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1 식후고혈당의식사요법 건국대학교병원영양팀유정아 Diet Therapy for Postprandial Hyperglycemia in Patients with Diabetes Jeong-a Yoo Nutrition Care Service Team, KunKuk University Hospital, Seoul, Korea Abstract The strict control of blood glucose levels is the most effective way to prevent and slow or prevent the development of diabetes complications. It is important to control postprandial hyperglycemia in order to maintain blood glucose levels in the normal range and reduce the risk of diabetes complications. Postprandial blood glucose levels are influenced by several factors such as diet pattern, meal composition (carbohydrate intake), amount of food intake, gastric emptying time, insulin resistance, and insulin and glucagon secretion. Postprandial blood glucose levels are particularly affected by food intake and activity. Thus, diet therapy is essential for maintaining postprandial blood glucose levels in the normal range. Maintaining a consistent meal time and amount of food intake, controlling the carbohydrate intake, using the glycemic index for additional benefit, and consuming dietary fiber (20-25 g/day) are all recommended for controlling postprandial blood glucose levels. In conclusion, it is important to not only control these factors, but also to develop a balanced diet plan that considers each individual patient s life style. (J Korean Diabetes 2012;13:33-38) 33 Keywords: Hyperglycemia, Diabetes mellitus, Diet therapy, Postprandial 서론 당뇨병환자에서의관리는식사, 운동그리고약물요법을통해목표혈당에도달하여합병증발생을예방하고지연시키는데그목적이있으며, 엄격한혈당조절이합병증의발생을예방하고발생된합병증의진행속도를늦출수있는가장효과적인방법이다. 당뇨병환자에서혈당이목표혈당에도달하였는지혹은목표에도달된후잘유지되고있는지를판단하기위한중요한지표로당화혈색소가사용되어져왔다. 그러나, DCCT (Diabetes Control and Complications Trial) 와 UKPDS (United Kingdom Prospective Diabetes) 에서당화혈색소만으로는합병증발생을예측하지못하며식후고혈당이당뇨병성합병증의 발생에영향을미친다는사실을지적하였고 [1,2], DECODE (Diabetes Epidemiology Collaborative Analysis of Diagnosis Criteria in Europe) 등의여러역학연구에서는당부하검사 (75 g) 에서 2 시간혈당이 140 mg/dl 을초과하는경우심혈관계질환의발생위험이증가하며, 식후고혈당이공복혈당보다심혈관계질환의위험과더큰연관이있는것으로나타났다 [3]. 그러므로혈당을정상에가깝게조절하고합병증의발생위험을줄이기위해서식후고혈당을조절하는것이중요한의미를갖는다. 식후혈당은여러요인에의해영향을받게되는데, 식사의구성성분 ( 탄수화물섭취량 ), 위배출시간, 식사패턴, 식사량, 인슐린저항성정도, 인슐린과글루카곤의분비등이그요인이라고할수있다. 특히, 식후혈당은식사와활동량에 교신저자 : 유정아, 서울시광진구화양동능동로 건국대학교병원영양팀, ilovekuh@kuh.ac.kr

