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1 대한한의학회지제 37 권제 3 호 (2016 년 9 월 ) J Korean Med. 2016;37(3):62-73 pissn eissn Original Article 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 김서영, 박영재, 박영배 경희대학교한의과대학진단 생기능의학과학교실 Review on predictors of dropout and weight loss maintenance in weight loss interventions Seo-Young Kim, Young-Jae Park, Young-Bae Park Department of Biofunctional Medicine & Diagnostics, College of Oriental Medicine, Kyung Hee University Objectives: Dropout and weight regain are common problems in most obesity treatments. The purpose of this study was to review previously published study results of the predictive factors associated with dropout during weight loss treatment and weight loss maintenance after successful weight loss. Methods: Authors searched for the articles related to dropout and weight loss maintenance, published from 2007 to 2016 found on Pubmed, Scopus, RISS, and KISS. A total of 19 articles were finally selected. From the study results, unchangeable and changeable predictors were extracted, and these predictors were examined according to dropout and weight loss maintenance categories. Results: The unchangeable predictors of dropout were younger age, lower education level and female, whereas the changeable predictors of dropout were lower initial weight loss, symptoms of depression and body dissatisfaction. The strongest factor for predicting the dropout was initial weight loss. The unchangeable predictors of weight loss maintenance were old age, male and family history of obesity, whereas the changeable predictors of weight loss maintenance were regular exercise, dietary restraint, self-weighing and low depressive symptoms. Initial weight loss, depressive symptoms, body image, dietary restraint, physical activity, weight loss expectation and social support were considered to be dominant factors for weight loss treatments. Conclusions: Our review results suggest that unchangeable and changeable predictors of dropout and weight loss maintenance should be carefully examined during treatments of obesity. Key Words : Dropout, Weight loss maintenance, Obesity treatment, Predictors, Factors 서론최근서구화된생활방식, 고칼로리식습관과운동부족등전반적인신체활동량의감소로인해전세계적으로비만과과체중의유병률은증가하는추세이다 1)2). 우리나라에서도꾸준히증가하여 2014년 도국민건강영양조사에따르면, 만 19세이상체질량지수 25kg / m2이상인비만인구가 1998년 26.0% 에서 2001년 29.2%, 2007년 31.7% 로증가한후최근 7년간 31~32% 수준을유지하고있다 3). 비만은제2형당뇨병, 고혈압, 관상동맥심장질환, 관절염, 간및담낭질환, 특정암의발병률을 Received:27 June 2016 Revised:28 September 2016 Accepted:29 September 2016 Correspondence to: 박영배 (Young-Bae Park) 경희대학교한의과대학진단생기능의학과학교실 Tel: , Fax: , bmppark@khu.ac.kr 62

