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1 만성폐쇄성폐질환환자에서열량섭취와폐기능지표와의상관관계 1 분당서울대학교병원폐센터, 서울대학교의과대학내과학교실및폐연구소, 2 분당서울대학교병원영양과, 3 경희대학교동서의학대학원의학영양학과윤호일 1, 박영미 2, 조여원 3, 강영애 1, 권성연 1, 이재호 1, 이춘택 1 Correlation between Caloric Intake and Lung Function Parameters in Patients with Chronic Obstructive Pulmonary Disease Ho Il Yoon, M.D. 1, Young Mi Park 2, Ryowon Choue 3, Yeong Ae Kang, M.D. 1, Sung Youn Kwon, M.D., Ph.D. 1, Jae Ho Lee, M.D., Ph.D. 1, Choon-Taek Lee, M.D., Ph.D. 1 1 Medicine and Respiratory Center, Seoul National University Bundang Hospital, Department of Internal Medicine, Seoul National University College of Medicine, Lung Institute of Seoul National University Medical Research Center, 2 Department of Nutrition, Seoul National University Bundang Hospital, 3 Department of Medical Nutrition, Graduate School of East-West Medical Science, Research Institute of Clinical Nutrition, Kyung Hee University, Seoul, Korea Background: There are reports that food deprivation causes emphysematous changes in the lungs of rats and humans. However, the meaning of this phenomenon in patients with chronic obstructive pulmonary disease has not been evaluated. The aim of this study was to determine the correlations between the caloric intake and parameters of the lung function in patients with chronic obstructive pulmonary disease. Methods: Patients with chronic obstructive pulmonary disease who had visited the respiratory clinic from March, 2006 for one year were enrolled in this study. The patients underwent pulmonary function tests, and a dietitian evaluated their nutritional intake using a food record method. Results: There was no correlation between the total caloric intake and forced vital capacity (FVC, %predicted) or forced expiratory volume in one second (FEV 1, %predicted). The total caloric intake showed a positive correlation with the diffusing capacity of carbon monoxide (DLCO %predicted, DLCO/VA %predicted), and a negative correlation with the total lung capacity (TLC, %predicted). Of the calories taken, only calories from protein intake correlated with the diffusing capacity of carbon monoxide (DLCO %predicted, DLCO/VA %predicted). Conclusion: The total caloric intake of patients with chronic obstructive pulmonary disease showed a positive correlation with the diffusing capacity of the lung, and a negative correlation with the total lung capacity. Further study on the linkage between the caloric intake and severity of emphysema is needed. (Tuberc Respir Dis 2008;65: ) Key Words: Chronic obstructive pulmonary disease, Nutrition, Emphysema, Energy intake, Lung function 서 론 This study was supported by a grant from the Korea Healthcare technology R&D Project, Ministry for Health, Welfare and Family Affairs, Republic of Korea. (A040153) Address for correspondence: Ho Il Yoon, M.D. Medicine and Respiratory Center, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam , Korea Phone: , Fax: dextro@snu.ac.kr Received: Aug. 8, 2008 Accepted: Oct. 6, 2008 만성폐쇄성폐질환은흡연이나대기오염등의외부인자에대한비정상적인기도의염증반응으로완전히가역적이지않은기도폐쇄를특징으로하는질환이다. 흡연에의한산화손상과기도염증이중요한기전으로알려져있지만아직도병태생리가명확하게밝혀지지는않았다. 과거에는기관지및폐에국한된단일장기의질환으로생각되었으나최근관련지식의증가로전신적인변화를동반하는전신질환으로이해되고있다 1-4. 이러한전신적인변화들로는심혈관계질환의증가, 골다공증, 빈혈, 근육의 385

