJ, Chung MY. Associations among body mass index, insulin resistance, and pancreatic β-cell function in Korean patients with new-onset type 2 diabetes. Korean J Intern Med 2012; 27(1):66-71 (Korean). Doi: /kjim Wilson PW, Meigs JB. Cardiometabolic risk: a Framingham perspective. Int J Obes 2008;32(Suppl 2):S17-S20. Doi: /ijo Lim S, Choi SH, Kim KM, Choi SI, Chun EJ, Kim MJ, et al. The asso

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DIABETES FACT SHEET IN KOREA 2012 SUMMARY About 3.2 million Korean people (10.1%) aged over 30 years or older had diabetes in 2010. Based on fasting g

DIABETES FACT SHEET IN KOREA 2012 Korean Diabetes Association (KDA) / Korea Centers for Disease Control and Prevention (CDC) DIABETES FACT SHEET IN KOREA 2012 SUMMARY About 3.2 million Korean people (10.1%)