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1 고중성지방혈증이동반된당뇨병환자의 식사관리 (Nutrition, Hypertriglyceridemia, and diabetes What is the right advice?) 강북삼성병원당뇨전문센터영양사최진선

2 중성지방과당뇨병 Clin Epidemiol. 2012;4:213-24

3 Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction N Engl J Med Jul 23;339(4):229-34

4 당뇨병환자의고중성지방혈증치료 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels ( 150 mg/dl [1.7 mmol/l]) and/or low HDL cholesterol (<40 mg/dl [1.0 mmol/l] for men, <50 mg/dl [1.3 mmol/l] for women). C

5 고중성지방혈증과당뇨병 활동량부족 인슐린저항성 알코올섭취과다 고중성지방혈증 & 당뇨병

6 고중성지방혈증및당뇨병관리를위한관리 체중조절 활동량증가 식생활개선 알코올섭취조절

7 고중성지방혈증및당뇨병환자의식사 식이요인 식사패턴 - Low carbohydrate diet - Mediterranean diet 음주 (Alcohol consumption) 식물성스테롤 ()

8 Dietary pattern Carbohydrate Effects of High vs Low Glycemic Index of Dietary Carbohydrate on Cardiovascular Disease Risk Factors and Insulin Sensitivity The OmniCarb Click to edit Randomized Master subtitle Clinical style Trial JAMA Dec 17;312(23):

9 Dietary pattern Carbohydrate Low glycemic index diets and blood lipids: A systematic review and meta-analysis or randomized controlled trials Nutr Metab Cardiovasc Dis Jan;23(1):1-10

10 Dietary pattern Carbohydrate A non-calorie-restricted low carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes Total calorie intake(kcal) = IBW X 25 Caloric restriction diet(c:p:f = 50~60%:<20%: 25%), n=12 Low-carbohydrate diet(carbohydrate intake < 130g), n=12 Intern Med. 2014;53(1):13-9

Dietary pattern Carbohydrate Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes LCD Click diet to and edit diabetic,

11 Dietary pattern Carbohydrate Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes LCD Click diet to and edit diabetic, Master subtitle n=24 style LCD diet and non-diabetic, n=119 LCKD diet and diabetic, n=78 LCKD diet and non-diabetic, n= 142 Nutrition 28 (2012)

12 Dietary pattern Carbohydrate LCD diet and diabetic LCD diet and non-diabetic LCKD Click diet to edit and Master diabetic, subtitle n=78 style LCKD diet and non-diabetic, n= 142 Nutrition 28 (2012)

13 Dietary pattern Carbohydrate LCD diet and diabetic LCD diet and non-diabetic LCKD Click diet to edit and Master diabetic, subtitle n=78 style LCKD diet and non-diabetic, n= 142 Nutrition 28 (2012)

14 Dietary pattern Carbohydrate Beneficial effect of low carbohydrate in low calorie diets on visceral fat reduction in type 2 diabetic patients with obesity. High carbohydrate, n=11 (C:P:F= 62:26:10) Low carbohydrate, n=11 (C:P:F= 39:25:35) Diabetes Res Clin Pract.2004 Sep;65(3):235-41

15 Dietary pattern Carbohydrate Comparison of low- and high- carbohydrate diets for type 2 diabetes management: a randomized trial Low-carbohydrate(C:P:F= 14:28:58), n=41 : 35% MUFA, 13% PUFA High carbohydrate diet(c:p:f=53:17:30), n=37 : 15% MUFA, 9% PUFA 52weeks follow up Am J Clin Nutr Oct;102(4):780-90

16 Dietary pattern Carbohydrate Four year follow up after two year dietary interventions N Engl J Med Oct 4;367(14): Low Click fat to edit Master subtitle style : a low fat, restricted calorie diet Med : a Mediterranean diet, restricted calorie diet Low carb : a low carbohydrate diet without calorie restriction

17 Dietary pattern Carbohydrate 요약 - 저탄수화물식사패턴 몇몇연구에서는유의적인결과를보이지는않았지만많은연구에서 1 일섭취량, 지방섭취제한보다탄수화물섭취제한이혈당및중성지방조절에도움이되는것으로보임. 당지수는혈당및중성지방수치조절에큰영향을미치지않음.

