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1 대한내과학회지 : 제 87 권제 2 호 특집 (Special Review) - 순환기분야에서최근개정된새로운가이드라인 심혈관위험을낮추기위한생활습관관리 전남대학교의과대학전남대학교병원순환기내과 박형욱 Lifestyle Management to Reduce Cardiovascular Risk Hyung Wook Park Division of Cardiovascular Medicine, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea A healthy lifestyle is important in the prevention and delayed progression of cardiovascular disease (CVD). The intent of this lifestyle management guideline review is to evaluate evidence describing particular dietary patterns, nutrient intake, and levels and types of physical activity associated with CVD risk. The recommendations of this article may be used in management of hypercholesterolemia and hypertension. The proposed guidelines emphasize the importance of dietary patterns rather than individual dietary components. Dietary patterns offer the opportunity to characterize the overall composition and quality of the eating behaviors of a population, such as a Mediterranean-style diet. Dietary sodium and potassium are particularly relevant in CVD due to their effects on blood pressure, while substantial epidemiologic evidence links higher levels of aerobic physical activity to lower rates of CVD and other chronic diseases such as Type 2 diabetes mellitus. This indicates that weight loss and maintenance are critical for prevention and control of CVD risk factors. (Korean J Med 2014;87: ) Keywords: Life style; Cardiovascular diseases; Risk 서론건강한생활습관은전세계적으로높은발생률과사망률의중요원인인심혈관질환예방에중요하다. 생활습관관리가심혈관질환으로인한심각한사회적, 경제적손실을경감시킬수있는중요한요소임에도불구하고이에대해서는고혈압, 관상동맥질환, 이상지질혈증, 심부전, 부정맥등에대한새로운치료지침이나날이변화되어감에도불구하 고그중요성에비하여권고안이부족했던것이사실이다. 2008년 National Heart, Lung, and Blood Institute (NHLBI) 가이전까지보고된심혈관위험인자를체계적으로분석하고심혈관위험인자변조에대한논문들을분석하여 2013년새롭게발표된이번 AHA/ACC 지침은특히식생활양식, 영양섭취, 신체활동의강도와유형이심혈관질환예방에미치는영향을분석하고고혈압과이상지질혈증치료등이중요함을강조하고있다 [1-6]. 이번권고안의특징중하나는 Correspondence to Hyung Wook Park, M.D. Department of Cardiovascular medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jaebong-ro, Dong-gu, Gwangju , Korea Tel: , Fax: , mdhwp@chol.com Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - The Korean Journal of Medicine: Vol. 87, No. 2, 식생활습관변조부분에서음식의성분보다는생활양식, 특히식습관 (dietary pattern) 을권장하고있으며고혈압조절을위하여염분섭취조절의중요성을강조하고있다는것이다. 신체활동의경우상당한강도의유산소운동은심혈관질환, 제2형당뇨병과같은만성질환을예방할수있고운동의강도와만성질환발생률은반비례관계에있다고보고하였다. 이글에서는심혈관위험을줄이기위한 2013 AHA/ACC 권고안을간략히소개하고자한다. 본론지중해식식습관이혈압과지질에미치는영향신선한과일, 야채, 녹황색채소, 전곡 (cereals, breads, rice, or pasta), 오메가-3-지방산이풍부한기름진생선 (fatty fish) 섭취를늘리고붉은색고기류 (red meat) 섭취는줄이며저지방또는무지방유제품, 견과류, 올리브또는카놀라오일, 평지씨 (rapeseed) 나아마씨 (flaxseed) 로만든마가린등을섭취하도록한다. 이런식생활습관은전체지방섭취를 32-35% 로줄일수있고, 포화지방산함량은 9-10%, 섬유소는 g/day 정도이다. 