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1 JMBS J Metab Bariatr Surg 2016;5(1):4-10 REVIEW ARTICLE 한양여자대학교식품영양과 백희준 Perioperative Nutritional Management of Morbid Obesity Hee-Joon Baek Department of Food and Nutrition, Hanyang Women s University, Seoul, Korea Morbid obesity is associated with several comorbidities and increase risk of mortality. To avoid risk multifactorial intervention must be implemented. Morbid obese subjects who failed dietary and medical treatment should be considered as candidates for bariatric surgery. Although bariatric surgery is the most effective and sustainable treatment for morbidly obese patients, several nutritional deficiencies and metabolic complications can occur. Therefore, the perioperative assessment of nutritional status and education in all undergoing bariatric surgery, and encouragement of adherence to supplementation are important aspects of long term result. The patient had bariatric surgery also should understand postoperative dietary habit and component. The postoperative bariatric diet is based on modification of food texture and consistency, volume of food and liquid, frequency, and duration of meal, food intolerance and nutrients requirement for the patients. In addition, the bariatric patients need to adhere to dietary guideline to optimize long-term weight loss. Therefore structured nutrition counseling and education by qualified dietitians is essential part in the lifetime management of the patients. Key Words: Morbid obesity, Postoperative bariatric diet, Nutritional management 서론 세계보건기구 (world health organization, WHO) 에의하면비만은 건강을손상시킬수있을정도로비정상적으로또는과다할정도로지방조직이축적된상태 라고정의하고있으며, 2014년전세계성인인구의 13% 가비만으로, 저체중에의한것보다과체중및비만으로인한사망률이더높다고한다 [1]. 우리나라역시 2014년도국민건강영양조사결과만 30세이상성인의비만유병률이비만은 32.9% 로 2005년이후 32-35% 수준을유지하고있다 [2]. 최근 2002년부터 2013년도에걸친검진빅 데이터를이용한최근 6년간의고도비만자의실태연구결과에서고도비만을체질량지수 (body mass index, BMI) 30 kg/m 2 이상, 초고도비만을 BMI 35 kg/m 2 이상으로정의한경우우리나라의초고도비만율은 10년사이에 0.49% 로상승하여최근 11년간 2.9배증가한것으로보고되었다 [3]. 비만은고혈압, 당뇨병, 심혈관질환및암등과관련되어생명을위협하는가장위험한요소이다. 미국의한연구에서비만으로인한사망률은 BMI 27 kg/m 2 부터증가하여 BMI 35 kg/m 2 의경우 1.8배, BMI 40 kg/m 2 의경우거의 3배에이른다고하며, 수명단축의위험률은흡연으로인한것과거의같다고한다 [4]. 고 투고일 : 2016 년 5 월 16 일, 심사일 : 2016 년 5 월 23 일, 게재확정일 : 2016 년 6 월 2 일책임저자 : 백희준, 서울시성동구살곶이길 200 한양여자대학교식품영양과우 : Tel: , Fax: , heejoon62@gmail.com Copyright 2016, The Korean Society for Metabolic and Bariatric Surgery