2011 Dec;14(12A):2274-84 Weekly Fish, White meat, eggs Red meat Every day Main meals Cereals

18 Dietary pattern Mediterranean diet Mediterranean diet pyramid today. Science and cultural updates Public Health Nutr Dec;14(12A): Weekly Fish, White meat, eggs Red meat Every day Main meals Cereals Vegetables Fruits - Water - Dairy products - Olive oil - Spiced, herbs, garlic and onions, olive, nuts - Wine Carbohydrate intake: ~50% of E Fat intake: 35~40% of E (mainly MUFA)

19 Dietary pattern Mediterranean diet Protective effects of the Mediterranean diet on type 2 diabetes and metabolic syndrome J Nutr Mar 9

20 Dietary pattern Mediterranean diet Meta-analysis comparing Mediterranean to low fat diets for modification of cardiovascular risk factors Am J Med Sep;124(9):841-51

21 Dietary pattern Mediterranean diet A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta analyses BMJ Open Aug 10;5(8)

22 Dietary pattern Mediterranean diet A Mediterranean-type diet is associated with better metabolic profile in urban Polish adults: Results from HAPIEE study Subjects Click to : 8821 edit adults Master subtitle style Dietary assessment : FFQ Mediterranean type diet score : A score indicating the degree of adherence to the Mediterranean diet (rating 0~5) Metabolism Jun;64(6):738-46

23 Dietary pattern Mediterranean diet Metabolism Jun;64(6):738-46

24 Dietary pattern Effects of diet composition and insulin resistance status on plasma lipid levels in a weight loss intervention in women. Lower Click fat to diet edit Master subtitle style : Choice lean protein sources, reduced fat dairy, emphasize vegetables, frits, whole grain Lower carbohydrate diet :lower carbohydrate choices, lean protein sources, high MUFA fat intake Walnut rich diet :lower carbohydrate choices, lean protein sources, consume an average 42g of walnuts J Am Heart Assoc Jan 25;5(1)

25 Dietary pattern A fruit and dairy dietary pattern is associated with a reduced risk of metabolic syndrome. Metabolism 2012 Jun;61(6): Korean traditional : Refined and whole grains, Korean seasonings, onions and garlic, vegetable oil, soy products, starch syrup, and sugar Alcohol and meat : Processed meats, eggs, fish paste, animal fat, and alcohol Sweets and fast food : Fruit juices, chocolate, ice cream, pizza, and hamburgers Fruit and dairy : Fruits and dairy products : (-) Refined grains, kimchi, pork, and instant noodles 406 adults

26 Dietary pattern Metabolism 2012 Jun;61(6):883-90

27 Dietary pattern Mediterranean diet 요약 - 지중해식식사패턴 Click 많은 to edit 식사패턴 Master subtitle 연구에서 style 지중해식식사패턴이당뇨병 환자에게있어혈당또는지질수치조절에도움을주는것으로보고되고있음. 지중해식식사패턴뿐아니라섬유소섭취등이충분한식사패턴이전반적인혈당및지질수치조절에도움이될수있는것으로기대됨.

28 고중성지방혈증및당뇨병환자의식사 식이요인 식사패턴 - Low carbohydrate diet - Mediterranean diet 음주 (Alcohol consumption) 식물성스테롤 ()

2011 Mar-Apr;46(2):113-6 Subjects: Click to 300patients edit Master

29 Dietary pattern Severe hyperglyceridemia influenced by alcohol(shiba) Alcohol Alcohol Mar-Apr;46(2):113-6 Subjects: Click to 300patients edit Master with subtitle TG level style 1000mg/dL (1unit =alcohol 10g) : Excessive alcohol intake > 21units/week(M), > 14 units/week(f)

30 Dietary pattern Association between alcohol consumption patterns and metabolic syndrome 7432 Click adults to edit Master subtitle style ( NHNES participants) Above moderate: >2dkspdy(M), >1dkspdy(F) Moderate: <0 to 2dkspdy(M), <0 to 1dkspdy(F) None Diabetes Metab Syndr Apr-Jun;8(2):119-23

31 Dietary pattern Inverse associations between light to moderate alcohol intake and lipid related indices in patients with diabetes Cardiovasc Diabetol Jul 17;12:104. 4groups(n=1477) Non Light: <22g ethanol/day Moderate : 22 and <44g ethanol/day Heavy : 44g ethanol/day

32 Dietary pattern Light to moderate alcohol consumption is protective for type 2 diabetes mellitus in normal weight and overweight individuals but not the obese J Obes. 2014;2014: group(n=5512) <5g/day <20g/day 20g/day

33 Dietary pattern J Obes. 2014;2014:634587

34 Dietary pattern 요약 - 알코올섭취 심각한고중성지방혈증에서는알코올섭취제한이필요함. 음주시에는적당량 (1~2 잔이내 ) 의알코올섭취권고.

35 고중성지방혈증및당뇨병환자의식사 식이요인 식사패턴 - Low carbohydrate diet - Mediterranean diet 음주 (Alcohol consumption) 식물성스테롤 ()

