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1 대한지역사회영양학회지 22(3): 207~217, ISSN (print) / (on-line) RESEARCH ARTICLE IT- 기반의임신성당뇨병영양관리프로그램개발을위한요구도조사 한찬정 1) 임선영 1) 오은숙 2) 최윤희 3) 윤건호 3) 이진희 1) 1) 가톨릭대학교유헬스케어사업단, 2) 미즈메디병원내분비내과, 3) 서울성모병원내분비내과 Needs for Development of IT-based Nutritional Management Program for Women with Gestational Diabetes Mellitus Chan-Jung Han 1), Sun-Young Lim 1), Eunsuk Oh 2), Yoon-Hee Choi 3), Kun-Ho Yoon 3), Jin-Hee Lee 1) 1) The Catholic Institute of Ubiquitous Health Care, The Catholic University of Korea, Seoul, Korea 2) Division of Endocrinology and Metabolism, Department of Internal Medicine, MizMedi Hospital, Seoul, Korea 3) Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary''s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Corresponding author Jin-Hee Lee The Catholic Institute of Ubiquitous Health Care, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, Korea Tel: (02) Fax: (02) jheelee@catholic.ac.kr ORCID: Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2013R1A1A ). Received: June 9, 2017 Revised: June 22, 2017 Accepted: June 22, 2017 ABSTRACT Objectives: The aim of this study was to examine self-management status, nutritional knowledge, barrier factors in dietary management and needs of nutritional management program for women with Gestational Diabetes Mellitus (GDM). Methods: A total of 100 women with GDM were recruited from secondary and tertiary hospitals in Seoul. The questionnaire composed of general characteristics, status of selfmanagement, dietary habits, nutrition knowledge, barrier factors in dietary management, needs for nutrition information contents and nutritional management programs. Data were collected by a self-administered questionnaire. All data were statistically analyzed using student s t-test and chi-square test using SAS 9.3. Results: About 35% of the subjects reported that they practiced medical nutrition and exercise therapy for GDM control. The main sources of nutrition information were internet (50.0%) and expert advice (45.0%). More than 70% of the subjects experienced nutrition education. The mean score of nutrition knowledge was 7.5 point out of 10, and only about half of the subjects were reported to be correctly aware of some questions such as the cause of ketosis, the goal of nutrition management for GDM, the importance of sugar restriction on breakfast. The major obstructive factors in dietary management were eating more than planned when dining out, finding the appropriate menu when dining out. The preferred nutrition information contents in developing management program were nutritional information of food, recommended food by major nutrients, the relationship between blood glucose and food, tips on menu selection at eating out. The subjects reported that they need management program such as example of menu by calorie prescription, recommended weight gain guide, meal recording and dietary assessment, expert recommendation, sharing know-how. Conclusions: Based on the results of this study, it is necessary to develop a program that provide personalized information by identifying the individual characteristics of the subjects and expert feedback function through various information and nutrition information contents that can be used in real life. Korean J Community Nutr 22(3): 207~217, 2017 KEY WORDS gestational diabetes mellitus (GDM), needs assessment, IT-based nutritional management program This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 207