2 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (363) 높이며, 이로인한사망률을증가시킨다 4)5). 비만환자에서체중감량효과에대해서는많은연구들이나와있는데, 1.5kg의체중감량으로총콜레스테롤이 22.0 mg/dl, 저밀도지단백-콜레스테롤이 22.1 mg/dl 감소하였고 6), 2-5% 의체중감량으로도수축기혈압을감소시킴으로써심혈관질환의위험성이감소되는결과를보였으며 8), 3kg이상체중을감량한지방성간질환환자의 86% 에서 ALT치가정상범위내로감소하였다 9). 체중감량이질병의위험요소들을개선시킬수있음에도 6)7), 체중감량프로그램을성공적으로완수하고, 감량한체중을장기적으로유지하는경우는드물다. 비만치료프로그램의중도탈락률은평균 37% 로 10) 체중감량시도에서흔하게발생하는문제이며 13), 체중감량에성공한후에도약 1/3에서 1년이내에, 나머지는 3-5년사이에원래의체중을회복하게된다 11)12). 이에본연구에서는 10년간보고된국내외논문들을대상으로, 비만치료시중도탈락및체중감량후감량체중유지에영향을주는요인을분석하였다. 그후중도탈락및체중유지요인들을다시가변요인과불변요인으로나누어분석하였다. 이를통해, 가변요인은비만치료및치료후감량체중유지시적극적으로활용함으로써치료효과를높이고, 불변요인은개인특성에따른적절한치료기간과감량목표를제시함으로써개인의특성에맞는효과적인맞춤형비만치료프로그램의개발을위한기초자료로활용될수있을것이다. 연구방법국내논문은한국교육학술정보원에서제공하는 RISS, KISS에서, 해외논문은 PubMed, Scopus에서검색하였다. 검색기간은 2007년부터 2016년현재까지최근 10년간의기간을설정하여검색하였고, 검색어는 비만치료요인, 비만치료인자, 비만치료효과, 체중감량요인, 체중감량인자, 체중감량효과, obesity treatment factor(s), obesity treatment predictor(s), weight loss factor(s), weight loss predictor(s) 를사용하였다. 검색필드 (search field) 를전체분야 (All field) 로설정하여검색했을때, RISS에서 2,067개, KISS에서 47개, PubMed에서 14,449개, Scopus에서 105,213 개가검색되었다. 주제와직접관련된논문을효과적으로수집하기위하여, 주검색어 ( 비만치료, 체중감량, obesity treatment, weight loss ) 는 Title 로검색하고, 세부검색어 ( 요인, 인자, 효과, factor(s), predictor(s) ) 는국내논문은 All field로하되, 해외논문은 Title/abstract 또는 abstract으로범위를좁혀다시검색하였다. 검색된국내논문 215편과해외논문 3,186편중영어또는한국어가아닌논문을제외하고, 연구대상을성인으로제한한다음, 초록및본문을검토하여비만치료에영향을주는요인을주제로한논문을검색하였으며, 그중중도탈락과감량후체중유지에관련된논문을선별한결과얻어진총 19편의국내외논문을분석하였다. 결과및고찰 1. 비만치료의중도탈락에영향을주는요인에관한연구 (Table 1) Fabricatore 13) 는약물요법과행동수정요법을병행하는임상시험에서체중감량과중도탈락의예측인자를조사하였다. 이를위해 224명의비만환자들을대상으로 sibutramine, lifestyle modification, sibutramine 투여및 lifestyle modification 병행, sibutramine 및 brief therapy 병행 4그룹으로나누어 52주간치료를시행하였다. 측정도구는 Weight and Lifestyle Inventory (WALI; 2006) 와 Beck Depression Inventory, Second Edition (BDI-II; 1996) 을사용하였다. 연구결과전체중도탈락률은 17.4%, 체중감량성공률 ( 5% reduction in bodyweight) 은 52.2% 였으며, sibutramine 투여및 lifestyle modification 병행그룹이다른그룹들에비해 5% 이상높은체중감량률을보였다. 나이가젊을수 63

3 (364) 대한한의학회지제 37 권제 3 호 (2016 년 9 월 ) DATABASE: RISS, KISS, Pubmed, Scopus Search word: RISS ; 전체 : 비만치료 <AND> 전체 : 요인, 전체 : 비만치료 <AND> 전체 : 인자, 전체 : 비만치료 <AND> 전체 : 효과, 전체 : 체중감량 <AND> 전체 : 요인, 전체 : 체중감량 <AND> 전체 : 인자, 전체 : 체중감량 <AND> 전체 : 효과 KISS ; 전체 = 비만치료 AND 전체 = 요인, 전체 = 비만치료 AND 전체 = 인자, 전체 = 비만치료 AND 전체 = 효과, 전체 = 체중감량 AND 전체 = 요인, 전체 = 체중감량 AND 전체 = 인자, 전체 = 체중감량 AND 전체 = 효과, PubMed ; ("obesity treatment") AND (factor OR factors), ("obesity treatment") AND (predictor OR predictors), ("weight loss") AND (factor OR factors), ("weight loss") AND (predictor OR predictors) Scopus ; ALL ( "obesity treatment" ) AND ALL ( factor ), ALL ( "obesity treatment" ) AND ALL ( predictor ), ALL ( "weight loss" ) AND ALL ( factor ), ALL ( "weight loss" ) AND ALL ( predictor ) RISS(n=2,067), KISS(n=40), PubMed(n=14,449), Scopus(n=105,213) Search word: RISS ; 제목 : 비만치료 <AND> 전체 : 요인, 제목 : 비만치료 <AND> 전체 : 인자, 제목 : 비만치료 <AND> 전체 : 