당뇨병이있고 3개이상의심혈관위험인자를갖고있는사람이지중해식식습관으로음식섭취를하면혈압을 6-7/2-3 mmhg 낮출수있고젊고건강한사람도혈압을 2-3/1-2 mmhg 낮출수있다. 그러나 LDL-C, HDL-C 와중성지방에대해일관적인연구결과는없어지질에대한영향은아직명확하지않다 [7-11]. DASH (dietary approach to stop hypertension) 식습관이혈압과지질에미치는영향 DASH 식습관은야채, 과일, 저지방유제품, 전곡, 가금, 생선, 견과류등은많이섭취하고감미료나설탕이함유된음료, 붉은고기등은적게먹는것이다. DASH 식습관은음식중포화지방, 전체지방, 콜레스테롤의함량은줄이고칼륨, 마그네슘, 칼슘, 단백질, 섬유소함량은올릴수있다. 혈압이 /80-95 mmhg 인경우 DASH 음식섭취를하면혈압을 5-6/3 mmhg 정도낮출수있으며총콜레스테롤 < 260 mg/dl, 저밀도지단백콜레스테롤 < 160 mg/dl인경우에 DASH 식습관으로음식섭취를하면 LDL-C를 11 mg/dl, HDL-C를 4 mg/dl 낮출수있다. 그러나중성지방에는영향이없다 [12-14]. 염분과칼륨 : 혈압과심혈관질환의예후에대한영향비타민과미네랄은일반적으로음식을통해얻게되므로때로는각각의미네랄성분들이심혈관질환예후에미치는영향을따로떼어내분석하는것이가능한데이번지침에서는주로염분과칼륨에대해서만언급을하고있다. 다른미네랄 ( 칼슘, 마그네슘등 ) 도심혈관질환에대하여영향이있으나이들미네랄섭취는특정식품이나식품군에제한적으로존재하기때문에제외되었다. 염분과혈압 : 음식으로섭취하는염분이혈압에미치는영향 25-80세성인이혈압 /80-95 mmhg 일때염분섭취를제한하면혈압을낮출수있는데이번지침에서염분섭취정도를가늠하는측정방법으로소변으로배출되는염분의양을제시하고있다. 하루염분배출량이 3.3 g/day에서 2.4 g/day로염분섭취를줄이면혈압을 2/1 mmhg 정도낮출수있고 1.5 g/day로줄이면 7/3 mmhg 감소시킬수있다. 고혈압존재유무와관련없이 30-80세에서하루염분배설량이 1.5 g이되도록염분섭취를제한하면혈압을 3-4/1-2 mmhg 낮출수있다 [14-16]. 염분과식습관변경 20-80세에서혈압이 /80-95 mmhg 인경우염분섭취를제한하고식습관변경을함께하면염분섭취만제한하는경우보다더혈압을낮출수있는데하루염분섭취를 1 g 줄이면심혈관계질환사고발생률을 30% 감소시킬수있다. 염분을과다섭취하게되면심혈관질환및심각한뇌졸중발생빈도가높아진다. 염분섭취과다가심부전발생과관련이있는지에대한증거는충분치않다. 심부전이있는환자에서염분섭취제한이심혈관질환예후에미치는영향에대해서도역시증거가충분치않다 [17-19]. 칼륨섭취가혈압및심혈관질환예후에미치는영향혈압조절, 염분섭취제한, 칼륨섭취를늘리면뇌졸중발생빈도가줄어든다는관찰연구가있으나칼륨섭취가직접적으로혈압강하에대해미치는효과는아직확실치않으며관상동맥질환, 심부전, 심혈관계사망률과의연관성에대한증거도충분치않다 [20-22]. 혈압조절을위한권장식습관 1) 야채, 과일, 전곡 (whole grain), 저지방유제품, 가금류, 생선, 콩류, 비열대성 (non-tropical) 식물성유지및

3 - Hyung Wook Park. Lifestyle management to reduce cardiovascular risk - Table 1. Summary of recommendations for lifestyle management Recommendations NHLBI Grade ACC/AHA COR ACC/AHA LOE DIET LDL-C: Advise adults who would benefit from LDL-C lowering to: 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet A (strong) I A 2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. A (strong) I A 3. Reduce percent of calories from saturated fat. A (strong) I A 4. Reduce percent of calories from trans fat. A (strong) I A BP: Advise adults who would benefit from BP lowering to: 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet. A (strong) I A 2. Lower sodium intake. A (strong) I A 3. a. Consume no more than 2,400 mg of sodium/d; b. Further reduction of sodium intake to 1,500 mg/d can result in even greater reduction in BP; and c. Even without achieving these goals, reducing sodium intake by at least 1,000 mg/d lowers BP. B (moderate) IIa B 4. Combine the DASH dietary pattern with lower sodium intake A (strong) I A PHYSICAL ACTIVITY Lipids 1. In general, advise adults to engage in aerobic physical activity to reduce LDL-C and non-hdl-c: 3-4 sessions