2 208 임신성당뇨병임부의영양관리프로그램요구도 서 임신성당뇨병 (GDM; Gestational diabetes mellitus) 은임신중에처음발견되었거나, 발생한내당능장애로정의하고있으며, 산모에게는자간전증, 양수과다증, 분만외상, 제왕절개술의빈도를증가시키고, 태아에게는거대아와그로인한분만손상, 견갑난산등의위험을높이는것으로보고되고있다 [1, 2]. 또한임신성당뇨병에이환된산모는분만이후제 2 형당뇨병발생및임신성당뇨병재발의위험이높은것으로알려져있다 [3]. 임신성당뇨병의유병률은진단방법과기준에따라많은차이를보이고있는데, 우리나라는임산부의약 2-5% 정도가임신성당뇨병으로보고되고있다 [4, 5]. 임신성당뇨병의위험인자는연령, 임신전 BMI, 체중증가, 당뇨병가족력등있으며 [6, 7], 서구화된생활습관으로인한비만도증가와고연령산모가지속적으로증가하는추세를보이고있다는점에서이로인한임신성당뇨병발생률은더욱증가할것으로보여진다. 식사요법은임신성당뇨병관리의기본으로 [8], 임신성당뇨병을동반한산모에서산모와태아의합병증을유발할수있는고혈당이나과다한체중증가없이필요한영양소를충분히공급하기위해서는올바른식사의섭취가매우중요하다 [9-11]. 그러나이러한영양관리의중요성에도불구하고임신성당뇨병산모의질병관련지식정도는매우낮은편이고 [12], 일반당뇨병과는달리분만시까지 3~4 개월의집중적인관리를위해짧은시간안에모든당뇨병관리내용을숙지해야한다는부담감과불안감등을느끼게된다 [13, 14]. 또한질병관리에대한실질적인정보가부족한실정이며 [15], 가장흔히접하는온라인상의정보역시비전문가에의한잘못된지식전달일수있고, 영양관리의기본적인개념이배제된특정이슈에대한편향된정보전달이문제가될수있다. 현재임신성당뇨병에대한치료나교육이체계적, 지속적이지않아관리에한계가있으며 [16] 특히, 단체교육이나 1 회성상담이외에전문가를통한지속적인영양관리는현실적으로어려운실정이다. 최근정보통신의발달로인터넷과스마트폰의사용이보편화되면서이를기반으로한건강및영양관리프로그램이다양하게활용되고있다 [17, 18]. Han & Jeong [19] 은당뇨병환자를대상으로웹기반의식사관리프로그램을개발하였고, 이에대한효과평가결과대상자들의식품섭취와식행동이유의하게개선되는것으로보고했다 [20]. Kim 등 [21] 은스마트폰어플리케이션을사용한당뇨자가간호수행에있어긍정적인변화를보인다고평가하였다. 이러한프 론 로그램은병원이나보건소등에직접방문하지않아도당뇨관리를보다편리하게할수있다는장점이있어꾸준한관리가필요한임신성당뇨병임부들에게는필수적인관리프로그램중하나가될것으로보여진다. 따라서본연구에서는임신성당뇨병임부의영양관리현황, 영양지식, 영양관리프로그램에대한요구도를파악함으로써임신성당뇨병영양관리를위한 IT-기반의영양관리프로그램개발의기초자료로활용하고자한다. 연구대상및방법 1. 연구대상 본연구는서울소재의 3차병원과 2차병원을내원하고있는임신성당뇨병임부중연구에대한동의를득한 100 명을대상으로설문조사를실시하였다. 조사기간은 2014년 9월부터 12월까지진행되었으며, 훈련된조사원이병원에방문하여조사를수행하였다. 본연구는가톨릭대학교서울성모병원생명윤리심의위원회 (KIRB-00484_1-001) 와미즈메디병원임상연구심의위원회 (IRB행정 -18) 의승인을받은후진행되었다. 2. 연구방법 1) 설문지개발 본연구의설문문항은관련연구자료 [12, 22-26] 및임신성당뇨병임부 6명을대상으로한포커스그룹인터뷰결과를바탕으로작성하였으며, 영양전문가, 내분비내과의료진과의토의를걸쳐최종설문지를개발하였다. 일차적으로본연구와관련된 42편의논문을조사 검토하였으며, 이중연구목적과관련성이높은 17편의논문을선별하여포커스그룹인터뷰수행의기초자료로활용할수있도록각주제 ( 식생활수준, 관리현황, 영양지식, 장애요인, 요구사항 ) 별로정리하고문서화하였다. 이를바탕으로포커스그룹인터뷰를위한연구문제를정의하였으며, 각연구문제별질의문항도출및중요도와소요시간을안배하여인터뷰를계획하였다. 인터뷰는 2명의진행자가 6명의임신성당뇨병임부를대상으로수행하였다. 인터뷰에대한내용분 석을수행한결과, 대상자대부분은식생활관리의중요성을인식하고스스로관리하려는태도를보이고있었으나, 관리의형태는총섭취량및탄수화물급원식품 ( 주로밥 ) 을줄이는행위로나타났으며, 균형있는영양소섭취부분은크게고려되지못하고있었다. 병원에서의개별또는집단영양교육을통해기본적인권장식단에대한이해도는높았으나, 외식등변화된환경에서의대처능력은낮은것으로나타났다.

3 한찬정 임선영 오은숙 최윤희 윤건호 이진희 209 또한일상생활에서스스로섭취하고있는식사가적절한지확인받고싶은욕구가대부분의대상자에게서두드러졌으며, 다양한식품에대한정보제공, 전문가와의용이한커뮤니케이션이주요요구되는사항이었다. 이를바탕으로양적연구를위한조사방향설정과설문문항을구성하였으며, 영양전문가 2인및임신성당뇨병환자진료를수행하고있는내분비내과전문의 2인을통한최종검토후본연구에서사용될문항및응답범주와구성을확정하였다. 2) 설문내용 대상자의일반특성은나이, 교육정도, 직업, 결혼상태, 월평균수입과출산경험, 당뇨가족력, 활동수준, 현재임신주수, 임신성당뇨병으로진단받은주수, 키, 현재체중, 임신전체중에대해조사하였다. 대상자의임신성당뇨병자가관리현황으로는당뇨병치료를위한관리방법, 영양정보제공경로, 영양교육현황 ( 경험여부및방법 ) 를살펴보았으며, 식사습관현황은임신후식습관변화여부, 하루식사섭취횟수, 간식섭취횟수, 식사배분, 식사속도, 임신후식욕변화를알아보았다. 총 10개의문항의설문으로대상자의영양지식을평가하였다. 이중 8개문항은 O, X 문항, 2개문항은객관식문항으로구성되었으며정답은 1점, 오답은 0점을부여해 10점만점으로구성하였다. 대상자의식생활관리시의장애요인을파악하기위해총 20개항목에대해 4점척도 (1점 : 전혀그렇지않다, 2점 : 그렇지않은편이다, 3점 : 그런편이다, 4점 : 매우그렇다 ) 로구성하였으며, 임신성당뇨병관리를위한영양정보컨텐츠및영양관리프로그램요구도는이에대한관심을 4점척도 (1점 : 전혀관심없다, 2점 : 관심없다, 3점 : 관심있다, 4점 : 매우관심있다 ) 로알아보았다. 3) 통계분석 조사진행이완료된임신성당뇨병임부 100명을대상으로결과를분석하였으며, SAS 9.3 program을이용하여대상자의일반적특성, 자가관리및식습관현황, 영양지식에대해빈도, 백분율을구하였고, 식생활관리시장애요인과영양정보컨텐츠및영양관리프로그램요구도에대해서는평균, 표준편차값을구하였다. 또한 chi-square test, student s t-test 를실시하여 2차병원과 3차병원간의차이를살펴보았다. 모든분석은유의수준은 5% 에서검정하였다. 결 1. 