Information Desk J Korean Diabetes 2019;20: Vol.20, No.1, 2019 ISSN 당뇨병환자의음료섭취 심지선 1,2 연세대학교의과

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1 J Korean Diabetes 2019;20:47-52 Vol.20, No.1, 2019 ISSN 심지선 1,2 연세대학교의과대학예방의학교실 1, 연세대학교의과대학심뇌혈관및대사질환원인연구센터 2 Beverage Consumption of Patients with Diabetes Jee-Seon Shim 1,2 1 Department of Preventive Medicine, Yonsei University College of Medicine, 2 Cardiovascular and Metabolic Diseases Etiology Research Center, Yonsei University College of Medicine, Seoul, Korea Abstract Beverage consumption is one of the most habitual dietary behaviors. Beverages such as coffee, tea, and juice are among the most widely and commonly consumed food. Recently, consumption of sugarsweetened beverages has been steadily increasing across the globe. Beverages, particularly sugarsweetened beverages, are the primary source of added sugars and contribute to energy overconsumption. A number of studies have shown positive associations of sugar-sweetened beverage consumption with weight gain, obesity, diabetes, hypertension, and cardiovascular diseases. This review presents consumption of diabetic patients, impact of beverage consumption on metabolic and cardiovascular health, and much healthier beverage choices for diabetic patients. Keywords: Beverages, Diabetes mellitus, Patients 서론 당뇨병환자의식사관리목표는혈당, 혈압, 혈중지질농 도를조절하여합병증을예방하는것이다 [1]. 합병증이동 반되지않은당뇨병식사요법의요지는정상적인활동을하면서적절한체중과바람직한영양상태를유지하는것으로, 특정영양소나식품섭취를제한하지않고일반적인건강한성인을대상으로하는식생활지침 [2] 을따르는한편, Corresponding author: Jee-Seon Shim Department of Preventive Medicine, Yonsei University College of Medicine and Cardiovascular and Metabolic Diseases Etiology Research Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea, shimjs@yuhs.ac Received: Jan. 18, 2019; Accepted: Jan. 23, 2019 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 2019 Korean Diabetes Association The Journal of Korean Diabetes 47

2 혈당조절에직접적인영향을주는당질섭취에주의를기울이는것이중요하다 [1]. 음료섭취는우리의일상에서빈번하게반복되는식행동으로다음과같은맥락에서주의깊은관심이필요하다. 첫째, 비타민과플라보노이드등이일부포함되어있으나음료에함유된영양소는대개단순당에국한된다 (Table 1) [3]. 따라서저혈당이발생했을때급속하게혈당을올리기위한목적으로일정량섭취가권고되지만, 습관적인음료섭취는단순당과에너지섭취과잉으로건강에부정적인영향을미친다 [4-7]. 둘째, 식생활을효율적으로조절하기위해서는드물게발생하는행동보다는규칙적으로빈번하게반복되는문제행동에관심을갖고이를바람직한방향으로조절하는것이효과적인데, 음료섭취는습관적으로반복되는식행동중의하나이다. 2016년국민건강통계 [8] 에의하면우리나라성인 ( 만 19~64 세 ) 의커피ㆍ녹차ㆍ탄산음료ㆍ과일주스등음료섭취빈도 ( 하루 2.0회 ) 는주식인쌀밥ㆍ잡곡밥의빈도 (2.1회) 와비슷한수준이다. 셋째, 개인의음료섭취량이빠르게증가하고있고 [8], 음료시장또한 지속적으로확대추세에있다 [9]. 우리국민 ( 만 1세이상 ) 이음료로섭취한단순당은가공식품을통한섭취량의 40% 에이르는등음료는첨가당섭취의주요급원이다 [9]. 넷째, 같은에너지의고형식품대비액상식품인음료는포만감이적어추가적인식품섭취를야기하고에너지섭취과잉을초래하여비만, 당뇨병, 고혈압및심뇌혈관질환과치아우식등질환발생에부정적인영향을준다 [4-7]. 그러나음료의영양학적질과건강에대한인식은저조하며 [10], 음료는상대적으로값이싸고어디서든지구할수있어서섭취과잉의가능성이높다 [11]. 사실상음료는액상형태의모든식품을통칭하며알코올함유여부에따라알코올성음료와비알코올성음료로세분되지만, 본고에서는비알코올성음료중음용수, 우유를제외한탄산음료, 과일채소주스, 커피, 차등의음료섭취에대한문제를언급하며, 특히당뇨병이있는환자의음료섭취실태와음료섭취시고려해야할사항에대해서기술한다. Table 1. Content of energy and sugars in beverages Types of beverage One serving size Energy Sugars Carbonated beverages Coke 250 ml 95 kcal 23 g Low-calorie coke 250 ml 5 kcal 0 g Fruit and vegetable drinks 200 ml 78 kcal 14 g Isotonic drinks 250 ml 93 kcal 14 g Coffee Tea Instant coffee mix 1 bag = 12 g 51 kcal 6 g Black coffee 200 ml 8 kcal 0 g Green tea 200 ml 2 kcal 0 g Black tea 200 ml 6 kcal 0 g National Institute of Agricultural Sciences, Rural Development Administration (2016). 9 th revision. Korean Food Composition Table. 48