효과, 제목 : 체중감량 <AND> 전체 : 요인, 제목 : 체중감량 <AND> 전체 : 인자, 제목 : 체중감량 <AND> 전체 : 효과 KISS ; 제목 = 비만치료 AND 전체 = 요인, 제목 = 비만치료 AND 전체 = 인자, 제목 = 비만치료 AND 전체 = 효과, 제목 = 체중감량 AND 전체 = 요인, 제목 = 체중감량 AND 전체 = 인자, 제목 = 체중감량 AND 전체 = 효과, Pubmed ; ("obesity treatment"[title]) AND (factor[title/abstract] OR factors[title/abstract]), ("obesity treatment"[title]) AND (predictor[title/abstract] OR predictors[title/abstract]), ("weight loss"[title]) AND (factor[title/abstract] OR factors[title/abstract]), ("weight loss"[title]) AND (predictor[title/abstract] OR predictors[title/abstract]) Scopus ; TITLE ( "obesity treatment" ) AND ABS ( factor ), TITLE ( "obesity treatment" ) AND ABS ( predictor ), TITLE ( "weight loss" ) AND ABS ( factor ), TITLE ( "weight loss" ) AND ABS ( predictor ) RISS(n=174), KISS(n=41), PubMed(n=1,811), Scopus(n=1,375) RISS(n=133), KISS(n=37), PubMed(n=1,067), Scopus(n=790) RISS(n=8), KISS(n=7), PubMed(n=64), Scopus(n=64) Full text Articles(n=19): Korean Articles(n=1), International articles(n=18) Articles on adults, written in English or Korean Articles screened on basis on title and abstract Removed records: Did not meet inclusion criteria Study on Predictors of weight loss maintenance and dropout Records after duplicates removed Fig. 1. A Review of predictors of drop out and weight loss maintenance. 64

4 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (365) 록, 비만년수가짧을수록, 교육수준이낮을수록, 자존감이낮고우울도가높을수록중도탈락률이증가하였으며, 초기 3주동안의체중감량률과참석률이높을수록탈락률이확연히감소하였다. Gunnarsdóttir 14) 는체중감량을위한식이중재프로그램에서의중도탈락과관련된예측인자를연구하였다. 이를위해 8주동안 140명의비만참가자들을총에너지섭취의 30% 는지방, 50% 는탄수화물, 20% 는단백질과식이섬유에서공급받도록 설계하여, 남성은평균 1,706 kcal/day, 여성은평균 1,354 kcal/day를섭취하는칼로리제한식이를시행하였다. 실험전신체계측, lifestyle 설문, 음식섭취성향과의연관성을조사한결과, 전체중도탈락률은 18.4% 로나타났으며, 평소항우울제를복용하거나청량음료를자주섭취할수록중도탈락률이높았다. Elfhag 15) 은 247명의비만환자를대상으로 6개월간의행동수정요법후체중감량및중도탈락과 Table 1. Study on Predictors of Dropout during Weight Loss Treatment. Author (year) Title Fabricatore (2009) 13) Predictors of attrition and weight loss success Results from a randomized controlled trial. Gunnarsdottir (2010) 14) Predictors of dropping out in a weight loss intervention trial. Initial weight loss is the best predictor for success in obesity Elfhag (2010) 15) treatment and sociodemographic liabilities increase risk for drop-out. Moroshko (2011) 16) Predictors of dropout in weight loss interventions a systematic review of the literature. Hadziabdic (2015) 17) Factors predictive of drop-out and weight loss success in weight management of obese patients. Yackobovitch-Gav Factors associated with dropout in a group weight-loss programme: an (2015) 18) a longitudinal investigation. Goode (2016) 19) Socio-demographic, anthropometric, and psychosocial predictors of attrition across behavioral weight-loss trials. (+; positive