대상자의일반사항 조사대상자는총 100 명으로평균연령은 33.8 세이며평 과 균임신주수는 28.2 주였고, 임신성당뇨병으로진단받은주수는 2차병원은평균 17.8±8.7주, 3차병원은 24.3±4.1 주로두병원간차이가있는것으로나타났다 (p <0.001). 대상자의평균임신전 BMI는 23.0 kg/m 2 이었으며, 임신중평균체중증가량은 2차병원에서 5.8±5.0 kg, 3차병원에서 6.2±3.1 kg로 3차병원내원대상자의체중증가량이높은것으로보여졌다 (p=0.002). 대상자의 48.0% 가당뇨병가족력이있다고답하였고, 대상자의 36.0% 가출산경험이있었으며, 이중 41.7% 의대상자가과거임신성당뇨병으로진단받은적이있는것으로나타났다. 활동수준은대부분의대상자가가벼운활동을하는것으로나타났다 (85.0%). 대상자의교육정도는대학교졸업이 53.0% 로가장많았으며, 전문대학졸업 18.0%, 대학원이상 15.0%, 고등학교졸업 14.0% 의분포를보였다. 대상자의반이상이주부였으며 (59.0%), 사무직이 17.0%, 전문 행정관리직이 16.0%, 서비스 판매직외기타가 8.0% 였다. 월평균수입은 300만원이상 ~500만원미만이 36.0%, 500만원이상이 33.0%, 300만원미만이 31.0% 로나타났다 (Table 1). 2. 임신성당뇨병임부의자가관리및식사습관현황임신성당뇨병임부의자가관리및식사습관현황은 Table 2에제시하였다. 대상자들의주요관리방법으로식사요법과운동요법을병행하는것이 35.0% 로가장많았으며, 식사요법과운동요법, 약물치료세가지를병행하는것이 20.0%, 식사요법만단독으로수행하는것이 19.0% 로나타났다. 반면, 가장낮은비율을차지한관리방법으로는운동요법과약물요법을수행 (1.0%) 하는경우였다. 관리방법으로식사요법을수행하고있는대상자는 92.0% 였다. 임신성당뇨병임부들의식사관리정보를얻는주요경로는인터넷활용이절반을차지하였고 (50.0%), 다음으로는전문가에게문의 (45.0%) 가많았으며, 이외 전문가문의및인터넷활용 (2.0%), 전문가문의와전문서적및인터넷활용 (1.0%), 인터넷활용및지인에게문의 (1.0%), TV 프로그램 (1.0%) 을통해식사관리정보를얻는것으로나타났다. 임신성당뇨병으로진단받은후식사관리에대한영양교육 ( 상담 ) 을받은적이있다고답한대상자는 76.0% 였으며, 교육받은횟수는 2차병원이 1.9±1.6 회, 3차병원이 1.1 ±0.4회로, 2차병원에내원하는환자들의교육횟수가더많았으며 (p=0.001) 2차병원에서는개별교육이 97.8%, 소규모그룹교육이 2.2%, 3차병원에서는개별교육이 83.3%, 소규모그룹교육이 16.7% 로유의한차이를보였

4 210 임신성당뇨병임부의영양관리프로그램요구도 Table 1. General characteristics of the subjects Variables Total (n=100) Secondary Hospital (n=60) Tertiary Hospital (n=40) P value 1) Age (years) ± ) ± ± 53.8 < Gestational period (weeks) ± ± ± 55.1 < Time on diagnosis of GDM 3) (weeks) ± ± ± 54.1 < 0.001*** Height (cm) ± ± ± 55.0 < Pregnancy weight (kg) ± ± ± 12.2 < Pre-pregnancy weight (kg) ± ± ± 12.2 < Pre-pregnancy BMI 1) (kg/m 2 ) ± ± ± 54.4 < Weight gain during pregnancy ± ± ± 53.1 < 0.002** Parity Primi-parity 64 (64.0) 4) 34 (56.7) 30 (75.0) Multi-parity 36 (36.0) 26 (43.3) 10 (25.0) < History of GDM (n=36) No 21 (58.3) 13 (50.0) 2 (20.0) < Yes 15 (41.7) 13 (50.0) 8 (80.0) Family history of diabetes No 52 (52.0) 30 (50.0) 18 (45.0) < Yes 48 (48.0) 30 (50.0) 22 (55.0) Activity level Low 85 (85.0) 52 (86.7) 33 (82.5) < Middle 15 (15.0) 8 (13.3) 7 (17.5) Education High School 14 (14.0) 11 (18.3) 3 (57.5) Collage 18 (18.0) 11 (18.3) 7 (17.5) University 53 (53.0) 29 (48.3) 24 (60.0) Graduate School 15 (15.0) 9 (15.0) 6 (15.0) Occupation Housewives 59 (59.0) 38 (63.3) 21 (52.5) < Officers 17 (17.0) 10 (16.7) 7 (17.5) Managers or technicians 16 (16.0) 7 (11.7) 9 (22.5) < Service workers or salespersons 8 (58.0) 5 (58.3) 3 (57.5) Household Monthly income (won) < 3,000, (31.0) 19 (31.7) 12 (30.0) 3,000,000~5,000, (36.0) 23 (38.3) 13 (32.5) < > 5,000, (33.0) 18 (30.0) 15 (37.5) 1) Continuous variables: Calculated using Student s t-test, Categorical variables: Calculated using Chi-square test or fisher s exact test 2) Mean ± SD 3) GDM, Gestational diabetes mellitus; BMI, Body Mass Index 4) N (%) **: p < 0.01, ***: p < 다 (p=0.033). 영양교육시교육자로는임상영양사가 87.8% 로가장많은비율을차지했으며, 다음으로간호사 (7.3%), 의사 (4.9%) 순으로나타났다. 영양교육의실질적인도움여부는 매우도움이됨 이 68.4%, 약간도움이됨 이 30.3%, 별로도움이안됨 이 1.3% 였다. 대상자의대부분이임신성당뇨병진단후임신후식사습관에변화 (98.0%) 가있었으며하루식사섭취횟수는 3 번 이라고응답한대상자가가장많은비율 (94.0%) 을차지했고, 2번 이 4%, 4번이상 이 2.0% 로나타났다. 하루동안간식섭취횟수를살펴보면 2차병원에서는하루 1-2번 (50.0%), 하루 3번이상 (50.0%) 이절반씩의비율로나타났으며, 3차병원에서는하루 1-2번의간식섭취가 75.0%, 3번이상의간식섭취가 25.0% 의비율로, 3차병원에서 3 번이상간식섭취를하는비율이더낮은것으로나타났다