2 HI Yoon et al: Caloric intake and lung function in COPD patients 변화와더불어저체중등의영양학적변화가있으며낮은체질량지수는만성폐쇄성폐질환의불량한예후와관련되어있는것으로알려져있다 세계 2차대전당시포로수용소에서아사한시체들을대상으로한부검연구에서젊은나이에도불구하고폐기종성변화가관찰되었음이보고된이래로영양섭취량와폐기종간의관계가관심의대상이되었다 11. 생쥐를대상으로한실험연구에서음식공급을줄이면쥐들의폐에 surfactant 의양이감소하고폐기종과유사한변화가유발되며이러한변화는음식공급량을늘이는것에의하여회복됨이증명된바있다 실제로거식증환자들을대상으로흉부전산화단층촬영을시행하였을때역시폐기종과유사한변화가관찰됨이여러차례보고되었다 하지만실제만성폐쇄성폐질환환자에서영양분의섭취량이질환에미치는영향은연구된바가없다. 저자들은본연구에서영양의섭취와폐기능지표와의상관관계를규명함으로써영양의섭취가질환에미치는영향을알아보고자하였다. 대상및방법 초로영양평가프로그램 CAN Pro version 3.0 (Computer aided nutritional analysis program, 한국영양학회, 2005) 를이용하여 1일영양소섭취량을분석하였다. 통계분석은 SPSS 15.0을이용하였으며변수간의상관관계는 Pearson 상관계수를구해분석하였으며 p<0.05 를기준으로통계적유의성을판단하였다. 본연구는분당서울대학교병원윤리위원회의심의를통과하였으며모든대상환자에게충분한설명후동의서를취득하였다. 결과분석의대상이된환자들은모두 44명이었다. 남자가그중 40명을차지했으며, 평균연령은 68.7±8.7세였다. 대상자들의평균 1초간노력호기량 (FEV 1 % 예측치 ) 은 64.7 ±21.1% 로 GOLD 병기를적용하면병기 I 혹은 II에속하는환자들이 71% 로대부분을차지하였다 (Table 1). 일당섭취열량의평균은 1,588±455.9 Kcal였으며열량의성분별구성은 Table 2와같았다. 총섭취열량과폐기능지표들간의상관관계를살펴보았을때 FEV 1 (% 예측치 ) (r=0.22, p=0.13), FVC (% 예측 본연구는 2006년 3월부터 2007년 2월까지 1년동안분당서울대학교병원에내원한만성폐쇄성폐질환환자를대상으로하였다. 연구의대상이되는모든환자에서폐활량검사, 폐확산능검사, 폐용적검사및식이섭취조사를시행하였다. 만성폐쇄성폐질환의진단은 GOLD지침을따라기관지확장제흡입후 FEV 1 /FVC 의비가 0.7 미만인환자로하였으며이전에천식으로진단받았거나, 흉부단순방사선소견상만성적인기도폐쇄를유발할만한다른폐질환이있는경우는배제하였다 21. 최근 8주간악화를경험한환자도배제제외하였다. 폐기능검사는폐활량측정기 (Vmax22, SensorMedics, Yorba Linda, CA, USA) 를이용하였으며방법은미국흉부학회의지침을준수하였다 22. 예측치의추정은모리스의예측식을사용하였다 23. 대상자들의영양소섭취상태평가는한명의영양사에의하여이루어졌다. 식품기록법 (food record) 을이용하였으며 3일간의식품섭취상태를조사하였다. 식사일기기록에앞서식사일기작성법을교육하였고일대일면접으로눈대중량과실제섭취량을비교하였다. 조사한자료를기 Table 1. Characteristics of subjects Total number of subjects Sex ratio (M:F) Age (years, mean±sd) FVC (% predicted) FEV 1 (% predicted) GOLD stage I GOLD stage II GOLD stage III GOLD stage IV DLCO (% predicted) DLCO/VA (% predicted) TLC (% predicted) Values are mean±standard deviation. Table 2. Evaluated caloric intake Total caloric intake Intake of calories from protein Intake of calories from carbohydrate Intake of calories from lipid Values are mean±standard deviation :4 (10:1) 68.7± ±18.1% 64.7±21.1% 14 (32%) 17 (39%) 11 (25%) 2 (5%) 81.8±17.3 % 82.2±20.3 % 117.6±12.0 % 1,588.0±455.9 (Kcal/day) 66.2±23.0 (Kcal/day) 237.5±64.8 (Kcal/day) 36.6±15.0 (Kcal/day) 386

3 Tuberculosis and Respiratory Diseases Vol. 65. No. 5, Nov 치 ) (r=0.02, p=0.88) 와는아무런상관관계를찾을수없었다. 반면폐확산능의지표인 DLCO (% 예측치 ) (r=0.37, p=0.02), DLCO/V A (% 예측치 ) (r=0.38, p=0.01) 와는양의상관관계를, 총폐용적 (total lung capacity, TLC % 예측치 ) 과는음의상관관계 (r= 0.34, p=0.04) 를보임을관찰할수있었다 (Figure 1). 총섭취열량과통계적으로의미있는상관관계를보였던폐기능지표들을대상으로성분별열량섭취와의상관관계를분석해보았을때섭취한열량중단백질섭취열량과 DLCO (% 예측치 ) (r=0.27, p=0.04), DLCO/V A (% 예측치 ) (r=0.38, p=0.01) 은통계적으로의미있는상관관계를보였다. 그러나탄수화물및지방섭취에의한 Figure 1. Correlation between total caloric intake and parameters of pulmonary function. r: Pearson s correlation coefficient. 387