36 The effect of plant sterols or stanols on lipid parameters in patients with type 2 diabetes: a meta-analysis Diabetes Res Clin Pract 2009 May;84(2):e33-7

37 Triglyceride lowering response to plant sterol and stanol consumption J AOAC Int May-Jun;98(3):707-15

38 Dietary pattern The effect of plant sterols on serum triglyceride concentrations is dependent on baseline concentrations: a pooled analysis of 12 randomised controlled trials Eur J Nutr Feb;52(1):153-60

39 Dietary pattern 중성지방수치조절을위한 식물성 Click to edit 스테롤 Master subtitle 권장섭취량 style Eur J Nutr Feb;52(1): 식물성스테롤 : 1.6~2.5g/day 식물성스타놀 : 2g/day

Dietary pattern 식물성스테롤강화식품 - Click Low to

Orange juice - Muesli - Bread - Biscuits

40 Dietary pattern 식물성스테롤강화식품 - Click Low to fat edit spread/margarine Master subtitle style - Yogurt drinks - Dairy-free drinks - Low- or reduced-fat milk - Soft cheese - Orange juice - Muesli - Bread - Biscuits Eur J Nutr Feb;52(1): 미강유, 옥수수유등의배아유

41 Dietary pattern 요약및정리 - 식물성스테롤 최근많은연구에서식물성스테롤이혈중콜레스테롤뿐아니라중성지방수치조절에도움이된다고보고됨.

42 Dietary pattern Carbohydrate 정리 - 저탄수화물식사패턴 몇몇연구에서는유의적인결과를보이지는않았지만많은연구에서 1 일섭취량, 지방섭취제한보다탄수화물섭취제한이혈당및중성지방조절에도움이되는것으로보임. 당지수는혈당및중성지방수치조절에큰영향을미치지않음. ADA 식사지침 Eating patterns and macronutrient distribution As there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind. E

43 Dietary pattern Carbohydrate 정리 - 저탄수화물식사패턴 Click 우리나라 to edit Master 식사패턴에서의 subtitle style 적용 - 일반적으로총에너지의 50~60% 를탄수화물로섭취하도록권고하나, 탄수화물, 단백질, 지방섭취량은식습관, 기호도, 치료목표등을고려하여개별화할수있다. C (2015 당뇨병진료지침 ) - 탄수화물섭취가많은동양의식사구성고려하여개별화된탄수화물섭취량권고가필요

44 Dietary pattern Mediterranean diet 정리 - 지중해식식사패턴 Click 많은 to edit 식사패턴 Master 연구에서 subtitle style 지중해식식사패턴이당뇨병 환자에게있어혈당또는지질수치조절에도움을주는것으로보고되고있음. 지중해식식사패턴뿐아니라섬유소섭취등이충분한식사패턴이전반적인혈당및지질수치조절에도움이될수있는것으로기대됨. ADA 식사지침 Dietary fat Whereas data on the ideal total dietary fat content for people with diabetes are inconclusive, an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates. B

45 Dietary pattern Mediterranean diet 정리 - 지중해식식사패턴 Click 우리나라 to edit Master 식사패턴에서의 subtitle style 적용하기 - 잡곡, 과일, 채소류같은식물성식품을기본으로하는식품을선택하되간식의개념으로섭취하는과일의경우섭취량은많아지지않도록주의가필요 - 음식조리시사용하는정도의지방사용 NCEP, ATP Ⅲ: SFA <7%, PUFA 10%, MUFA 15% ESC/EAS Guidelines for the management of dyslipidemias: SFA <7% of total energy, PUFA 10%

46 Dietary pattern 정리 - 알코올섭취 심각한고중성지방혈증에서는알코올섭취제한이필요함. 음주시에는적당량 (1~2 잔이내 ) 의알코올섭취권고. ADA 식사지침 Alcohol Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men). C

47 Dietary pattern 정리 - 식물성스테롤 최근많은연구에서식물성스테롤이혈중콜레스테롤뿐아니라중성지방수치조절에도움이된다고보고됨. 우리나라식사패턴에의적용 - 음식조리시다양한식물성기름을이용

48 결론및제언 고중성지방혈증이동반된당뇨병환자에게있어탄수화물섭취의제한은혈당및중성지방수치조절에도움이될수있을것으로기대됨. 지중해식식사와같은식사패턴은다양한이점을가지고있어우리나라의식사패턴에적절히이용시혈당및지질수치조절에도움이될수있음. 알코올섭취는권장되지는않으나알코올섭취를하게될경우 1~2 잔이내로섭취량제한이필요함. 다양한식물성기름을이용한식사로중성지방수치조절을기대해볼수있음.

49 경청해주셔서감사합니다.

서론 34 2

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