2 영향을많이받게되므로식후혈당조절에있어식사관리는매우중요하다고할수있다. 이에본고에서는당뇨병환자에서식후고혈당에영향을미치는요인중식사적요인을알아보고각요인에따른식사요법을살펴보고자한다. 하루 3 회와 9 회로나누어서각각 2 주씩섭취하게하였을때하루 3 회식사와 9 회식사간에혈당, 인슐린, 당화혈색소등에별차이가없었다. 이에하루 3 회이상더자주섭취하는것이식후혈당조절에있어별다른이익이나불이익이없는것으로보인다 열량영양소의구성 본론 식후고혈당을조절하기위해권장하는 3 대영양소의비율은탄수화물 55~60%, 단백질 15~20%, 지방 20~25% 정도이다 년국민건강영양조사결과우리나라사람들의탄수화물섭취비율은 67%, 단백질 14.7%, 지방 18.4% 이었음 [4] 을감안하였을때혈당조절을위하여혈당에가장큰영향을미치는영양소인탄수화물의섭취를줄이고상대적으로지방의섭취비율을높이는것을권장한다. 혈당조절이잘된군과그렇지않은군의식사를비교한우미혜등의연구에서혈당조절이잘된군의식사패턴이한국인영양섭취기준에서권장하는 3 대영양소의섭취비율과유사하다고보고하였다 [5] 년미국당뇨병학회권고안에따르면위와같은다량영양소의비율을참고하되, 개인의대사적, 영양적요구도와생활습관에따라각개인에게가장적합한개별화된식사패턴을결정하라고권고하고있다 [6]. 2. 식사시간및식사량분배의일관성 일정한식후혈당을유지하기위해서식사시간, 식사량특히, 탄수화물의섭취를일정하게유지하는것이중요하다. 같은열량의식사를 2~3 회나누어서섭취하는대신 5~6 회의식사및간식으로섭취하여 1 일음식섭취횟수를늘리는경우혈당변동이줄어들고식후혈당조절에도움이된다. 하루세끼식사및간식대신 1~2 끼만식사를하는경우공복감으로인하여과식을할가능성이높으며과식을할경우식후혈당이상승하게되므로하루세끼식사와간식을규칙적으로섭취하는것이권장된다 [7,8]. 제 2 형당뇨병의주요대사적문제중의하나는일정한포도당부하에대한인슐린의분비능이제한되었다는점이다. 따라서포도당부하를줄이기위해음식 ( 특히, 당질 ) 을소량씩나눠서섭취하면췌장에서분비되는인슐린의이용도가증가하여식후혈당을조절하는데도움을줄수있다는논리가가능하다. 제 2 형당뇨병환자들을대상으로실시한연구에서일정한열량의식사를 3. 탄수화물섭취조절 탄수화물은인슐린의분비와식후혈당을결정하는중요한영양소이기때문에식후혈당을조절하기위해탄수화물섭취를조절하는것은가장중요하다. 탄수화물이혈당에미치는영향을보면, 음식으로섭취하는탄수화물의형태나종류보다는식사나간식에포함된탄수화물의총양이더중요하다 [8]. 따라서당뇨병환자의식후혈당조절을위해탄수화물계산, 식품교환또는경험에의한측정등의다양한방법으로탄수화물섭취총량을모니터링하는것이중요하다 [9]. 당질섭취량이일정치많아혈당의기복이심한환자의경우전체열량보다는식후혈당을좌우하는당질섭취량에초점을맞춘식사계획방법인당질계산법을사용하는것도하나의방법이될수있다. 당질계산은당질에만초점을맞추었기때문에비교적쉽고, 환자들스스로음식섭취가혈당조절에어떤영향을주는지이해하는데유용하며비교적정확한혈당조절이가능하다. 이용대상과목적에따라기본당질계산법과고급당질계산법으로나누어적용할수있다. 기본당질계산법은당질음식에대한관심을가지게하고, 매일비슷한시간에일정한양의당질을식사와간식으로배분하여당질섭취를일정하게하는것이다. 반면고급당질계산법은다회인슐린이나인슐린펌프를사용하는환자에게명절이나외식, 모임등평소와다른식사상황에서개별적인당질 / 인슐린비를이용하여실제섭취한당질의양에맞는적절한양의인슐린용량을조정하고, 고혈당발생시인슐린감수성지수를이용하여고혈당을교정하는것이다 [7]. 탄수화물은전곡류, 과일, 채소, 저지방우유와같은식품으로구성하여야되며, 규칙적인시간에일정한양의탄수화물을섭취하는것이식후혈당조절에도움이된다 [8]. 일반적으로설탕섭취는제한하도록하나동량의전분보다혈당을더상승시킨다는근거가없기때문에적은양의설탕섭취는식사의일부로포함시키고대신다른당질급원을조절하도록한다 [10].