4 HI Yoon et al: Caloric intake and lung function in COPD patients 열량은어떤폐기능지표와도의미있는상관관계를보이지않았다. 고찰본연구에서저자들은총칼로리섭취, 그중에서도단백질섭취에의한칼로리의섭취가만성페쇄성폐질환환자들의 1초간노력호기량과는관계없이폐확산능이나폐용적과관련되어있음을확인하였다. 이같은결과는칼로리의섭취양이폐기종의변화와관련되어있을가능성을제시한다. 만성폐쇄성폐질환환자에서여러가지영양학적인문제가동반되어있고그러한영양학적문제가질환의중등도나예후와관련되어있다는연구는많이발표된바있다. 그러나대부분영양분의섭취자체보다는체질량지표등의영양학적지표들을이용한연구가대부분이다 24,25. 하지만식이섭취가폐기능에영향을준다는연구결과도많은데예를들면가공육을즐겨먹을수록폐기능이감소한다는결과나항산화비타민이나비타민 D의혈중농도가폐기능과관련되어있다는연구등이있다 이같은연구에서보듯이만성폐쇄성폐질환환자의식이섭취가질병의중등도나유형과관련되어있을가능성은다분하다. 본연구는만성폐쇄성폐질환환자의기능적지표인폐기능과영양학적지표가아닌섭취자체-섭취된칼로리- 와의상관관계를분석한연구라는데그의의가있다고하겠다. 본연구의제한점으로는전산화단층촬영등의영상검사를분석하지못해과연확산능이나총폐용적이폐기종성변화와관련되어있는지를규명하지못하였다는점과상관관계만을분석하였기때문에원인과결과를규명할수없다는점, 대상자수가적어개별영양소와폐기능지표와의상관관계는규명할수없다는점등이있다. 본연구에서사용한영양소의섭취량평가가지난 3일간 ( 주중 2일, 주말 1일 ) 의섭취량에대한회상을기반으로하여이루어졌으므로과연장기적인섭취량을반영할것인지의문제가있고이는이연구의또다른제한점으로생각된다. 그러나현실적으로오래전의섭취량을기억한다는것이불가능하여장기간의섭취량조사는신뢰도가떨어지는문제가존재한다. 그럼에도불구하고이전의연구결과에서만성폐쇄성폐질환이없는사람에서도음식의섭취량과폐기종성변화가관련되었을가능성이제시된바있으므로본연구의 상관관계가실제로섭취열량과폐기능지표와관련되어있을가능성이있다. 앞으로추가연구를통해과연만성폐쇄성폐질환환자에서섭취열량이폐기종성변화와관련되어있는지, 그렇다면어떤기전에의한것인지가밝혀져야할것으로기대된다. 요 연구배경 : 이전의연구에서섭취의제한은폐기종과유사한변화를유발할수있음이알려져왔다. 그러나이러한현상이만성폐쇄성폐질환환자에서갖는의미는밝혀진적이없다. 저자들은만성폐쇄성폐질환환자에서영양섭취량과폐기능지표와의상관관계를알아보고자본연구를수행하였다. 방법 : 분당서울대학교병원에서 2006년 3월부터 1년동안진료받은만성폐쇄성폐질환환자들을대상으로하였으며폐활량검사, 확산능검사, 폐용적검사와함께영양섭취상태평가를시행한후분석하였다. 결과 : 총섭취열량과 1초간노력호기량이나최대노력호기량 (% 예측치 ) 과는아무런상관관계를찾을수없었다. 반면폐확산능의지표인 DLCO (% 예측치 ), DLCO/VA (% 예측치 ) 와는양의상관관계를, 총폐용량 (% 예측치 ) 과는음의상관관계를보임을관찰할수있었다. 섭취한열량중단백질섭취열량과폐확산능 DLCO (% 예측치 ), DLCO/VA (% 예측치 ) 은통계적으로의미있는상관관계를보였다. 그러나탄수화물및지방섭취에의한열량과폐기능지표는의미있는상관관계를보이지않았다. 결론 : 만성폐쇄성폐질환환자의하루섭취열량은그환자의폐확산능과는양의상관관계, 총폐용량과는음의상관관계에있어섭취열량과폐기종의관련성에대한추가연구가필요하다. 약 참고문헌 1. Walter RE, Wilk JB, Larson MG, Vasan RS, Keaney JF Jr, Lipinska I, et al. Systemic inflammation and COPD: the Framingham Heart Study. Chest 2008;133: Agusti A. Systemic effects of COPD: just the tip of the Iceberg. COPD 2008;5: Hoeper MM, Welte T. Systemic inflammation, COPD, and pulmonary hypertension. Chest 2007;131: Fabbri LM, Rabe KF. From COPD to chronic systemic 388

5 Tuberculosis and Respiratory Diseases Vol. 65. No. 5, Nov inflammatory syndrome? Lancet 2007;370: Ohara T, Hirai T, Muro S, Haruna A, Terada K, Kinose D, et al. Relationship between pulmonary emphysema and osteoporosis assessed by CT in patients with COPD. Chest 2008;0:chest v Cote CG, Pinto-Plata VM, Marin JM, Nekach H, Dordelly LJ, Celli BR. The modified BODE index: validation with mortality in COPD. Eur Respir J 2008;32: Sin DD, Man SF. Skeletal muscle weakness, reduced exercise tolerance, and COPD: is systemic inflammation the missing link? Thorax 2006;61: Mascitelli L, Pezzetta F. Anemia and COPD. Chest 2005;128: John M, Hoernig S, Doehner W, Okonko DD, Witt C, Anker SD. Anemia and inflammation in COPD. Chest 2005;127: Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350: Stein J, Fenigstein H. Pathological anatomy of