5 한찬정 임선영 오은숙 최윤희 윤건호 이진희 211 Table 2. Status of self-management and dietary habits of the subjects Variables Total (n=100) Secondary Hospital (n=60) Tertiary Hospital (n=40) Practical therapy Diet therapy 19 (19.0) 2) 9 (15.0) 10 (525.0) Diet therapy + Physical activity 35 (35.0) 18 (30.0) 17 (542.5) Diet therapy + Physical activity + Drug therapy 20 (20.0) 14 (23.3) 6 (515.0) Diet therapy + Drug therapy 18 (18.0) 14 (23.3) 4 (510.0) Physical activity + Drug therapy 1 (51.0) 0 (50.0) 1 (552.5) Drug therapy 6 (56.0) 5 (58.3) 1 (552.5) None of the above 1 (51.0) 0 (50.0) 1 (552.5) Sources of nutrition information Expert 45 (45.0) 30 (50.0) 15 (537.5) p-value 1) Expert + Books + Internet 1 (51.0) 0 (50.0) 1 (552.5) Expert + Internet 2 (52.0) 1 (51.7) 1 (552.5) Internet 50 (50.0) 28 (46.7) 22 (555.0) Internet + Family or Friends 1 (51.0) 0 (50.0) 1 (552.5) TV 1 (51.0) 1 (51.7) 0 (550.0) Experience of nutrition education No 24 (24.0) 14 (23.3) 10 (525.0) Yes 76 (76.0) 46 (76.7) 30 (575.0) Number of education (n=76) 51.6 ± 1.3 3) 51.9 ± ± ** Method of education (n=76) Group education 6 (57.9) 51 (52.2) 55 (516.7) 0.033* Counseling 70 (92.1) 45 (97.8) 25 (583.3) How helpful was nutrition education? (n=76) Not helpful 1 (51.3) 0 (50.0) 1 (553.3) Helpful 23 (30.3) 11 (23.9) 12 (540.0) Very helpful 52 (68.4) 35 (76.1) 17 (556.7) Change of dietary habits during pregnancy No 2 (52.0) 2 (53.3) 0 (550.0) Yes 98 (98.0) 58 (96.7) 40 (100.0) Meal frequency per day 2 times 4 (54.0) 3 (55.0) 1 (552.5) 3 times 94 (94.0) 56 (93.3) 38 (595.0) times 2 (52.0) 1 (51.7) 1 (552.5) Snacking frequency per day 1 2 times 60 (60.0) 30 (50.0) 30 (575.0) 0.012* 3 times 40 (40.0) 30 (50.0) 10 (525.0) Distribution of meals (%) Breakfast 26.1 ± 7.2 3) 26.3 ± ± 5.5 Lunch 35.9 ± 5.7 3) 35.4 ± ± Dinner 38.1 ± 6.3 3) 38.5 ± ± 6.2 Eating speed Fast 19 (19.0) 13 (21.7) 6 (515.0) Normal 73 (73.0) 44 (73.3) 29 (572.5) Slow 8 (58.0) 3 (55.0) 5 (512.5) Change of appetite during pregnancy Increase 45 (45.0) 30 (50.0) 15 (537.5) Decrease 16 (16.0) 10 (16.7) 6 (515.0) Not changed 39 (39.0) 20 (33.3) 19 (547.5) 1) Continuous variables: Calculated using Student s t-test, Categorical variables: Calculated using Chi-square test or fisher s exact test 2) N (%) 3) Mean ± SD *: p < 0.05, **: p <

6 212 임신성당뇨병임부의영양관리프로그램요구도 (p=0.012). 아침, 점심, 저녁각끼니별섭취량분배정도는아침 26.1%, 점심 35.9%, 저녁 38.1% 로저녁섭취가가장많은비율을차지하였다. 대상자의반이상 (73.0%) 이 보통속도로식사한다고하였으나 19.0% 는빠른편 (10분미만 ) 이라고응답하였으며, 8.0% 는느린편이라고답하였다. 임신후식욕은 45.0% 가많이늘었다고응답하였고 Table 3. Nutrition knowledge about gestational diabetes mellitus Questions Total (n=100) Secondary Hospital (n=60) Tertiary Hospital (n=40) P-value 1) Calorie control is very important for GDM care. 93 (593.0) 2) 58 (596.7) 35 (587.5) Since unsweetened juice has no sugars, it can be eaten without restriction. 97 (597.0) 3) 59 (598.3) 38 (595.0) Hypoglycemia occurred by lack of calorie intake or irregular meal time. 71 (571.0) 3) 43 (571.7) 28 (570.0) When you get insulin injections, you don't need to practice diet therapy and engage 100 (100.0) 3) in physical activity 60 (100.0) 40 (100.0) It is good to abstain from snack consumption for correct blood glucose control. 69 (569.0) 3) 42 (570.0) 27 (567.5) You should restrict sugar for breakfast rather than lunch and dinner. 52 (552.0) 3) 28 (546.7) 24 (560.0) Too much calorie can cause ketosis. 51 (551.0) 3) 29 (548.3) 22 (555.0) Protein foods do not have a significant effect on blood sugar and you can feel fullness. 