3 식후고혈당의식사요법 4. 혈당지수를고려한식품선택 탄수화물의질을나타내기위해식후탄수화물의소화흡수의속도를반영하는것이혈당지수 (Glycemic Index; GI) 이다. 혈당지수는당질 50 g 을함유한표준식품 ( 포도당또는흰빵 ) 섭취후의혈당반응에대한특정식품을섭취한후의혈당반응정도를비교하여백분율로표시한값이다. 혈당지수가 55 이하는저혈당지수식품, 56~69 이면중혈당지수, 70 이상은고혈당지수식품으로분류된다 [11]. 흰빵과흰쌀등은고혈당지수식품의대표적인보기이고, 밀, 보리, 고구마등은저혈당지수식품의대표적인보기이다. 혈당지수가 높은음식을섭취하면식후혈당, 혈중유리지방산, 인슐린등이증가하고인슐린저항성이유발될수있으며, 혈당지수가낮은음식은혈당을천천히상승시키므로인슐린필요량을줄이고포만감을늘려식사섭취량을감소시키며인슐린저항성을개선하여식후혈당조절에효과가있다 [12]. 따라서식사량은동일하지만혈당지수가높은식품을낮은식품으로대체할경우식후혈당조절에도움이된다 [11,13]. 미국당뇨병학회에서는당질의총량을지키는것이혈당조절에가장중요하며, 총탄수화물섭취량만을고려하는것보다혈당지수를활용하면혈당조절에부가적인이득을준다고하였다 [8]. 하지만, 혈당지수는 Table 1. The average glycemic index (GI) of common foods High-carbohydrate GI Breakfast cereals GI Fruit and fruit GI Vegetables GI foods products White wheat bread a 75 ± 2 Cornflakes 81 ± 6 Apple, raw b 36 ± 2 Potato, boiled 78 ± 4 Whole wheat/whole 74 ± 2 Wheat flake biscuits 69 ± 2 Orange, raw b 43 ± 3 Potato, instant mash 87 ± 3 meal bread Specialty grain bread 53 ± 2 Porridge, rolled oats 55 ± 2 Banana, raw b 51 ± 3 Potato, French fries 63 ± 5 Unleavened wheat 70 ± 5 Instant oat porridge 79 ± 3 Pineapple, raw 59 ± 8 Carrots, boiled 39 ± 4 bread Wheat roti 62 ± 3 Rice porridge/congee 78 ± 9 Mango, raw b 51 ± 5 Sweet potato, boiled 63 ± 6 Chapatti 52 ± 4 Millet porridge 67 ± 5 Watermelon, raw 76 ± 4 Pumpkin, boiled 64 ± 7 Corn tortilla 46 ± 4 Muesli 57 ± 2 Dates, raw 42 ± 4 Plantain/green banana 55 ± 6 White rice, boiled a 73 ± 4 Peaches, canned b 43 ± 5 Taro, boiled 53 ± 2 Brown rice, boiled 68 ± 4 Strawberry jam/jelly 49 ± 3 Vegetable soup 48 ± 5 Barley 28 ± 2 Apple juice 41 ± 2 Sweet corn 52 ± 5 Orange juice 50 ± 2 Spaghetti, white 49 ± 2 Spaghetti, whole meal 48 ± 5 Rice noodles b 53 ± 7 Udon noodles 55 ± 7 Couscous b 65 ± 4 35 Dairy products and GI Legumes GI Snack products GI Sugars GI alternatives Milk, full fat 39 ± 3 Chickpeas 28 ± 9 Chocolate 40 ± 3 Fructose 15 ± 4 Milk, skim 37 ± 4 Kidney beans 24 ± 4 Popcorn 65 ± 5 Sucrose 65 ± 4 Ice cream 51 ± 3 Lentils 32 ± 5 Potato crisps 56 ± 3 Glucose 103 ± 3 Yogurt, fruit 41 ± 2 Soya beans 16 ± 1 Soft drink/soda 59 ± 3 Honey 61 ± 3 Soy milk 34 ± 4 Rice crackers/crisps 87 ± 2 Rice milk 86 ± 7 Values are presented as mean ± SEM. a Low-glycemic index varieties were also identified. b Average of all available data. Adapted from Atkinson et al. Diabetes Care 2008;31: [14].