correlation, -; negative correlation, < >; the sign of inequality) Predictors ageyears since onset of overweighteducation levelsymptoms of depression+ self-esteemattendance at week 3- weight loss at week 3- antidepressants+ soft drinks+ education levelbeing an immigrant+ lack of occupation+ body dissatisfaction+ weight cycling+ ageeducation levelbody imageprevious dieting attempts+ physical activityself efficacysocial supportweight loss expectations+ initial weight losstravel distance to clinic+ financial difficulties+ female > male education levelinitial weight+ initial weight loss- ageeducation levelinitial weight+ binge eating+ previous dieting attempts+ financial difficulties+ 65

5 (366) 대한한의학회지제 37 권제 3 호 (2016 년 9 월 ) 관련된요인을분석하였다. 연구결과, 전체중도탈락률은 63% 이었으며, 중도탈락의가장중요한예측인자는교육수준이었다. 그외에도이민자, 무직상태, 신체불만족, 과거체중감량시도가적었던것이중도탈락예측인자로보고되었다. Moroshko 16) 는 60년대중반부터 2011년 5월이전까지출판된비만치료관련논문중, 중도탈락과관련된요인들을다룬 61개의논문들을분석하였다. 그결과, 고령, 고학력일수록탈락률이낮았으며, 비만상태에대한불만족, 장기간체중감량시도, 낮은신체활동성, 취약한사회적지원 (social support), 높은감량기대감, 초기저조한감량결과및경제적부담시탈락률이높았다. Hadžiabdić 17) 은중도탈락관련예측인자들을연구하기위해비만환자 124명을대상으로지중해식및표준저지방식이요법을 1년간시행하였다. 이와함께하루 30분걷기의행동수정요법을실시한후, 사회인구학적, 신체계측적, 임상적특징을조사하였다. 연구결과, 전체적인체중감량성공률 ( 5% reduction in the initial weight) 은 33.1%, 중도탈락률은 32.3% 였으며, 남성보다여성에서, 교육수준이낮을수록, 초기비만도가높을수록중도탈락률이높은것으로나타났다. Yackobovitch Gavan 18) 은비만환자 587명을대상으로 10주간체중감량치료프로그램을시행한후중도탈락과관련된요인을분석하였다. 연구결과, 초기 2주동안의저조한체중감량결과가중도탈락의가장강력한 (strongest) 예측인자였다. 초기 2 주동안평균체중감량은치료완수군에서 BMI units, 중도탈락군에서 BMI units으로나타났다. Goode 19) 는식이및신체활동수정중재시험에참가한비만환자 504명을대상으로, 중도탈락의인구통계학적, 신체계측적, 심리사회적예측인자를연구하였다. 연구결과, 전체중도탈락률은 19.4% 였으며, 예측인자로는높은초기비만도, 폭식습관, 잦은체중감량시도, 젊은나이, 낮은교육수준, 경제적인부담으로나타났다. 2. 체중감량후유지에영향을주는요인에관한연구 (Table 2) Wing 20) 은감량후체중유지와관련된행동, 심리요인들에대하여연구하였다. 이를위해최근에체중의 10% 이상을감량했던비만환자 261명을대상으로 18개월간체중변화와신체활동, 식이규제, 자가체중측정관리, 우울정도와의상관성을조사하였다. 참가자들을 face-to-face, Internet, 대조군의 3 그룹으로나눈후 Paffenbarger Questionnaire, Block Food Frequency Questionnaire, Eating Inventory, Frequency of weighing를사용하여평가하였다. 연구결과, 신체활동량과자가체중측정관리가감량후체중유지와강하게관련된것으로나타났으며, 우울증상, 식이규제와도유의한연관성이있는것으로나타났다. 특히, face-to-face 그룹이 internet 그룹과대조군그룹에비하여신체활동, 자가체중측정관리, 식이규제가확연히잘지속되었으며, 체중유지도잘되었다는것이중요한발견이라는결론을얻었다. A. S. Collings 21) 는감량후체중유지의심리적예측인자특히신체이미지, 우울증상, 자존감을조사하였다. 이를위해 73명의여성비만환자들을대상으로비만치료프로그램에참여하기전, 참여후 3 개월, 12 개월에각각우울증, 자존감및신체이미지를측정하였다. 측정도구는 Multidimensional Body Self-Relations Questionnaire (MBSRQ), Body Image Assessment for Obesity (BIA-O), Body Image Avoidance Questionnaire (BIAQ), Center for Epidemiologic Studies Depression Scale (CES-D) 를사용하였다. 연구결과평소부정적인신체이미지즉, 자신을현실보다더욱비만한것으로인식할수록감량후체중유지가잘되지않는것으로나타났으며, 우울증상과자존감은이연구에서는유의한연관성이나타나지않았다. Sonja 22) 는감량후체중유지에영향을미치는심리요인들에대해 2003년에서 2009년사이에연구된논문 25편을조사하였다. 연구결과, 비현실 66