3 심지선 본론 1. 현황우리나라현황에대한연구는없었으나, 우리나라성인의음료섭취빈도는하루평균 2회에이르며 [8], 만 1세이상국민중하루 1회분량 (serving size) 이상의가당음료섭취율는 32.1% 수준이었다 [12]. 미국국민건강영양조사 (2003~2006) 참여자가운데제2 형당뇨병환자를분석한연구에의하면, 당뇨병인지군의음료섭취율은비인지군 (60%) 에비해낮았지만, 혈당조절여부에따른차이 ( 조절군 38%, 비조절군 43%) 는크지않았다 [13]. 저소득라틴계인종을대상으로한다른연구에서는조절되지않은제2형당뇨병환자에서가당음료로인한에너지섭취량이총섭취에너지의 9.6% (~170 kcal) 에달하였다 [14]. 또한뉴질랜드의제2형당뇨병환자 580 명을대상으로한연구 [15] 에서는합병증으로인한투석환자 206명을포함하였는데, 가당음료섭취율은투석여부와무관하였다 ( 투석군 47%, 비투석군 49%). 대개합병증발생으로투석치료를병행하는당뇨병의식사관리는인산, 칼륨, 수분섭취제한이요구되어콜라, 과일주스같은액상식품섭취가보다엄격하게제한되는상황이나, 투석군의음료섭취는관리되지않고있었으며, 투석군과비투석군모두에서하루 4회분량이상의가당음료섭취자또한환자 10명중 1명에이르고있었다. 즉, 제2형당뇨병환자에게가당음료섭취제한은주요한권고사항이지만 [16], 메시지에반응하지않는환자가다수이고, 엄격한제한이요구되는합병증환자에서도음료섭취지침에대한순응도는낮은수준이다. 2. 가건강에미치는영향같은액상식품이라도차, 커피, 탄산음료등각식품이함유한영양소와생리활성물질에따라음료섭취가건강에미치는영향은상이하다. 녹차, 홍차등의차와코코아는심 혈관계질환의발생위험을경감하는것으로보이는데, 이는차와코코아에함유된플라바놀 (flavanol) 이산화질소 (nitric oxide) 합성을촉진하여혈압을낮추고혈관건강과인지기능에긍정적인영향을주기때문인것같다 [17]. 우리나라성인이하루평균 1.6회섭취 [8] 하는커피는섭취직후인슐린민감도가감소되는즉각적인반응이관찰되나, 장기간습관적으로섭취한경우에는제2형당뇨병과간질환의발생위험이감소되는데 [18], 이는커피에포함된카페인 (caffeine), 클로로겐산 (chlorogenic acid), 페놀성화합물 (phenolic compounds), 카페스톨 (cafestol), 카와월 (kahweol) 등이소장내당흡수와당신생합성및글리코겐분해를저해하고, 기초대사율을증진시켜에너지소비량증가등에관여하기때문인것으로보인다 [19]. 그러나식품자체에포함된물질이건강에긍정적인영향을주더라도이에설탕을첨가한음료의영향력은다를수있어일부연구에서는가당음료범주에탄산음료, 과일채소주스, 코코아등의단음료와함께설탕을첨가하여마시는커피와차도포함한다 [7,20]. 선행연구에의하면일반인구집단에서하루가당음료 1회분량이상섭취시당뇨병발생위험은 18~26% [5,21-23], 고혈압 8~12% [4,6,24,25], 허혈성심장질환 16~17% [6,26], 뇌졸중 10% [6], 치아우식ㆍ손실ㆍ충전치아의위험은 31% [7] 높았다. 가당음료섭취의부정적인영향은당뇨병환자에서도여전한데, 미국건강위험요인감시조사 (Behavioral Risk Factor Surveillance System 2012) 에의하면, 가당음료를하루 2번이상섭취한당뇨병환자군은비섭취환자군에비하여치아손실위험이 2.35배높았다 [27]. 가당음료와치아손실의연관성은당뇨병이없는정상군에서도확인되었으나그연관성의크기는환자군에서보다높았으며, 이는당뇨병환자가첨가당섭취증가에더욱민감하게반응할가능성이있기때문인것으로생각된다 [28]. 가당음료는대표적인텅빈칼로리식품 (empty calorie food) 으로에너지섭취과잉을초래하여비만위험을가중시키는데, 이러한영향은당뇨병환자에서도유효하다. 평균유병기간 6.4년에달하는환자군을대상으로한선행연구에의하면, 주 1회분 49