per wk, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity. B (moderate) IIa A BP 1. In general, advise adults to engage in aerobic physical activity to lower BP: 3-4 sessions per wk, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity. B (moderate) IIa A NHLBI, National Heart, Lung, and Blood Institute; ACC, American College of Cardiology; AHA, American Heart Association; COR, class of recommendation; LOE, level of evidence; LDL-C, low density lipoprotein-cholesterol; DASH, dietary approach to stop hypertension; USDA, United States of Department of Agriculture; BP, blood pressure; HDL-C, high density lipoprotein-cholesterol

4 - 대한내과학회지 : 제 87 권제 2 호통권제 648 호 견과류를섭취하도록권장하며감미료, 설탕함유청량음료 (sugar-sweetened beverage), 붉은고기류 (red meat) 섭취는제한한다. 2) 염분섭취를제한한다. 3) 하루염분섭취량은 2.4 g 이하로제한한다. 하루 1.5 g 이하로제한하면혈압강압효과는더커지며이를더욱권장한다. 고혈압이있거나고혈압전단계인경우에는하루 1 g 이하로줄이면고혈압발생을예방하고조절을용이하게하며심혈관사고발생을줄일수있다. 4) DASH 음식습관으로변경을권장한다. 운동 : 지질과혈압성인에서유산소운동은 LDL-C 를 3-6 mg/dl, non-hdl-c 는 6 mg/dl 낮출수있으나중성지방에대한효과는일관되지않다. 근력운동은 LDL-C, TG, non-hdl-c 를 6-9 mg/dl 낮출수있으며 HDL-C에대한효과는없다. 고혈압존재유무와상관없이유산소운동은수축기혈압 2-5 mmhg, 이완기혈압 1-4 mmhg 을감소시킨다. 근력운동이혈압조절에미치는영향은일관된연구결과들이불충분하다. 운동은 LDL-C, non-hdl-c 를떨어뜨리기위하여주 3-4회, 1회에 40분이상, 중-고강도 (moderate-to-vigorous intensity) 의운동을권장한다. 혈압강하를위해서도같은양의운동을권장한다 [23-25]. 요약음식저밀도지단백조절야채, 과일, 전곡 (whole grain), 저지방유제품, 가금류, 생선, 콩류, 비열대성 (non-tropical) 식물성유지및견과류를섭취하도록권장하며감미료, 설탕함유청량음료 (sugar-sweetened beverage), 붉은고기류 (red meat) 섭취는제한한다. 포화지방산으로부터얻는칼로리는전체칼로리의 5-6% 정도로유지되도록하며포화지방산섭취를줄인다. 트렌스지방으로얻는칼로리도줄인다. 혈압조절야채, 과일, 전곡 (whole grain), 저지방유제품, 가금류, 생선, 콩류, 비열대성 (non-tropical) 식물성유지및견과류를섭취하도록권장하며감미료, 설탕함유청량음료 (sugar-sweetened beverage), 붉은고기류 (red meat) 섭취는제한한다. 염분섭 취를줄여하루염분을 2,400 mg 이상섭취하지않도록한다. 1,500 mg 이하로줄이면혈압감소효과가더크다. 운동 지질저밀도지단백 (LDL-C) 및비고밀도지단백 (non-hdl-c) 을감소시키기위하여중-고강도 (moderate-to-severe intensity) 유산소운동을 1회평균 40분, 주 3-4회하도록권장한다. 혈압 혈압을낮추기위하여도같은정도의유산소운동을중- 고강도 (moderate-to-severe intensity) 로 1회평균 40분, 주 3-4 회하도록권장한다. 결 지금까지식생활습관조절, 운동등이혈중지질및혈압에미치는영향을최근발표된지침을통하여살펴보았다. 심혈관질환의발생, 사망률을감소시키기위하여권장하는지중해식, DASH 식습관, 운동강도, 시간등도제시되었다. 그러나이런지침과지금까지알려진많은전략들이일차진료의사, 공중보건시스템, 지역또는정부, 지역사회등에서환자들에게어떻게알리고교육되어야할지에대한연구와노력이필요하겠다. 론 중심단어 : 생활습관 ; 심혈관질환 ; 위험 REFERENCES 1. Eckel RH, Jakicic JM, Ard JD, et al AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation 2014;129(25 Suppl 2):S Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Srinath Reddy K, Katan MB. Diet, nutrition and the prevention of hypertension and cardiovascular diseases. Public Health Nutr 2004;7(1A): Diet, nutrition, and the prevention of chronic diseases:

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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