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1 Biomedical Science Letters 2017, 23(3): 215~222 eissn : Original Article The Blood Pressure Response during Graded Exercise Test in Obese Adults Kyung-A Shin Department of Clinical Laboratory Science, Shinsung University, Chungnam 31801, Korea Obesity has been directly associated with the development of hypertension and cardiovascular disease. The purpose of this study was to investigate the blood pressure response during graded exercise test in obese adults. 189 subjects (age: 47.96±10.23) were assigned to two groups: non-obese group (N=105, BMI: 22.05±1.57, waist circumference: 76.90±6.17) and obese group (N=84, BMI: 26.96±2.51, waist circumference: 88.29±6.41). The subjects underwent health screening and exercise treadmill test from January 2012 to December Graded exercise test was performed according to the Bruce protocol. Exercise duration (P=0.046) and METs (P=0.015) were significantly lower in obese group than non-obese group. There was no difference in the rate of change in blood pressure response between obese group and non-obese group during exercise, and the recovery rate of systolic blood pressure was delayed in the obese group compared to non-obese group in the first recovery period (P=0.020). The significant factors of increasing rate of change in maximum systolic blood pressure was waist (P=0.046) and hip circumference (P=0.008). In conclusion, these results demonstrate that, for hypertension prevention in obese adults, waist and hip circumference levels should be managed within normal range. Key Words: Blood pressure, Obesity, Graded exercise test 서론체중증가는고혈압및당뇨병등대사이상의발생과직접적인관련이있으며, 뇌졸중, 관상동맥심장질환및동맥경화의위험요인으로인식되고있다 (Kotsis et al., 2010; Bekkers et al., 2012; Landsberg et al., 2013; Brunner et al., 2015; Chen et al., 2015). 체중과안정시혈압간에는밀접한관련이있으며, 체중이증가할수록고혈압유병률은증가하는것으로알려져있다 (Richards et al., 1996; Kotsis et al., 2010). 그기전으로비만은나트륨저류, 인슐린저항성, 심장의형태학적변화및염증반응을유발하여이에따른혈관내피기능의변화로인해고혈압이촉진된다 (Kotsis et al., 2010). 한편, 단계적점증부하운동시혈압상승이클수록고혈압유병률은증가하며 (Lund-Johansen, 2002; Miyai et al., 2002), 안정시혈압보다운동시혈압반응은심장에가해지는부하를반영하므로심혈관사건발생을더잘예측하는지표로보고된바있다 (Filipovský et al., 1992). 또한정상혈압의당뇨환자에서운동에따른혈압반응의증가는표적기관손상지표이며, 고혈압환자에서운동중과도한혈압반응은혈관내피계확장기능의손상에의한것으로보고된다 (Stewart et al., 2004; Ajayi et al., 2010). 혈압은심박출량 (cardiac output, CO) 과총말초저항 (total peripheral resistance, TPR) 의곱으로나타내며, 심박출량은수축기혈압을, 총말초저항은이완기혈압을결정하는주 * Received: April 25, 2017 / Revised: August 9, 2017 / Accepted: August 9, 2017 Corresponding author: Kyung-A Shin. Department of Clinical Laboratory Science, Shinsung University, 1 Daehak-Ro, Dangjin-Si 31801, Korea. Tel: , Fax: , mobitz2@hanmail.net C The Korean Society for Biomedical Laboratory Sciences. All rights reserved. CC 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