6 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (367) 적인체중감량기대치, 감량목표치도달에의실패, 이분법적인사고방식, 감정에따른식사, 탈억제성식이는감량후체중유지실패와관련되어있으며, 식이의꾸준한규제와높은비용대비효과만족도, 안정적이고낮은수준의우울증상, 긍정적인신체이미지가체중유지성공과관련되어있었다. Osayi 23) 는 89,746명의비만환자를대상으로장기적인체중감량및체중유지와관련된요인들을연구하기위해인구통계자료, 개선된영양, 개선된운동및감소된스트레스와체중감량및 1년후속기간동안의체중유지와의연관성을조사하였다. 연구결과, 성공적인체중유지와관련된요인으로는남성, 높은연령 (57+>48-56>39-47), 감소된스트레스, 개선된영양이있었으며운동의증가는개선된영양과병행되었을때연관성이있는것으로나타났다. Stubbs 24) 는체중감량및감량후체중유지와관련된연구문헌들을토대로긍정적요인과부정적요인으로나누어분석하였다. 체중유지에있어서긍정적인예측인자는신체활동, 자가모니터링, 긍정적인대처스타일, 사회적지지, 절제된식이, 동반질환의감소가있었으며, 부정적인예측인자는부정적인사건이나가족의기능상실등의정신적스트레스, 높은수준의우울증상, 탈억제성식이, 폭식등이있었다. Delahanty 25) 는감량후체중재증가와관련된유전적요인을조사하기위해 3,234명의비만환자를대상으로 16개의비만성향단일염기유전자다형성과의연관성을시험하였다. 연구결과, NEGRl rs , BDNF rs6265, PPARG rsl 보유환자는치료방법에상관없이, TMEM18 rs 및 KTCD15 rs29941 보유환자는치료방법에따라, 감량후체중재증가와연관성이있는것으로나타났다. 이 26) 는비만환자 104명을대상으로체중감량및감량후장기간의체중유지에관련된요인을조사하였다. 연구결과, 식습관개선, 규칙적인운동, 주기적인자가체중측정, 비만의가족력이감량후체중유지와관련된요인으로나타났다. Brantley 27) 는감량후체중유지의심리사회적예측인자를연구하였다. 이를위해참가자 1025명을 Personal Contact group, Interactive Technology group, Self-Directed group으로나누어평가하였다. 연구결과, 건강관련삶의질점수가높을수록감량후체중유지가잘되었으며, 스트레스, 운동및식사에대한격려점수가높을수록유지가잘되지않은것으로나타났다. 3그룹중 Personal Contact group이 Interactive Technology group과 Self-Directed groups 모두에비하여체중유지가잘된것으로나타나대면접촉관리가감량후체중유지에중요한영향을준다는결론을얻었다. Abilso 28) 는감량후체중유지에영향을주는행동요인들을연구하기위해체중관리프로그램에참여했던 450명의비만환자들을대상으로설문조사를시행했다. 연구결과, 매주규칙적인자가체중측정, 야식제한, 한끼식사분량의제한, 매일충분한신체활동이체중감량유지와관련된요인으로나타났다. Nikolić 29) 은비만수술을받은환자들의초기체중감량이이후의체중유지를예측할수있는지연구하였다. 이를위해비만수술을받은총 80명의비만환자를대상으로연구한결과, 초기 1-3개월간의체중감량결과가 1년후의체중유지를예측하는인자로나타났다. Santos 30) 는감량후체중유지의심리, 행동예측인자를연구하였다. 이를위해 1년간체중감량시험에참여하고, 2년간추적검사를받은 154명의여성비만환자를대상으로운동의욕, 정신적건강도, 식이행동및식습관, 신체활동등의행동, 심리변수들을조사하였다. 연구결과, 신체이미지 (body image) 가좋을수록, 자발적인운동의욕이높을수록감량후장기간의체중유지가잘되는것으로나타났다. Ross 31) 는감량후체중유지와일주기유형및수면의질과의연관성을조사하기위해아침형-저 67

7 (368) 대한한의학회지제 37 권제 3 호 (2016 년 9 월 ) Table 2. Study on Predictors of Weight Loss Maintenance after Successful Weight Loss Author (year) Title Rena (2008) 20) Maintaining Large Weight Losses: The Role of Behavioral and Psychological Factors. A prospective study of predictors of successful weight Collings (2008) 21) maintenance by women enrolled in community-based weight-loss programs. Bulimia and Obesity. Sonja Psychological factors influencing weight loss maintenance: an (2011) 22) integrative literature review. Factors associated with long-term weight loss and weight Osayi (2011) 23) maintenance: analysis of a comprehensive workplace wellness program. Stubbs (2011) 24) Problems in identifying predictors and correlates of weight loss and maintenance: Genetic predictors of weight loss and weight regain after Delahanty (2012) 25) intensive lifestyle modification, metformin treatment, or standard care in the diabetes prevention program. Lee Related factors of long-term maintenance of weight loss in obese (2014) 