hunger disease. In: Winick M, editor. Hunger disease: studies by the Jewish physicians in the Warsaw Ghetto: current concepts in nutrition. New York: Wiley & Sons; Sahebjami H, MacGee J. Effects of starvation on lung mechanics and biochemistry in young and old rats. J Appl Physiol 1985;58: Kerr JS, Riley DJ, Lanza-Jacoby S, Berg RA, Spilker HC, Yu SY, et al. Nutritional emphysema in the rat: influence of protein depletion and impaired lung growth. Am Rev Respir Dis 1985;131: Dauber JH, Claypool WD. The role of nutrition in the pathogenesis of emphysema. Surv Synth Pathol Res 1984;3: D'Amours R, Clerch L, Massaro D. Food deprivation and surfactant in adult rats. J Appl Physiol 1983;55: Sahebjami H, Vassallo CL. Influence of starvation on enzyme-induced emphysema. J Appl Physiol 1980;48: Gail DB, Massaro GD, Massaro D. Influence of fasting on the lung. J Appl Physiol 1977;42: Stanescu D, Pieters T. Anorexia nervosa and emphysema. Am J Respir Crit Care Med 2005;172: Coxson HO, Chan IH, Mayo JR, Hlynsky J, Nakano Y, Birmingham CL. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med 2004;170: Wilson NL, Wilson RH, Farber SM. Nutrition in pulmonary emphysema. J Am Diet Assoc 1964;45: Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007;176: Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of spirometry. Eur Respir J 2005;26: Morris JF, Koski A, Johnson LC. Spirometric standards for healthy nonsmoking adults. Am Rev Respir Dis 1971;103: Harik-Khan RI, Fleg JL, Wise RA. Body mass index and the risk of COPD. Chest 2002;121: Wouters EF. Nutrition and metabolism in COPD. Chest 2000;117:274S-80S. 26. Siedlinski M, Postma DS, van Diemen CC, Blokstra A, Smit HA, Boezen HM. Lung function loss, smoking, vitamin C intake, and polymorphisms of the glutamate-cysteine ligase genes. Am J Respir Crit Care Med 2008;178: Jiang R, Paik DC, Hankinson JL, Barr RG. Cured meat consumption, lung function, and chronic obstructive pulmonary disease among United States adults. Am J Respir Crit Care Med 2007;175: Pearson P, Britton J, McKeever T, Lewis SA, Weiss S, Pavord I, et al. Lung function and blood levels of copper, selenium, vitamin C and vitamin E in the general population. Eur J Clin Nutr 2005;59: Mannino DM, Holguin F, Greves HM, Savage-Brown A, Stock AL, Jones RL. Urinary cadmium levels predict lower lung function in current and former smokers: data from the Third National Health and Nutrition Examination Survey. Thorax 2004;59: Gilliland FD, Berhane KT, Li YF, Gauderman WJ, McConnell R, Peters J. Children's lung function and antioxidant vitamin, fruit, juice, and vegetable intake. Am J Epidemiol 2003;158: Britton JR, Pavord ID, Richards KA, Knox AJ, Wisniewski AF, Lewis SA, et al. Dietary antioxidant vitamin intake and lung function in the general population. Am J Respir Crit Care Med 1995;151:

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서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of