77 (577.0) 3) 48 (580.0) 29 (572.5) What should I do if I get hypoglycemia? 90 (590.0) 3) 56 (593.3) 34 (585.0) What is the goal of nutrition management for GDM? 51 (551.0) 3) 28 (546.7) 23 (557.5) Total score 7.5 ± 1.5 3) 7.5 ± ± ) Continuous variables: Calculated using Student s t-test, Categorical variables: Calculated using Chi-square test or fisher s exact test 2) N (%), percentages of correct answers 3) Mean ± SD Table 4. Barriers factors for dietary management of the study subjects Variables Total (n=100) Secondary Hospital (n=60) Tertiary Hospital (n=40) P-value 1) It is difficult to limit the amount of food intake. 2) 2.6 ± 0.7 3) 2.6 ± ± It is difficult to eat regularly. 2.5 ± ± ± It is difficult to eat the recommended snack every time. 2.7 ± ± ± It is difficult to eat slowly. 2.2 ± ± ± It is hard to break the habit of eating salty food. 1.9 ± ± ± It is hard to resist the urge to eat. 2.7 ± ± ± I can t find the appropriate menu when I dine out. 2.9 ± ± ± I eat more than planned when I dine out. 3.0 ± ± ± I want to eat sugary snacks on impulse. 2.9 ± ± ± It is difficult to get enough vegetables. 2.4 ± ± ± It is difficult to eat protein foods every time. 2.6 ± ± ± It is difficult to apply food exchange lists in real time. 2.7 ± ± ± I don t know how much I should eat by visual observation. 2.6 ± ± ± It is difficult to eat considering the sugars suitable for me. 2.6 ± ± ± I don t have a strong commitment to diet therapy. 1.9 ± ± ± I hate having to eat differently from others. 2.5 ± ± ± It is difficult to limit food intake in front of others. 2.5 ± ± ± I don t have appetite. 1.8 ± ± ± I don t know whether I m doing well on diet therapy. 2.5 ± ± ± I have no one to ask about my dietary management. 2.5 ± ± ± ) Continuous variables: Calculated using Student s t-test, Categorical variables: Calculated using Chi-square test or fisher s exact test 2) 1=Never, 2=Rarely, 3=Sometimes, 4=Always 3) Mean ± SD

7 한찬정 임선영 오은숙 최윤희 윤건호 이진희 % 는변화가없었고, 16.0% 는임신후식욕이줄었다고답하였다. 3. 임신성당뇨병임부의영양지식 Table 3은임신성당뇨병임부의영양지식정답률및총점을제시한것이다. 총지식점수는평균 7.5±1.5점이었고, 2차병원과 3차병원간의유의한차이는없었다. 이중정답률이 70.0% 이상인문항은 인슐린주사시식이와운동병행여부, 무가당주스섭취의문제, 열량조절의중요 성, 저혈당시대처법, 혈당조절을위한간식섭취, 저혈당의원인, 단백질식품의영향 등으로이와관련한문항의지식정도는높은편으로나타났다. 반면, 약 50.0% 의낮은정답률을보인문항은 점심, 저녁식사때보다는아침식사에당질을제한해야한다, 섭취열량이너무많아지면케톤증이발생할수있다, 임신성당뇨병환자의영양관리의목표로맞는것은무엇일까요? 에대한것이각각 52.0%, 51.0%, 51.0% 로나타나임신성당뇨병관리에대한영양지식이부족한것으로보여졌다. Table 5. Needs for nutrition information contents and nutritional management programs Variables Total (n=100) Secondary Hospital (n=60) Tertiary Hospital (n=40) P-value 1) Nutrition information contents Medical information 2) 3.3 ± 0.5 3) 3.3 ± ± Diet therapy 3.3 ± ± ± Nutritional information of food 3.4 ± ± ± Recommended food by major nutrients 3.4 ± ± ± Relationship between blood glucose and food 3.4 ± ± ± GI index 3.3 ± ± ± Insulin therapy and diet therapy 3.2 ± ± ± Management of ketosis 2.9 ± ± ± Tips on menu selection at eating out 3.4 ± ± ± Tips on snacks selection 3.3 ± ± ± Diet therapy for GDM with hypertension 2.7 ± ± ± * Consumption of vitamin and nutrient supplement 3.0 ± ± ± Sick day dietary management 3.2 ± ± ± Practical dietary management tips in real life 3.2 ± ± ± Healthy recipes 3.3 ± ± ± Update on information of dietary therapy 3.3 ± ± ± Nutritional management programs Evaluation