26) patients. Brantley Psychosocial predictors of weight regain in the weight loss (2014) 27) maintenance trial Abildso Predictors of weight loss maintenance following an insurance (2014) 28) -sponsored weight management program. Initial weight loss after restrictive bariatric procedures may Nikolić (2015) 29) predict mid-term weight maintenance: Results from a 12-month pilot trial. Santos Predicting long-term weight loss maintenance in previously (2015) 30) overweight women: A signal detection approach. Ross Successful weight loss maintenance associated with morning (2016) 31) chronotype and better sleep quality. (+; positive correlation, -; negative correlation, < >; the sign of inequality) Predictors physical activity+ self-weighing+ hungerdietary disinhibitiondepressive symptoms- body image+ weight loss expectationweight loss goals+ dichotomous thinking styleeating to regulate mooddietary disinhibitionperceived benefits outweighing costs+ depressive symptomsbody image+ male gender+ age+ stressdietary restaint+ exercise combined with diet+ (+) physical activity self-monitoring a positive coping style social support normalization of eating patterns reduction of comorbidities flexible coping strategies eating breakfast (-) negative life events family dysfunction higher levels of depression dietary disinhibition binge eating SNPs-; NEGRI rs , BDNF rs6265, PRARGrs , TMEM18 rs , KTCD15rs29941 dietary restaint+ Regular exercise+ Regular weight check+ Family history of obesity+ health-related quality of life+ stress- Self-weighing+ dietary restaint+ physical activity+ Initial weight loss+ body image+ exercise autonomous motivation+ morning chronotype+ sleep quality+ 68

8 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (369) 녁형설문지 (Morningness Eveningness Questionnaire: MEQ) 및피츠버그수면질지수점수를평가하였다. 연구결과, 아침형유형 ( 일찍자고일찍일어남 ) 을가지면서수면시간이충분하고수면의질이좋은경우감량후체중유지가더잘되는것으로나타났다. 3. 비만치료에있어서중도탈락및감량후체중유지에영향을주는불변, 가변요인 (Table 3) 비만치료에있어서중도탈락및감량후체중유지와관련된요인에는각각유전적요인, 생리적요인, 심리적요인, 식이행동요인, 사회인구학적요인, 치료관련요인등의다양한요인들이있었다. 이것을다시크게두가지종류즉, 체중감량및감량후체중유지시적극적으로활용함으로써치료효과를높일수있는가변요인과환자개인특성에맞는적절한치료기간과감량목표를제 시하는예후설정의근거가될수있는불변요인으로분류하였다. 비만치료에있어서중도탈락에영향을주는주요요인에는초기의저조한체중감량결과, 우울증후, 부정적인신체이미지등의가변요인과낮은교육수준, 젊은연령, 경제적부담감등의불변요인이있었다. 그중초기의저조한체중감량결과가중도탈락의가장강력한예측요인이었다. Fabricatore 13) 는초기 3주동안의성공적인체중감량결과가중도탈락을막고지속적으로비만치료에동기를부여하는중요요인이라고보고하였다. Moroshko 16) 는 1960년대에서 2011년까지의중도탈락관련요인에대한문헌연구를통해, 초기의저조한체중감량이중도탈락의예측인자였다고제시하였다. Yackobovitch Gavan 18) 역시초기 3주동안의체중감량이전체 10주간의비만치료에있어서매주마다의중도탈락을예측하는가장강력하고 (strongest) 독립적인 (independent) 예측인자라고 Table 3. Predictors of Drop-out and Weight loss Maintenance. Process Changeable predictors Unchangeable predictors drop out weight maintenance Initial weight loss- 13)16)18) depressive symptoms+ 13)14)16) body image- 13)15)16) binge