4 36 함유된당질의특성에따라달라질수있고, 음식에대한개인차가크며, 같은식품이라도조리, 가공, 숙성정도, 함께섭취하는음식에따라서도달라지고, 혈당지수가낮은식품중에지방을많이함유하여열량이높은식품들이많아혈당지수에전적으로의존하여식품을선택하는것은주의가필요하다. 그러므로, 식후혈당조절을위해서는혈당지수만으로식품을선택하기보다는혈당지수가낮은식품을선택하되지방함량과열량을함께고려하여개인의열량범위내에서적절하게사용하도록한다. 혈당지수를낮추기위해서아래와같은식사요령을환자에게교육하는것도도움이될수있다 [7]. 흰밥보다는잡곡밥을, 흰빵보다는통밀빵을, 찹쌀보다는멥쌀을선택한다. 채소류, 해조류, 우엉등식이섬유소함량이높은식품을선택한다. 주스형태보다는생과일, 생채소형태로섭취한다. 잘익은과일, 당도높은과일은피한다. 식사시한가지식품만먹기보다는골고루섭취한다. 천천히꼭꼭씹어먹는다. 5. 식후혈당에영향을주는기타영양소 1) 식이섬유소섭취식이섬유소는소화된음식물이장으로흡수되는 속도를지연시켜혈당이급격하게올라가는것을방지할뿐아니라인슐린절약작용, 인슐린감수성을증가시켜식후혈당조절에도움을준다 [8,18]. 식이섬유소는물에대한용해도를기준으로수용성섬유소 (soluble fiber) 와불용성섬유소 (insoluble fiber) 로분류된다. 불용성섬유소에는 cellulose, lignin, hemicellulose 가있으며, 대변양을증가시키고장내통과시간을짧게줄여준다. 수용성섬유소에는 p e c t i n, g u m, m u c i l a g e, hemicellulose 가있으며, 소장에서의포도당흡수를방해하여식후혈당조절에도움을준다. 전향적코호트연구를메타분석한연구에서식이섬유소함량이높은전곡류의섭취가높을수록당뇨병유병률을낮춘다는결과가보고되었다 [15]. De NataleC 등은 randomized crossover study 를수행하여에너지의 52% 의탄수화물, 28 g/1000 kcal 의식이섬유소를포함한식사를섭취한군의식후혈당이유의적으로감소하였다는보고를보고하였다 [16]. Chandalia 는 Randomized controlled trial 에서당뇨병환자에서 1 일 50 g 의식이섬유소섭취가혈당조절을향상시킨다는연구를보고하였다 [17]. 한국인영양섭취기준에서는식이섬유소의충분섭취량 (12 g/1000 kcal) 에근거하여식이섬유소섭취권고량을 1 일 20~25 g 으로설정하였고, 채소는 1 일 300 g 이상의섭취를목표로한다. 이를달성하기위하여흰쌀밥보다는잡곡류, 도정이덜된곡류를섭취하고, Table 2. Problems and solution of pattern management Problems Causes Solutions Hyperglycemia after breakfast Deficiency of insulin for morning -Adjustment of time and dose of or miscalculated maximal acting afternoon intermediate-acting insulin or time of insulin, surfeit of breakfast long acting insulin. -Decrease of amount of breakfast : control amount of carbohydrate intake of breakfast or serve breakfast in 2 different times Afternoon hyperglycemia Deficiency of morning -Dose and time adjustment of intermediate-acting insulin, or afternoon insulin excessive intake of snack or lunch -Skip or decrease the amount of afternoon snack. Decrease the amount of carbohydrate intake of lunch Night hyperglycemia after Deficiency of insulin for dinner, -Adjustment of time and dinner or excessive intake of dinner dose of afternoon insulin -Decrease the amount of dinner or decrease of carbohydrate intake of dinner -Adjustment of time, kind, and dose of insulin from or before sleep

5 식후고혈당의식사요법 채소는즙보다는생야채로, 과일은주스보다는생과일로이용하며껍질째섭취하는것이권장된다. 또한채소나해조류 ( 미역, 다시마 ) 등의섭취를늘리는것이좋다 [7]. 2) 지방섭취지방은섭취한식사의소화를지연시켜대사될때여분의인슐린을필요로하지않는것으로간주되었다. 그러나, DCCT 연구결과고지방식사는흔히식사 5~6 시간후에고혈당을초래하였다고보고하였다. 전끼니의고지방식사가 5~6 시간후의다음식사의식후혈당에영향을미칠수있으므로, 하루권고되는지방섭취량내에서식사와간식으로일정하게분배하여섭취하는것이권장된다. 6. 식후고혈당에적합한패턴관리 패턴관리는당뇨병환자가자신의자가혈당검사결과의패턴을파악하고철저한혈당조절을위해서어떠한변화가필요한지를결정하는데도움을주는체계적인접근법이다. 식후고혈당이발생시에는식사, 혈당, 약물, 신체활동에관한기록들을검토하여당뇨병관리의일관성이유지되고있는지살펴보고정상범위를벗어나는혈당패턴을초래하게된요인파악하고조정하도록한다 (Table 2)[19]. 결 지금까지식후고혈당에영향을미치는식사적요인을살펴보고그에따른식사요법에대하여정리해보았다. 식후고혈당의예방과조절을위해서위요인들의조절이필수적이긴하나, 당뇨병관리가지속적인점을감안하였을때어떤특정요인만을조절하기보다는총섭취열량및탄수화물의양조절, 영양소비율, 식사시간및식사배분의일관성과함께환자의기호도와생활패턴을충분히반영한식사요법을꾸준히실천하는것이무엇보다도중요하다. 