2 요인자이다 (Lim et al., 1996). 점증적인운동부하에의해수축기혈압은심박출량증가에비례하여상승하는반면총말초저항의감소와혈관확장으로인해이완기혈압은변화없이일정하게유지된다 (Lim et al., 1996). 비만인의과도한체지방은운동수행에필요한조직및호흡순환계에과부하를주며, 수축기혈압과혈관저항이증가하여폐기능및심박출량을저하시킨다 (Sung et al., 1997; Lazarus et al., 1998; Barone et al., 2009; Ceylan et al., 2009). 또한비만은교감신경계를활성화하여심혈관반응에변화를일으켜운동과같은스트레스로인해지속적인혈관수축반응을유발하는것으로알려져있다 (Jern et al., 1992). 이와같이여러연구에서혈압과비만관련요인간의관련성에대해평가하였으나, 비만과운동시혈압반응을평가한연구는매우제한적이다. 이연구는단계적운동부하검사시운동단계별뿐만아니라운동후회복기동안에정상체중군과비교해비만군의혈압반응을평가하고혈압에영향을미치는요인을확인하여비만인의운동에따른심혈관위험가능성을알아보고자하였다. 재료및방법연구대상자및비만진단본연구의대상자는 2012년 1월부터 2014년 12월까지일개종합병원의건강검진센터를통해운동부하검사를실시한 20세이상 80세이하성인을대상으로하였다. 전체대상자총 196명중고혈압진단을받았거나고혈압약제를복용중인사람과결측치를포함하는 7명을제외한최종연구대상자는 189명이었다. 복용중인약물은자기기입식문진표를통해조사하였으며, 본연구는경기지역종합병원에서기관생명윤리위원회승인을받아시행하였다 (IRB No: D ). 비만진단기준은비만치료지침에따라체질량지수가 25 kg/m 2 이상이거나복부비만기준인허리둘레남성 90 cm 이상, 여성 85 cm 이상일경우비만군 (obese, N=84), 두기준에해당하지않는경우정상체중군 (non-obese, N=105) 으로분류하였다 (Korean Endocrine Society, 2010). 신체계측및운동부하검사 DS-103M (Jenix, Seoul, Korea) 자동신체계측기로신장과체중을측정하였으며, 체질량지수 (body mass index, BMI) 는체중 (kg) 을신장 (meter) 의제곱으로나눈값으로계산하였다. 허리둘레는양발간격을 25~30 cm 정도벌 리고서서체중을균등히분배시키고, 숨을내쉰상태에서최하위갈비뼈하부와골반엉덩뼈능선과의중간부위를측정하였다. 엉덩이둘레는옆에서보았을때엉덩이의가장높은곳을측정하였다. 허리둘레- 엉덩이비 (waist to hip ratio, WHR) 는허리둘레를엉덩이둘레로나누어구하였으며, 허리둘레-키의비 (waist to height ratio, WHtR) 는허리둘레를신장으로나누어구했다. 안정시혈압은 10분이상안정을취한후의자에앉은상태에서수은혈압계로측정하였으며, 10분간격으로 2회측정하여평균값을구하여기록하였다. 운동부하검사는 treadmill (Medtrack ST 55, Quinton Instrument Co., USA) 을이용하여 Bruce 프로토콜에따라시행하였으며, Bruce 프로토콜은 3분간격으로회전속도와경사도를통해부하량에따라단계 (stage) 를증가시키는방법이다. 운동직전과운동중 1분간격으로심전도를기록하였고심박수와혈압은 2분간격으로측정하였으며, 회복기는 1분, 3분, 5분에심전도, 심박수, 혈압을측정하였다. 운동부하검사중심박수측정및심전도측정을위해 12채널 Quinton stress test system (Q4500, Quinton Instrument Co., USA) 을이용하였으며, 최대심박수 (220- 나이 ) 의 85~90% 이상도달할때까지시행하였다. 또한 treadmill의속도와경사도를이용하여대사당량 (metabolic equivalents, METs) 을구하였으며, 구체적인공식은다음과같다. METs = [(Speed 0.1) + (Grade/ Speed) + 3.5] / 3.5이다. 회복기는운동직후 30~40초간경사도 0% 에서속도를 1.3 mph로하여걷고 treadmill이완전히멈춘후침대에누워 5분간회복기반응을확인하였다. 평균동맥압 (mean arterial pressure, MAP) 은혈액을체순환계로밀어내는평균압력으로이완기혈압 + ( 수축기혈압 - 이완기혈압 ) 1/3의공식으로계산하였다. 안정시, 운동부하검사중, 회복기동안의 Delta 심박수, Delta 수축기와이완기혈압, Delta 평균동맥압은운동부하검사전안정시값을 100으로하여운동부하검사시각단계별변화값을백분율로제시하였다. 혈액검사혈액검사는 8시간이상공복상태로위팔정맥 (antecubital vein) 에서채혈하였으며, 총콜레스테롤, HDL (high density lipoprotein)-콜레스테롤, LDL (low density lipoprotein)-콜레스테롤, 중성지방, 공복혈당, 고감도 C-반응단백질 (high sensitivity C-reactive protein, hs-crp), 요산을 TBA-200FR NEO (Toshiba, Tokyo, Japan) 생화학자동분석기로측정하였다. 당화혈색소 (hemoglobin A1c, HbA1c) 는고성능액체