of dietary habit and Goal setting 3.1 ± ± ± Calorie prescription 3.2 ± ± ± Recommended weight gain guide 3.3 ± ± ± Meal recording and dietary assessment 3.3 ± ± ± Expert recommendation 3.3 ± ± ± Example of menu by calorie prescription 3.4 ± ± ± Sharing know-how 3.3 ± ± ± Q&A 3.2 ± ± ± Needs for design in providing information Text form 12 (12.0) 4) 2 (53.3) 10 (25.0) 0.003** Picture and table form 88 (88.0) 58 (96.7) 30 (75.0) Needs for method in meal recording Direct recording 41 (41.0) 24 (40.0) 17 (42.5) Choice of category 59 (59.0) 36 (60.0) 23 (57.5) 1) Continuous variables: Calculated using Student s t-test, Categorical variables: Calculated using Chi-square test or fisher s exact test 2) 1=Definitely Not Interested, 2=Not Interested, 3=Interested, 4=Definitely Interested 3) Mean ± SD 4) N (%) *: p < 0.05, **: p < 0.01

8 214 임신성당뇨병임부의영양관리프로그램요구도 4. 임신성당뇨병임부의식생활관리시장애요인 임신성당뇨병임부의식생활관리시장애요인을점수화하여나타낸것은 Table 4와같다. 임부들이식생활관리시어려웠던점으로는 외식할때계획보다더많이먹게된다 (3.0±0.7점) 가가장높은점수를보였고, 다음으로 외식할때적절한메뉴를찾을수가없다 (2.9±0.7점 ), 충동적으로단맛이나는간식을먹고싶다 (2.9±0.8점 ) 가뒤를이었다. 반면, 장애요인점수가가장낮은것으로는 식욕이없다 (1.8±0.6점) 였으며, 음식을짜게먹는습관을고치기힘들다 (1.9±0.8점 ), 혈당조절을위해식사요법을반드시해야겠다는의지가강하지않다 (1.9±0.6점) 도 2점이하로장애요인으로는낮은점수인것으로나타났다. 5. 임신성당뇨병임부의영양정보컨텐츠및영양관리프로그램요구도 임신성당뇨병임부의영양정보컨텐츠에대한요구도는 2문항을제외하고모두 3점이상의높은점수를보이고있는데, 이중영양정보컨텐츠요구도가가장높은항목들은 식품의영양성분정보 (3.4±0.5점), 주요영양소별권장하는식품 (3.4±0.5점), 혈당과식품과의관계 (3.4±0.5 점 ), 외식시식사관리요령 (3.4±0.5점) 으로나타났다. 반면요구도가낮은항목은 고혈압동반시식사요법 (2.7± 0.8점 ), 케톤증관리 (2.9±0.7점) 이었다. 영양관리프로그램에대해서는모든항목들이 3점이상의높은요구도를보여주고있으며이중가장높은요구도를보인항목은 처방열량별권장식단제공 (3.4±0.5점) 이었고, 다음으로 적절한체중증가가이드 (3.3±0.5점), 식사일지기록과섭취량분석 (3.3±0.5점 ), 전문가권고 (3.3±0.5점 ), 노하우공유 (3.3±0.5점) 에대한요구도가높았던것으로나타났다. 영양정보컨텐츠제공형식에대하여텍스트형식 (12.0%) 보다는그림이나표형식 (88.0%) 를선택하였고, 병원별로비교했을때그림이나표위주의형식을원한다고답한대상자가 2차병원에서는 96.7%, 3차병원에서는 75.0% 로유의한차이가있었다 (p=0.003). 식사일기작성프로그램이용시, 섭취한음식입력방법으로는주어진카테고리안에서선택하는형식 (59.0%) 을직접기록하는형식 (41.0%) 보다더선호하는것으로나타났다 (Table 5). 고 본연구는임신성당뇨병임부를대상으로하여대상자들의자가관리및식습관현황과영양지식, 식생활관리시의장애요인들을파악하고, 영양정보컨텐츠와영양관리프로 찰 그램에대한요구도를조사하여영양관리프로그램개발에대한기초자료를제공하고자수행되었다. 조사수행결과대상자들은식사및운동요법, 영양교육등질병에대한관리를실천하고있었고, 이와관련된영양지식정도도높은편이었으나실제식생활관리시에여러가지어려움을겪는것으로보여졌으며, 올바른질병관리를위해다양한영양정보컨텐츠및프로그램에대한요구도가높은것으로나타났다. 임신성당뇨병임부들의자가관리방법으로식사요법과운동요법병행이가장많았으며이는 Ko 등 [27] 의조사와비슷한결과를보였고, 92% 의임부가임신성당뇨병관리의기본인식사요법을실천하고있는것으로제시되었다. 대상자들이식사관리에대한정보를얻는주요경로는인터넷이가장많았다. 인터넷을통한정보습득은직접병원에방문하는것보다쉽게원하는정보를얻을수있는장점을가졌으며, 특히임부는연령층이젊기때문에인터넷사용이매우익숙하므로이러한결과를나타낸것이라생각된다. 현재까지당뇨환자를대상으로한 IT-기반의관리프로그램개발은지속적으로이루어져왔으나국내임신성당뇨병임부만을대상으로한관리프로그램은많지않으며, 특히영양관리와정보만을심도있게다루고있는프로그램은매우드물다. 현재임신성당뇨병임부를대상으로영양교육수혜율에대한조사결과가없어비교가어려우나본연구대상자는임신성당뇨로진단받은후영양교육을받은경험은절반이상의비율을나타냈고, 교육횟수는 2차병원에내원하는대상자의교육횟수가 3차병원에내원하는대상자비해더많았다. 그러나두그룹모두이러한영양교육이지속적이지는않았다. 영양교육수혜여부가당뇨병관리에미치는영향을살펴본 Lim 등 [28] 의연구에따르면영양교육을받은환자에서식사요법에대한지식과실천및인지도가높았지만실제공복혈당감소나당화혈색소감소에는뚜렷한차이가없었다는것을확인하였고, 이는지속적이지못한교육이일부기인한다고보고하였다. Park [29] 은당뇨교육의효과로일시적인증가를보인이행이나건강신념은장기간재교육이나자극없이방치했을때교육의효과가완전히소멸되기때문에주기적이고계속적인교육이필요할것이라고보고하였다. 이러한결과들로미루어보았을때지속적인관리를필요로하는임신성당뇨병관리에있어서 IT-기반의영양관리프로그램의개발은필수적이라고생각된다. 임신성당뇨병관리에대한영양지식점수는비교적높은것으로나타났다. 이는많은연구에서보고된바와같이당뇨교육이당뇨관리에대한지식증가에영향을미친다는결과 [28, 30] 와비슷한양상으로나타났다. 이와같은결과를나타낸이유는본연구대상자의 76% 가임신성당뇨병을판