2 백희준 : 도비만환자는과체중또는경도비만에비해훨씬심각하게인류의건강을위협하는것으로생활습관교정과약물요법등에체중감량의반응이없는경우수술요법을권장하고있으며, 고도비만환자에게근거있는유용한치료방법으로제시되고있다 [5,6]. 비만수술이란수술을통해위장의구조변화를일으켜장기적으로충분한체중감소를유도하고, 이를통해비만과관련된동반질환을개선하여의료비절감과환자의삶의질을향상시키고비만으로인한생명의단축을예방할수있다고한다 [7]. 우리나라도 2003년비만수술인베리아트릭 (bariatric) 수술이시작되어 2011년도이후매년 1,000여건정도수술이이루어지고있는것으로보고되었다 [8]. 그러나이러한비만수술도비만의다각적치료방법중의하나이나수술후소화관구조의변화와식사섭취량의제한으로영양상태에영향을미칠수있는다양한부작용이발생할수있다. 예를들어덤핑증후군, 메스꺼움과구토, 설사와변비, 및영양소결핍등영양문제가발생할수있으며, 장기적인측면에있어서다시체중이증가하는경우도있으므로이와같은문제를최소화하기위한전문적인영양관리가필수적이다. 또한수술후연결부누출 (anastomotic leakage), 만성적인구토와메스꺼움, 심한흡수불량과설사등으로영양불량의위험이높은환자의경우영양집중지원 (nutrition support) 이필요할수있으며, 영양집중지원시환자상태에따라적절한영양공급방법 ( 경장영양대정맥영양 ) 의선택에깊은관심을기울여야한다 [5]. 따라서미국의대사비만학회 (The American Society of Metabolic and Bariatric surgery, ASMBS), 미국임상내분비학회 (American Association of Clinical Endocrinologists, AACE), 및비만학회 (The Obesity Society, TOS) 등비만관련학회에서는비만수술을앞둔고도비만환자의경우수술전후영양상태평가, 음식섭취방법, 및식습관등총체적인영양문제와관련하여전문영양사와의지속적인영양상담과교육을권장하고있다 [5,9]. 또한비만수술은음식물섭취를제한하거나영양소의흡수를억제하는방법을이용하여체중감량효과를높이는것으로영양상담과교육을담당하는영양사는적용되는수술방법과선택된수술법에따른체중감량의기전, 및발생가능한합병증에대해서잘알고업무를수행하는것이매우중요하다 [8-11]. 따라서본저자는성공적인체중감량을위해비만수술법과치료과정에따른영양상태평가및영양관리방법에대한참고문헌을검토하고자한다. 본론 1. 수술전영양상태평가및영양관리 (preoperative nutritional assessment and management) 1) 수술전영양상태평가역설적으로보이겠지만비만한사람들은과다한열량을섭취한것에비하여여러영양소의영양결핍현상이나타난다. 과체중과비만자의영양소결핍현상의원인이완벽하게이해되지않지만주요원인으로질이낮은식품의섭취즉, 열량밀도는높으나, 영양소의밀도가낮은음식섭취와관련된다고한다 [12]. 이와같은결핍현상은고도비만자가비만수술을하는경우수술방 Table 1. Monitoring schedule in patients undergoing bariatric surgery a Micronutrient Duration Presurgery 3 Mo Postsurgery 6-9 Mo Postsurgery Yearly Thiamin (vitamin B1) Cobalamin (vitamin B12) Methylmalonic acid (MMA) Vitamin D (25-hydroxyvitamin D) Calcium and intact PTH Folic acid Iron Vitamin A (BPD/DS and RYGB) Vitamin K (BPD/DS) Zinc (BPD/DS and RYGB) b Copper (BPD/DS and RYGB) b Mo = month; PTH = parathyroid hormone; BPD = biliopancreatic diversion; DS = duodenal switch; RYGB = Roux-en-Y gastric bypass. a Data based on Mechanick et al. [5]. b With clinical findings. 5