3 크로마토그래피법 (high performance liquid chromatography, HPLC) 의원리로 Variant II (Bio Rad, CA, USA) 장비로측정하였다. 인슐린은전기화학발광면역분석법 (electrochemiluminescence immunoassay, ECLIA) 의원리로 Modular Analytics E170 (Roche, Mannheim, Germany) 장비로검사하였다. 자료처리방법본연구의통계학적분석은 SPSS Windows 21.0 (IBM, Armonk, USA) 통계프로그램을이용하여기술통계치를산출하였다. 비만군과정상체중군간의신체구성및혈액학적변인, 운동부하검사시혈압반응의차이를알아보기위해독립표본 t 검증 (Independent t-test) 을실시하였으 며, 두집단간성별의차이를알아보기위해카이제곱검정 (chi-square test) 을실시하였다. 운동부하검사중최대수축기와이완기혈압의변화율을종속변수로하여영향을미치는위험요인을알아보기위해성별과연령을보정한후중다회귀분석 (multiple regression analysis) 을실시하였으며, 모든통계적유의수준은 P<0.05로설정하였다. 결과비만군과정상체중군간의신체구성및혈액학적특성의차이이연구에참여한대상자를비만군 (Obese) 과정상체중군 (Non-Obese) 으로분류하여집단간신체구성및혈액학 Variable Table 1. The body composition and hematological characteristics of subjects Obese (N=84) Non-obese (N=105) P-value Male (%) * 64 (76.2) 68 (64.8) Age (years) 49.82± ± Height (cm) ± ± Weight (kg) 74.99± ±8.00 <0.001 BMI (kg/m 2 ) 26.96± ±1.57 <0.001 Waist circumference (cm) 88.29± ±6.17 <0.001 Hip circumference (cm) 98.40± ±4.36 <0.001 WHR (cm) 0.93± ±0.06 <0.001 WHtR (cm) 0.53± ±0.03 <0.001 Resting HR (bpm) 64.13± ± Resting SBP (mmhg) ± ±15.28 <0.001 Resting DBP (mmhg) 77.91± ±11.05 <0.001 Total cholesterol (mg/dl) ± ± HDL-cholesterol (mg/dl) 50.03± ± LDL-cholesterol (mg/dl) ± ±27.40 <0.001 Triglyceride (mg/dl) ± ± Fasting glucose (mg/dl) 98.14± ± hs-crp (mg/dl) 0.28± ± HbA1c (%) 5.91± ± Insulin (μu/ml) 8.14± ±2.63 <0.001 Uric acid (mg/dl) 5.79± ± Calculated by Independent t-test. Values are presented as mean ± SD. *; Calculated by χ 2 -test. Data are presented as number (%). Abbreviations: BMI, body mass index; WHR, waist to hip ratio; WHtR, waist to height ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate; HDL, high density lipoprotein; LDL, low density lipoprotein; hs-crp, high sensitivity C-reactive protein; HbA1c, hemoglobin A1c

4 적특성의차이를비교한결과연령은집단간차이가있었으며, 정상체중군보다비만군의연령이높았다 (P= 0.025). 신체구성을측정하는항목중체중, BMI, 허리둘레, 엉덩이둘레, WHR, WHtR 은정상체중군보다비만군에서높게나타났다 ( 각각 P<0.001). 안정시수축기와이완기혈압은정상체중군보다비만군이높았으나 ( 각각 P< 0.001), 심박수는집단간차이가없었다. 혈액학적변인중총콜레스테롤 (P=0.002), LDL-콜레스테롤 (P<0.001), 인슐린 (P<0.001), 요산 (P=0.007) 은정상체중군보다비만군에서통계적으로유의하게높았다. 그러나중성지방, 공복혈당, hs-crp, HbA1c는정상체중군에비해비만군에서높은경향을보였으나통계적유의성은없었으며, HDL- 콜레스테롤은정상체중군보다비만군에서낮은경향을 보였으나통계적유의성은없었다 (Table 1). 비만군과정상체중군간의운동부하검사중운동능력및심혈관반응의차이정상체중군과비만군의운동부하검사중심혈관반응의차이를비교한결과운동능력을나타내는운동지속시간 (P=0.046) 과 METs (P=0.015) 는정상체중군보다비만군이유의하게낮았다. 운동부하검사전누운상태의수축기혈압 (P=0.040) 및이완기혈압 (P=0.042), 평균동맥압 (P=0.029) 은정상체중군보다비만군에서유의하게높았으나, 누운상태의심박수는차이가없었다. 