9 한찬정 임선영 오은숙 최윤희 윤건호 이진희 215 정받은후영양교육의경험이있었고, 최근수주내에이러한교육이이루어졌기때문이라고생각된다. 그러나임신성당뇨병영양관리에있어주요한정보인 임신성당뇨병영양관리의목표, 케톤증의발생원인, 아침식사에서당질제한의중요성 항목에서는정답률이 51~52% 인것으로나타나이에대한교육이강조되어야할것으로보여진다. 임신성당뇨병임부들은식생활관리를할때외식시발생하는어려움을호소하였고이와관련된정보제공을원했으며, 당뇨관리를위한올바른식품선택및섭취한식사에대한분석과평가에대해도움을필요로했다. 또한, 영양정보및영양관리프로그램의많은문항에서요구도가높게나타나임신성당뇨병에대한영양관리의의지가높은것으로판단된다. 프로그램에서제공되는컨텐츠제공형식으로는그림이나표를선호하였고, 섭취한음식입력방법으로는카테고리안에서선택하는형식을조금더선호하여향후프로그램개발시이와같은사항을반영한다면프로그램사용성에대한만족도를높일수있을것이다. 당뇨병환자를대상으로의료급여기관형태에따른대상자의특성을파악하고자수행된몇몇선행연구 [31, 32] 에의하면, 의료기관의형태에따라방문하는대상자의특성에차이가있음을알수있었다. 이에, 임신성당뇨병환자를대상으로하는본연구에서도기관형태에따른대상자의특성과응답수준의차이파악및이를반영한결과도출을위해연구계획단계에서 2차기관과 3차기관을각각선정하여조사를수행하였으며, 자료수집후기관형태에따른층화분석을수행하였다. 그러나본연구에서는대부분의문항에서기관형태에따른차이가나타나지않았으며, 이는이환기간이길고병원에지속적으로내원하여관리를받아온당뇨병환자와다르게임신성당뇨병환자대부분은진단후치료를받기시작하는시점에있어대상자의특성이보다균일하여본연구에서파악하고자하는문항에대한응답성향에차이를보이지않았을것으로사료되었다. 본연구의결과를바탕으로추후 IT-기반의영양관리프로그램개발시임신성당뇨병임부들의개별적특성을파악하여맞춤정보를제공할수있도록연령, 임신주수, 신장및체중, 활동정도등기본정보와식사기록이가능해야하며, 입력된정보를통해열량을처방하고, 본인의식사섭취및영양상태를확인하여이에대한문제점과보완점을파악할수있도록전문가의피드백기능이반드시추가되어야할것으로생각된다. 또한다양한영양교육자료들이제공되어야하는데, 대상자들의요구도가높았던외식시메뉴선택, 올바른식품선택, 처방열량에따른식단등실생활에서쉽게활용가능한정보의제공이필요하다. 뿐만아니라임신성당 뇨병에대한기본적인개념및영양관리의목표등영양지식의정답률이낮았던문항의내용을강조하여임신성당뇨병관리에필요한지식을습득할수있도록전반적인관리에대한컨텐츠들이포함되어야하며, 이를통하여현재뿐만아니라출산후의올바른영양관리가습관화될수있는프로그램이되어야하겠다. 본연구의제한점으로는영양교육이기본적으로제공되고있는 2차, 3차병원에내원한대상자들만조사하였기때문에 1차병원이나보건소에내원하는임신성당뇨병임부들간영양관리현황및요구도에대한전반적인비교가어려웠다는점이었으며, 대상자들의식이조사가이루어지지않아대상자의실제적인영양섭취실태를파악할수없었다는점이다. 그러나현재까지국내임신성당뇨병임부를대상으로자가관리현황및영양관리프로그램에대한전반적인요구도를조사한연구는없었으며, 이는향후프로그램개발의기초자료로서가치가있다. 이에제시된결과들을바탕으로임신성당뇨병임부에게보다효과적인 IT-기반의영양관리프로그램개발이필요할것으로사료된다. 요약및결론 본연구는임신성당뇨병임부를위한 IT-기반의영양관리프로그램개발의기초자료로활용하고자서울소재의 2 차병원과 3차병원에내원하는임신성당뇨병임부 100명을대상으로대상자들의자가관리및식습관현황과영양지식, 식생활관리시의장애요인을파악하고영양정보컨텐츠와영양관리프로그램에대한요구도를조사하였다. 대상자의평균연령은 33.8 세이며평균임신주수는 28.2 주였다. 대상자의 35.4% 가식사요법과운동요법을병행하는것으로보고되었으며, 식사관리정보를얻는주요경로로인터넷활용이 50.0%, 전문가에게문의가 45.0% 로나타났다. 영양교육을받은경험이있는대상자의전체대상자의 76.0% 였고, 주로개별교육 (92.1%) 의형태로교육받은것으로나타났다. 대상자의평균영양지식점수는총 7.5±1.5 점이었으며, 정답률이약 50.0% 로낮았던문항은 케톤증의원인 (51.0%), 임신성당뇨병관리의목표 (51.0%), 아침식사에서당질제한 (52.0%) 에대한것으로보고되었다. 대상자들은식생활관리시에 외식시계획된것보다과식하게되는것 (3.0±0.7점), 외식시올바른메뉴선택 (2.9±0.7점) 등에대해어려움을느낀다고응답하였다. 임신성당뇨병임부를위한영양관리프로그램개발에있어영양정보컨텐츠요구도는 2문항을제외하고모두 3점이상의높은점수를보였는데, 이중가장높은항목은 식품의영양

10 216 임신성당뇨병임부의영양관리프로그램요구도 성분정보 (3.4±0.5점 ), 주요영양소별권장하는식품 (3.4 ±0.5점 ), 혈당과식품과의관계 (3.4±0.5점 ), 외식시식사관리요령 (3.4±0.5점) 으로나타났다. 영양관리프로그램에대해서는모든항목들이 3점이상의높은요구도를보였으며, 이중가장높은요구도를보인항목은 처방열량별권장식단제공 (3.4±0.5점 ) 이었고다음으로 적절한체중증가가이드 (3.3±0.5점), 식사일지기록과섭취량분석 (3.3±0.5점), 전문가권고 (3.3±0.5점), 노하우공유 (3.3±0.5점 ) 가높은요구도를나타냈다. 영양정보컨텐츠제공형식으로는그림이나표형식 (88.0%) 을선호하였으며, 섭취한음식입력방법으로는카테고리안에서선택하는형식 (59.0%) 을조금더선호하는것으로보여졌다. 본연구에참여한임신성당뇨병임부들은식사및운동요법, 영양교육등질병에대한관리를실천하고있었으며이와관련된영양지식정도도높은편이었으나실제식생활관리시여러가지어려움을호소하였고, 올바른질병관리를위해다양한영양정보컨텐츠와프로그램에대한요구도가높은것을알수있었다. 향후임신성당뇨병임부를위한영양관리프로그램개발의기초자료로활용될수있으며, 제시된결과들을바탕으로임신성당뇨병임부에게보다효과적인 IT-기반의영양관리프로그램개발이필요할것으로사료된다. References 1. Metzger BE. Summary and recommendations of the third international workshop-conference on gestational diabetes mellitus. Diabetes 1991; 40(S2): Paek YC, Oh MJ. Update in management of gestational diabetes mellitus. Korean J Perinatol 2009; 20(1): Jang HC. Gestational diabetes in Korea: incidence and risk factors of diabetes in women with previous gestational diabetes. Diabetes Metab J 2011; 35(1): Jang H, Jung K, Cho N, Metzger B. Gestational diabetes mellitus in Korea: is universal screening necessary? Korean J Obstet Gynecol 1996; 39(39): Jang HC, Cho YM, Park KS, Kim SY, Lee HK, Kim MY et al. Pregnancy outcome in Korean women with gestational diabetes mellitus diagnosed by the Carpenter-Coustan criteria. J Korean Diabetes Assoc 2004; 28(2): Koo YJ, Ryu HM, Yang JH, Lim JH, Lee JE, Kim MY et al. Pregnancy outcomes according to increasing maternal age. Taiwan J Obstet Gynecol 2012; 51(1): Di Cianni G, Volpe L, Lencioni C, Miccoli R, Cuccuru I, Ghio A et al. Prevalence and risk factors for gestational diabetes assessed by universal screening. Diabetes Res Clin Pract 2003; 62(2): Korean Diabetes Association Treatment Guidelines for Diabetes. 