eating+ 19) soft drink+ 14) physical activity+ 16) weight loss expectation+ 16) social support- 16) Initial attendance- 13) Regular exercise physical activity+ 20)23)24)26)28)30) hunger20)dietary restraint +20)22)23)24)26)28) self-weighing self-monitoring+ 20)24)26)28) depressive symptoms 20)22)24) stress+ 23)24)27) body image+ 21)22)30) health-related quality of life+ 24)27) positive coping strategies+ 22)24) morning chronotype+ 32) sleep quality+ 31) weight loss expectation- 22) Initial weight loss+ 29) social support+ 24) weight loss goal+ 22) benefits outweighing costs+ 22) (+; positive correlation, -; negative correlation, < >; the sign of inequality) education level- 13)15)16)17)19) age- 13)16)19) finantial difficulties+ 15)16)19) previous weight loss attempts+ 16)19)-15) Initial weight+ 17)19) female > male 17) age+ 23) male > female 23) Family history of obesity+ 26) SNPs- 25) 69

9 (370) 대한한의학회지제 37 권제 3 호 (2016 년 9 월 ) 보고하였다. 교육수준은대학교육을기준으로나누어분석했으며, 대졸이상에서중도탈락률이유의하게낮았다. Fabricatore 13) 는고등졸업이하, 대학중퇴, 대학교졸업, 석사학위이상으로분류하여분석하였으며, 대학중퇴또는대학졸업과고등졸업이하간의유의한차이가나타났고대학교육과석사사이에는유의한차이가없었다. Elfhag 15) 은치료를완수한사람들중대학교육을받은사람의비율은 39% 인데비해중도탈락한사람들중의비율은 19% 로나타났다. Hadziabdic 17) 도대학교육을받은사람들이치료를완수한사람들중의 41.0% 였던반면, 중도탈락한사람들중의 21.1% 를차지하여상대적으로낮게나타났다. 연령과의연관성에대한연구결과는공통적으로 30대에서 50대까지의비만환자들을대상으로하여연령에따른탈락률의유의한차이가있었다는결론을얻었다. Fabricatore 13) 의연구에서는연령 (43.8±10.2) 이증가할때마다탈락률이 5% 감소한다는결과를얻었다. Goode 19) 의연구에서는치료완수그룹에서의연령 (48.20±9.23) 이중도탈락그룹의연령 (43.89±11.04) 보다유의하게높았다. 체중감량후유지에영향을주는주요요인으로규칙적인운동과지속적인식이규제, 주기적인자가체중측정이있었으며그다음으로낮은우울증후, 낮은스트레스, 긍정적인신체이미지등의가변요인이있었다. 그외불변요인으로높은연령, 남성, 비만의가족력등이있었다. 그중규칙적인운동및신체활동이감량후체중유지의중요요인이라는연구결과가가장많았다. Wing 20) 은계단오르기, 걷기, 스포츠활동등일주일간소비한신체에너지를평가한후, 신체활동량이체중감량후유지의중요한예측요인이라는결과를얻었다. Osayi 23) 는식이개선과규칙적인운동의병행이감량후체중유지의예측인자라고제시하였다. 이 26) 는규칙적인운동을한다는경우가체중을유지한그룹의 63%, 체중이다시증가한그룹의 30.2% 로유의한차이를보였 으며, 체중을유지한그룹의운동빈도는주당평균 4.3회, 총운동시간은주당평균 254.1분인반면체중이다시증가한그룹의운동빈도는주당평균 2.9회, 총운동시간은주당평균 173.1분이었다. Santos 30) 의연구에서는자발적운동의욕이높을수록감량후체중유지가유의하게잘된것으로나타났다. 지속적인식이규제는아침식사를포함한규칙적인식사, 하루섭취총칼로리의제한, 한끼식사분량의제한, 야식및간식횟수제한, 지방섭취제한등이있었다. 환자관리방식또한감량후체중유지에중요한요소로나타났는데, Wing 20) 과 Brantley 27) 의연구에서공통적으로치료자와직접적인대면접촉관리 (face-to-face) 그룹이인터넷, 또는전화상담과같은간접적인관리그룹에비해규칙적인운동, 꾸준한식이관리, 주기적인체중측정이잘지속되었으며감량후체중유지가잘되었다. 이상의결과를바탕으로비만치료시중도탈락과감량후체중재증가에영향을주는공통요인은초기의저조한체중감량결과, 우울증후, 부정적인신체이미지, 식이규제와신체활동량의감소, 비현실적인체중감량기대치, 사회적지지부족, 낮은연령, 여성의경우로요약될수있다. 이러한요인들은체중감량단계에서부터감량후체중유지까지영향을주므로지속적으로예의주시하여야할주요한요인이라고볼수있다. 결론비만치료의중도탈락에영향을주는주요요인으로치료초기의저조한체중감량결과, 우울증후, 신체불만족과관련된부정적인신체상등의가변요인과, 낮은교육수준, 젊은연령, 경제적부담등의불변요인이있었다. 감량후성공적인체중유지를위해서는주당평균 4회, 평균 250분이상의규칙적인운동과아침식사를포함한규칙적인식사, 야식및간식제한, 70