운동부하검사전상태를기준으로운동부하검사 1단계의심박수, 수축기와이완기혈압, 평균동맥압의변화율은정상체중군과 Variable Table 2. Comparison of the cardiovascular response during graded exercise test by obese and non-obese Obese (N=84) Non-obese (N=105) P-value Exercise duration (min) 9.34± ± Exercise capacity (METs) 11.16± ± Supine HR (bpm) 61.94± ± Supine SBP (mmhg) ± ± Supine DBP (mmhg) 77.53± ± Supine MAP (mmhg) 92.57± ± Δ stage 1 HR (%) ± ± Δ stage 1 SBP (%) ± ± Δ stage 1 DBP (%) ± ± Δ stage 1 MAP (%) ± ± Δ stage 2 HR (%) ± ± Δ stage 2 SBP (%) ± ± Δ stage 2 DBP (%) ± ± Δ stage 2 MAP (%) ± ± Δ stage 3 HR (%) ± ± Δ stage 3 SBP (%) ± ± Δ stage 3 DBP (%) ± ± Δ stage 3 MAP (%) ± ± Δ maximum HR (%) ± ± Δ maximum SBP (%) ± ± Δ maximum DBP (%) ± ± Δ maximum MAP (%) ± ± Calculated by Independent t-test. Values are presented as mean ± SD. Abbreviations: METs, metabolic equivalents; HR, heart rate; SBP, systolic blood pressure; DBP, diastolic blood pressure; MAP, mean atrial pressure; Δ, change values

5 Table 3. Comparison of the cardiovascular response during graded exercise test recovery by obese and non-obese Variable Obese (N=84) Non-obese (N=105) P-value Δ recovery 1 min HR (%) ± ± Δ recovery 1 min SBP (%) ± ± Δ recovery 1 min DBP (%) ± ± Δ recovery 1 min MAP (%) ± ± Δ recovery 3 min HR (%) ± ± Δ recovery 3 min SBP (%) ± ± Δ recovery 3 min DBP (%) ± ± Δ recovery 3 min MAP (%) ± ± Δ recovery 5 min HR (%) ± ± Δ recovery 5 min SBP (%) ± ± Δ recovery 5 min DBP (%) ± ± Δ recovery 5 min MAP (%) ± ± Calculated by Independent t-test. Values are presented as mean ± SD. Abbreviations: HR, heart rate; SBP, systolic blood pressure; DBP, diastolic blood pressure; MAP, mean atrial pressure; Δ, change values. 비만군간의차이가없었다. 운동부하검사 2단계에서심박수, 수축기와이완기혈압, 평균동맥압의변화율의집단간차이가없었으며, 운동부하검사 3단계에서의심박수, 수축기와이완기혈압, 평균동맥압의변화율에는집단간차이가없었다. 또한최대운동부하검사시심박수, 수축기와이완기혈압, 평균동맥압의변화율은정상체중군과비만군간에차이가없었다 (Table 2). 최대수축기와이완기혈압변화율에영향을미치는위험요인연령과성별을보정한후최대수축기와이완기혈압의변화율에영향을미치는위험요인을확인한결과허리둘레 (P=0.046) 와엉덩이둘레 (P=0.008) 는최대수축기혈압변화율에영향을미치는위험요인으로나타났다 (Table 4). 비만군과정상체중군간의운동부하검사회복기동안심혈관반응의차이 고 찰 운동부하검사회복기동안의집단간심혈관반응의차이를비교한결과운동부하검사후회복기 1분대의심박수, 이완기혈압, 평균동맥압의변화율은정상체중군과비만군간에차이가없었으나, 수축기혈압의변화율은정상체중군보다비만군에서크게나타났다 (P=0.020). 운동부하검사후회복기 3분대의심박수, 수축기와이완기혈압, 평균동맥압의변화율은집단간차이가없었다. 또한회복기 5분대의심박수, 수축기와이완기혈압, 평균동맥압의변화율은집단간차이가없는것으로나타났다 (Table 3). 비만은잠재적으로교정가능한심혈관질환의중요한결정인자로체중조절을통한비만관리에관심이고조되고있다 (Brunner et al., 2015). 여러연구에서혈압과비만지표간의연관성을평가하였으나 (Kotsis et al., 2010; Landsberg et al., 2013), 비만과운동시혈압반응을평가한연구는매우제한적이다. 이연구는성인비만인을대상으로단계적운동부하검사시나타나는혈압반응을평가하고자하였다. 그결과비만군은짧은운동시간과낮은운동능력에도불구하고운동단계별혈압반응변화율은정상체중군과차이가없었으며, 비만군에서회복기 1분대에수축기혈압회복율이더디게나타났다. 또한허리둘레와엉덩이둘레는운동부하검사시최대수축기혈압상승률에영향을미치는요인으로나타났다

6 Table 4. Association between systolic/diastolic blood pressure and the cardiovascular risk factors in non-obese group Variable Δ maximum SBP (%) Δ maximum DBP (%) β SE P VIF β SE P VIF BMI (kg/m 2 ) Waist circumference (cm) Hip circumference (cm) Triglyceride (mg/dl) HDL-cholesterol (mg/dl) LDL-cholesterol (mg/dl) Fasting glucose (mg/dl) F=4.478 **, R 2 =0.166, Adj R 2 =0.147 F=4.101 **, R 2 =0.170, Adj R 2 =0.131 Calculated by multivariable linear regression analysis adjusted for age and gender. **; P<0.01. Abbreviations: Δ, change values; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; HDL, high density lipoprotein; LDL, low density lipoprotein. 