4 량이상가당음료섭취군의복부비만위험은비섭취군대비 4.93배, 주 3회분량이상섭취군은 5.07배에달하는등 [20] 당뇨병환자의가당음료섭취는심뇌대사질환의위험을가중시킨다. 3. 시주의사항가당음료에포함된단순당을인공감미료로대체한다이어트음료는에너지함량이거의 0에가까워에너지섭취경감에따른이점이있을것으로생각된다. 이와함께일부연구에서는다이어트음료섭취로치아우식증감소, 체질량지수감소와같은긍정적인영향이보고된바있다 [29]. 그러나최근연구에서는다이어트음료를섭취하여도제2형당뇨병, 고혈압의발생위험이유의하게높아 [24,30], 다이어트음료섭취가질병예방에크게효과적이지는않은것으로생각된다. 반면, 가당음료대신물을섭취하면에너지섭취감소로비만율도낮아지는데 [31], 비만군에서혈중중성지방농도와대사증후군의유병위험감소가뚜렷하였다 [32]. 이러한경향은다이어트음료를물로대체한경우에도유사했는데, 비만여성을대상으로 6개월간식사후물섭취를지속한군과다이어트음료섭취군의변화를비교한임상시험연구에의하면물섭취군에서체중이더많이감소되었고, 인슐린저항성을포함한전반적인당대사지표가개선되었다 [33]. 또한평소다이어트음료섭취가빈번했던비만한제2형당뇨병환자에서도식후물섭취를시도한군에서 24주후유의한체중감소가확인되었다 [34]. 결론 음료는단순당의주요급원식품으로에너지와단순당의섭취과잉을유도할뿐아니라고형식품대비포만감이적고추가적인식품섭취를초래하여지속적인혈당관리를필요로하는당뇨병환자에게는특별한주의가요구된다. 차와코코아에포함된플라보노이드, 비타민등생리활성 물질은체내긍정적인영향을주지만, 함께섭취하는첨가당은조심해야한다. 가당음료에포함된단순당을인공감미료로대체시킨다이어트음료는에너지함량은낮지만, 질병의발생위험경감에크게효과적이지는않는것으로보인다. 갈증이나거나수분이필요할때는당이첨가된음료보다는물을마시는건강한음료섭취습관에대한교육이중요하겠다. REFERENCES 1. Korean Diabetes Association treatment guidelines for diabetes. Seoul: Korean Diabetes Association; Korean Nutrition Society. Dietary reference intakes for Koreans Seoul: Korean Nutrition Society; National Institute of Agricultural Science. Korean food composition table. 9th revision. Wanju: National Institute of Agricultural Science; Jayalath VH, de Souza RJ, Ha V, Mirrahimi A, Blanco- Mejia S, Di Buono M, Jenkins AL, Leiter LA, Wolever TM, Beyene J, Kendall CW, Jenkins DJ, Sievenpiper JL. Sugar-sweetened beverage consumption and incident hypertension: a systematic review and meta-analysis of prospective cohorts. Am J Clin Nutr 2015;102: Imamura F, O'Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ 2015;351:h Xi B, Huang Y, Reilly KH, Li S, Zheng R, Barrio-Lopez MT, Martinez-Gonzalez MA, Zhou D. Sugar-sweetened beverages and risk of hypertension and CVD: a doseresponse meta-analysis. Br J Nutr 2015;113: Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Suominen AL. Sugar-sweetened beverages and dental 50

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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