10 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (371) 하루총섭취칼로리제한, 한끼식사량의적절한제한과같은지속적인식이규제및주기적인자가체중측정관리가중요하며특히우울증후또는스트레스도가높을수록, 연령이낮을수록, 여성일수록치료자와직접적인대면접촉관리를통해운동과식이, 자가체중측정관리를꾸준히지속하도록관리하는것이중요하다는결론을얻을수있었다. 이상의결과를바탕으로비만치료시중도탈락과감량후체중재증가에영향을주는공통요인은초기의저조한체중감량결과, 우울증후, 부정적인신체이미지, 식이규제와신체활동량의감소, 비현실적인체중감량기대치, 사회적지지부족, 낮은연령, 여성의경우로요약될수있다. 이러한요인들은체중감량단계에서부터감량후체중유지까지영향을주므로지속적으로예의주시하여야할주요한요인이라고볼수있다. 이러한가변요인들과불변요인들에대한연구결과를이론적근거기반으로하여향후개인의특성에맞는효과적인맞춤형비만치료프로그램개발을위한임상연구가이루어져야할것으로사료된다. 참고문헌 1. World Health Organization (CH). Obesity and overweight [Internet]. Geneva: WHO Media Centre Available at: URL: who.int/mediacentre/factsheets/fs311/en/. Accessed Jun 16, Haidar YM, Cosman BC. Obesity epidemiology. Clinics in Colon and Rectal Surgery. 2011; 24: Ministry of Health and Welfare, Korea Centers for Disease Control and Prevention. Korea Health Statistics 2014: Korea National Health and Nutrition Examination Survey (KNHANES Ⅵ-2). 4. Kopelman P. Health risks associated with overweight and obesity. Obesity Reviews. 2007;8(1): Kopelman PG. Obesity as a medical problem. Nature.2000;404(6778): Park JW. The Effect of Weight Reduction on Chronic Inflammatory Molecules and Insulin Resistance in type 2 DM. Ajou Univ.; Nam JS. Gene polymorphism of 5-HT2c receptor influences on the therapeutic effects of sibutramine to obesity. Journal of Korean Diabetes. 2007;1: Wing RR. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes care. 2011;34(7): Yang SK, Lee YS, Lee HS, Kim CY. Histologic Findings of the Liver in HbsAg -Negative Patients with Chronic Aminotransferase Elevations. Korean Journal of Medicine. 1992;42(2): Fabricatore AN, Wadden TA, Moore RH, Butryn ML, Gravallese EA, Erondu NE, et al. Attrition from randomized controlled trials of pharmacological weight loss agents: a systematic review and analysis. Obesity Review. 2009;10: Christopher N. Sciamanna. Michaela Kiernan. Practices associated with weight loss versus weight-loss maintenance results of a national survey. American journal of preventive medicine. 2011;41(2): Kim SY. General Characteristics and Psychological and Environmental Factors Related to Successful Weight Reduction Programs in Obese Premenopausal Women. Journal of the East Asian Society of Dietary Life. 2007; 17(5):

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12 비만치료에있어서중도탈락과감량후체중유지에영향을주는인자들에대한고찰 (373) 29. Nikolić MA, Kruljac IB, Kirigin LC, Mirošević GB, Ljubičić NA, Pezo Nikolić BD. Initial weight loss after restrictive bariatric procedures may predict mid-term weight maintenance: Results from a 12-month pilot trial. Bariatric Surgical Practice and Patient Care. 2015;10(2): Santos I, Mata J. Predicting long-term weight loss maintenance in previously overweight women: A signal detection approach. Obesity. 2015;23(5): Kathryn MR, J Graham T, Wing RR. Successful weight loss maintenance associated with morning chronotype and better sleep quality. Journal of Behavioral Medicine. 2016; 39(3):