1st ed. Seoul: Goldgihoek; p Franz MJ, Bantle J, Beebe C, Brunzell J, Chiasson J, Garg A et al. Nutrition principles and recommendations in diabetes. Diabetes care 2004; 27(S1): S36-S Gunderson EP. Gestational diabetes and nutritional recommendations. Curr Diabetes Rep 2004; 4(5): Petry CJ. Gestational diabetes: risk factors and recent advances in its genetics and treatment. Br J Nutr 2010; 104(6): Choi ES, Oh JA, Hur MH, Lee IS, Choi SY. The knowledge and learning needs about gestational diabetes in pregnant women. J Korean Acad Womens Health Nurs 2000; 6(1): Park JE. Effective education strategies for women with gestational diabetes mellitus. J Korean Diabetes 2012; 13(3): Daniells S, Grenyer BF, Davis WS, Coleman KJ, Burgess JAP, Moses RG. Gestational diabetes mellitus. Diabetes care 2003; 26(2): Hjelm K, Berntorp K, Frid A, Åberg A, Apelqvist J. Beliefs about health and illness in women managed for gestational diabetes in two organisations. Midwifery 2008; 24(2): Kim H. Development and evaluation of an integrated selfmanagement program for women with gestational diabetes mellitus. J Korean Soc Matern Child Health 2013; 17(1): Park SY, Yang YJ, Kim Y. Effects of nutrition education using a ubiquitous healthcare (u-health) service on metabolic syndrome in male workers. Korean J Nutr 2011; 44(3): Nes AA, van Dulmen S, Eide E, Finset A, Kristjánsdóttir ÓB, Steen IS et al. The development and feasibility of a web-based intervention with diaries and situational feedback via smartphone to support self-management in patients with diabetes type 2. Diabetes Res Clin Pract 2012; 97(3): Han JS, Jeong JH. A web-based internet program for nutritional counseling and diet management of patient with diabetes mellitus. J Korean Soc Food Sci Nutr 2004; 33(1): Park SY, Han JS. Effects of web-based nutrition counseling on dietary behavior and food intake of type II diabetic patients. J Korean Soc Food Sci Nutr 2006; 35(4): Kim YJ, Rhee SY, Byun JK, Park SY, Hong SM, Chin SO et al. A smartphone application significantly improved diabetes selfcare activities with high user satisfaction. Diabetes Metab J 2015; 39(3): Park SY. A study on the correlation between diabetes patients' knowledge, self-care behavior and the educational demand [master's thesis]. Sahmyook University; Ahn Y, Bae J, Youn JE, Kim HS. Needs assessment for webbased self-management program by the nutrition knowledge levels of diabetic patients. Korean J Community Nutr 2011; 16(1): Choi KI. The relationships between knowledge of diabetes, barrier and compliance with sick role behavior of diabetic patients [master's thesis]. Ewha Womans University; Gastrich MD, Peck S, Janevic T, Bachmann G, Lotwala N, Siyam A. Gestational diabetes mellitus: An educational opportunity. J Diabetes Nurs 2013; 17(6): Jun JE. A study on barriers and problem solving related to dietary therapy in diabetics mellitus patients [master's thesis]. Kyungwon University; 2008.

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