론 참고문헌 01. S The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329: S Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352: S DECODE Study Group, the European Diabetes E p i d e m i o lo g y G ro u p. G l u co s e t o le rance a n d cardiovascular mortality: comparison of fasting and 2 - h o u r d i a g n o stic c r i t e r i a. A rc h I n t e r n M e d 2001;161: S Ministry for Health, Welfare and Family Affairs; Korean Centers for Disease Controls and Prevention Korea National Health and Nutrition Examination Survey (KNHANES). Seoul: Ministry for Health, Welfare and Family Affairs; S Woo MH, Park S, Woo JT, Choue R. A comparative study of diet in good and poor glycemic control groups in elderly patients with type 2 diabetes mellitus. Korean Diabetes J 2010;34: S American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2010;33 Suppl 1:S S Korean Diabetes Association. Korean food exchange lists for diabetes. 3rd ed. Seoul: Gold' planning and development; p.46, S American Diabetes Association, Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, Hoogwerf BJ, Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler ML. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008;31 Suppl 1:S S Sheard NF, Clark NG, Brand-Miller JC, Franz MJ, Pi-Sunyer FX, Mayer-Davis E, Kulkarni K, Geil P. Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the American Diabetes Association. Diabetes Care 2004;27: S Wheeler ML, Pi-Sunyer FX. Carbohydrate issues: type and amount. J Am Diet Assoc 2008;108(4 Suppl 1):S S Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, Bowling AC, Newman HC, Jenkins AL, Goff DV. Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr 1981;34: S Kim IJ. Glycemic index revisited. Korean Diabetes J 2009;33: S Ma Y, Olendzki BC, Merriam PA, Chiriboga DE, Culver AL, Li W, Hebert JR, Ockene IS, Griffith JA, Pagoto SL. A randomized clinical trial comparing low-glycemic index versus ADA dietary education among individuals with type 2 diabetes. Nutrition 2008;24: S Atkinson FS, Foster-Powell K, Brand-Miller JC. International tables of glycemic index and glycemic load values: Diabetes Care 2008;31: S Schulze MB, Schulz M, Heidemann C, Schienkiewitz A, Hoffmann K, Boeing H. Fiber and magnesium intake and incidence of type 2 diabetes: a prospective study 37

6 and meta-analysis. Arch Intern Med 2007;167: S De Natale C, Annuzzi G, Bozzetto L, Mazzarella R, Costabile G, Ciano O, Riccardi G, Rivellese AA. Effects of a plant-based high-carbohydrate/high-fiber diet versus high-monounsaturated fat/low-carbohydrate diet on postprandial lipids in type 2 diabetic patients. Diabetes Care 2009;32: S Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med 2000;342: S Wheeler ML, Dunbar SA, Jaacks LM, Karmally W, Mayer-Davis EJ, Wylie-Rosett J, Yancy WS Jr. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, Diabetes Care 2012;35: S Holler HJ, Pastors JG. Diabetes medical nutrition therapy. Chicago: American Dietetic Association;

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<30315F D C1BEBCB35FB1E8C0CEC1D65FC0FAC0DA20B0A3BBE720B1B3C1A4B9DDBFB52E687770> DOI : 10.4093/kdj.2009.33.4.261 REVIEW 혈당지수의재조명 부산대학교의학전문대학원내분비대사내과 김인주 Glycemic Index Revisited In Joo Kim Department of Endocrinology and Metabolism, Pusan National University School of Medicine, Busan,