비만은고혈압, 당뇨병, 고지혈증과인슐린저항성및동맥경화의위험을증가시켜심혈관질환이환율에영향을미치며, 이와관련된질환에의한사망률을증가시키는것으로보고된다 (Kim et al., 2005; Park et al., 2005; Després et al., 2008). 체중과안정시혈압간에관련이있으며, 체중증가에비례하여고혈압유병률이증가하는것으로알려져있다 (Richards et al., 1996; Kotsis et al., 2010). 그기전으로비만에의한내분비계의대사조절장애, 교감신경계활성에의한혈관수축반응, 좌심실질량증가및좌심실비대와같은심장구조의변형으로인한혈역학적변화에기인하는것으로알려진다 (Jern et al., 1992; Choi et al., 2010; Dibeklioglu et al., 2017). 고혈압에대한선행연구들은대부분안정시혈압을기준으로평가되었으며, 이는운동시심장에가해지는부하에의한혈압변화를충분히반영할수없었다 (Kim et al., 2001). 또한안정시수축기혈압상승보다운동시수축기혈압의상승정도가심혈관계질환의강력한위험인자이며 (Filipovský et al., 1992), 안정시혈압이정상이더라도운동시수축기혈압의상승폭이클수록향후안정시에도고혈압으로이환될가능성이높음을알수있다 (Weiss et al., 2010). 본연구결과에서비만군은운동부하검사를일찍중단하여짧은운동시간과낮은운동능력에도불구하고정상체중군과비교해운동단계별혈압반응의변화율에는차이가없었다. 이는비만군에서혈압이더상승할조건을갖췄음에도불구하고운동능력이낮았기때문에운동단계별혈압반응변화율에차이가없었던것으로생각되며, 동일한체력이라면혈압반응에차이가있을것으로예상된다. 비만은나트륨저류, 인슐린저항성및염증반응과관련이있어혈관내피기능의변화로고혈압을촉진시킬수있다 (Kotsis et al., 2010). 본연구결과를통해정상체중군과비교해비만군에서짧은운동시간에도동일한혈압상승률을보이는것을확인하였으며, 정상체중군보다비만군에서회복기 1분대의수축기혈압이더디게회복되는반응을보였다. 운동후회복기동안수축기혈압의회복이지연되는반응은관상동맥질환의가능성을높인다고알려져있어비만군에서안정시혈압뿐만아니라운동중또는회복기동안주기적으로혈압을측정하는것이요구된다 (McHam et al., 1999). 운동부하검사중나타나는높은혈압반응은혈관벽의저항을증가시킴으로혈관내피세포의손상을유발하며, 심근의산소소모량및혈관벽두께의증가를통해동맥경화를촉진시켜심혈관질환을유도한다고보고된다 (Allison et al., 1999). 체중감소는인슐린민감성과그에따른교감신경계의적절한조절, 순환혈액량감소로인한심박출량감소, 혈중전해질변화에따른혈관저항감소기전에의해혈압의감소가나타난다 (Reisin, 1997; Stone and Kushner, 2000). 비만인이라할지라도모두고혈압으로이환되지는않지만, 체중과체지방량은혈압증가와높은상관관계를보인다 (Becker Mde et al., 2007). Kim (2011) 은 BMI가증가함에따라혈압이상승하며, BMI, 체지방률, WHR과같은비만지표중혈압과높은상관성을보이는지표는 BMI라보고하였다. 또한복부비만과고혈압및

7 당뇨병발병은관련이있으며, WHR과 BMI는운동중수축기혈압과상관성을보인다고보고된다 (Folsom et al., 1990; Kim, 2006). 본연구에서허리둘레와엉덩이둘레가운동부하검사시최대수축기혈압상승률에영향을미치는위험요인으로나타나비만지표가혈압상승과관련이있다는선행연구와유사한결과를보였으며, 비만지표를개선하여심혈관계질환의발병위험을낮추려는시도가이루어져야할것이다 (Adams et al., 2006). 또한비만인에서운동부하검사를통해사전에혈압상승반응및심혈관변화를관찰함으로써운동중나타날수있는심혈관계위험을미리예측하는것이필요하리라생각된다 (Kim, 2006). 본연구는비만에영향을미치는식이요법, 신체활동수준과흡연여부에대한정보가배제되었다는제한점이있다. 또한일개종합병원에서건강검진을시행한성인을대상으로하였으므로결과를다른대상자에게확대해석하는데제한이있으며, 후향적연구로결과의인과관계를밝힐수없었다. 향후임상경과를비교하여비만군에서고혈압으로발전할가능성에대한연구와체중조절에의해운동부하검사시혈압반응에어떠한변화가나타나는지에대한전향적연구가요구된다. CONFLICT OF INTEREST The authors have no conflicts of interest to disclose. REFERENCES Adams KF, Schatzkin A, Harris TB, Kipnis V, Mouw T, Ballard- Barbash R, Hollenbeck A, Leitzmann MF. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. New England Journal of Medicine : Ajayi EA, Balogun MO, Akintomide OA, Adebayo RA, Ajayi OE, Ikem RT, Ogunyemi SA, Oyedeji AT. Blood pressure response to an exercise treadmill test, and echocardiographic left ventricular geometry in Nigerian normotensive diabetics. Cardiovascular Journal of South Africa : Allison TG, Cordeiro MA, Miller TD, Daida H, Squires RW, Gau GT. Prognostic significance of exercise-induced systemic hypertension in healthy subjects. American Journal of Cardiology : Barone BB, Wang NY, Bacher AC, Stewart KJ. Decreased exercise blood pressure in older adults after exercise training: contri- butions of increased fitness and decreased fatness. British Journal of Sports Medicine : Becker Mde M, Barbosa e Silva O, Moreira IE, Victor EG. Arterial blood pressure in adolescents during exercise stress testing. Arquivos Brasileiros de Cardiologia : Bekkers MB, Brunekreef B, Koppelman GH, Kerkhof M, de Jongste JC, Smit HA, Wijga AH. BMI and waist circumference; cross-sectional and prospective associations with blood pressure and cholesterol in 12-year-olds. Public Library of Science One : e Brunner EJ, Shipley MJ, Ahmadi-Abhari S, Tabak AG, McEniery CM, Wilkinson IB, Marmot MG, Singh-Manoux A, Kivimaki M. Adiposity, obesity, and arterial aging: longitudinal study of aortic stiffness in the Whitehall II cohort. Hypertension : Ceylan E, Cömlekçi A, Akkoçlu A, Ceylan C, Itil O, Ergör G, Yeşil S. The effects of body fat distribution on pulmonary function tests in the overweight and obese. Southern Medical Journal : Chen X, Du H, Zhang J, Chen X, Luo G, Que X, Zhang N, Bian Z, Guo Y, Li L, Chen Z, Wu X. Adiposity and blood pressure among relatively lean rural adults in southwest of China. Journal of Human Hypertension : Choi HM, Chun JM, Park CH, Yoo H, Nho HS, Kim JK. The cardiovascular response in exercise intensity with obese middle aged women. The Korean Journal of Growth and Development : Després JP, Lemieux I, Bergeron J, Pibarot P, Mathieu P, Larose E, Rodés-Cabau J, Bertrand OF, Poirier P. Abdominal obesity and the metabolic syndrome: contribution to global cardiometabolic risk. Arteriosclerosis, Thrombosis, and Vascular Biology : Dibeklioglu SE, Çevik BŞ, Acar B, Özçakar ZB, Uncu N, Kara N, Çaycı Ş, Çakar N. The association between obesity, hypertension and left ventricular mass in adolescents. Journal of Pediatric Endocrinology and Metabolism : Filipovský J, Ducimetière P, Safar ME. Prognostic significance of exercise blood pressure and heart rate in middle-aged men. Hypertension : Folsom AR, Prineas RJ, Kaye SA, Munger RG. Incidence of hypertension and stroke in relation to body fat distribution and other risk factors in older women. Stroke : Jern S, Bergbrant A, Björntorp P, Hansson L. Relation of central hemodynamics to obesity and body fat distribution. Hypertension :

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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%)