3 Vol. 5, No. 1, 2016 법과관련하여특정영양소의영양결핍위험을증가시키는데중요한역할을할수있다고한다 [13]. 따라서비만수술환자를위한 AACE/TOS/ASMBS guidelines에서는비만수술이전부터비만관련합병증을비롯한철분, 비타민B 12, 엽산, 및비타민 D 등특정영양소에대한영양검색 (nutrition screening) 및전문영양사에의한임상영양상태평가를권장한다 [5]. 또한비만수술에따른모니터링일정은다음과같으며 (Table 1), 결과에따라수술전영양제보충이되어야한다고한다 [5]. 2) 수술전체중감량비만수술전체중감량은환자상태를최적화시키는중요한사항으로, 약 10% 의체중감량은내장지방과복부지방의감소뿐아니라비만과관련된심혈관계질환, 혈전색전성 (thromboembolic) 위험요인, 만성적인전염증성상태 (pro-inflammatory status) 및호흡기전의개선효과를얻을수있다고한다 [14]. 또한수술전단기간의걸친체중감량은간의크기를줄여수술과정을용이하게하며수술시간의단축, 수술후합병증을낮출수있다고한다 [15]. 비만수술관련모든센터에서이용되는표준화된수술전식사요법은정해져있지않지만, 열량제한과엄격한탄수화물제한식은수술후합병증의위험을효과적으로감소시킬수있다고한다 [16]. Adrianzén Vargas 등 [17] 의연구에서초저열량식 (very low-calorie diet, VLCD) 은위풍선 (intragastric balloon) 보다는비용면에있어서저렴하고부작용이적으며, 저열량식 (low-calorie diet, LCD) 에비해짧은시간내목표체중감량효과를얻을수있다고한다. 또한 1일 30 g 이하의탄수화물을포함한케톤성 (ketogenic) 초저열량식은안전하나, 모든환자에게적합하지않을수있다고한다 [18]. 따라서수술전체중감량에대해아직논쟁점은남아있지만 AACE/TOS/ASMBS guidelines에서는비만수술을앞둔모든환자에게공격적인체중감량을권장하지않으며, 고위험환자의경우수술팀의신중한판단에의해적용되어야한다고제시하고있다 [5]. 2. 수술후영양상태평가및영양관리 (postoperative nutritional assessment and management) 수술후초기부터전문영양사에의한단계적식사계획과식사진행과정에대한관리가요구되며, 수술방법에따라향후적응하고실천해야할새로운식사패턴과식사원칙에대한영양교육이반드시실시되어야한다. 1) 수술방법에따른영양문제비만수술은크게음식물의섭취하는제한술식 (restrictive procedure) 과영양분의흡수억제술 (malabsorptive procedure), 그리고제한술과흡수억제술의혼합술식등으로나누며, 수술방법에따라예상되는영양문제에차이가있다. 복강경조절형위밴드술 (laparoscopic adjustable gastric banding, LAGB) 은식욕을억제하고쉽게포만감을느끼게하는제한술로비타민과무기질의결핍이다른수술방법에비하여낮다 [19]. 복강경루와이위우회술 (laparoscopic Roux-en-Y gastric bypass, RYGB) 은대표적인혼합술식으로음식물의섭취와영양소흡수제한으로체중감량효과를얻게된다. 그러나소화관의경로변화에의해덤핑증후군 (dumping syndrome) 의발생과철, 비타민B 12, 엽산, 칼슘등의대사이상으로수술후평생영양소보충이필요하다 [20]. 복강경위소매절제술 (laparoscopic sleeve gastrectomy, LSG) 은제한술로분류되지만호르몬의변화로인한당뇨병과같은대사질환의개선효과도기대하고있다. 그러나위기저부 (gastric fundus) 를포함한위의 70-80% 를절제한경우위산과내인성인자 (intrinsic factor) 의감소로미량영양소의흡수가감소될수있다 [21]. 체중감량과동반질환의치유에가장좋은결과를보이는방법이담췌십이지장전환술 (biliopancreatic diversion with/without duodenal switch, BPD/DS) 으로장기적으로볼때수술후합병증과사망률이가장높으며, 단백질과비타민, 각종무기질의치명적인흡수장애가생기며, 신장결석과대사성골질환의가능성이높다고한다 [22]. 따라서 BPD와 DS 방법은다른수술에비하여집중적인영양모니터링이필요하고예상되는결핍위험예방을위한영양보충이적시에이루어져야한다. 2) 비만수술후다량영양소요구량무기질과비타민과같은미량영양소의보충과함께최소한의탄수화물, 단백질, 지방의공급이이루어져야한다. 초기수술후식사에서권장하는열량은정해져있지않으나, 일반적으로수술후목표열량은 1일 1,000-1,400 kcal 정도이며, 더욱중요한것은충분한수분공급, 단백질공급과균형잡힌식사를섭취하는것이다. (1) 단백질 (protein): 비만수술방법에따라단백질영양불량이나타날수있는데 LAGB의경우다른수술방법에비해서덜나타나는것같으며, 특히 BPD/DS를한경우단백질의흡수불량으로인한영양불량위험이증가되는것으로보고되고있다 [19]. 전형적으로단백질영양불량은환자가단백질을불충하게섭취하거나단백질이풍부한식품에대한불내성 (intolerance) 에의해발생된다고하며 [21], 단백질식품에대한섭취개선은수술후 1년정도걸린다고한다 [16]. ASMBS에서는체단백을보존하기위해 1일 g 또는이상체중 (ideal body weight) 당 1.5 g까지의단백질섭취를권장하며, 단백질의영양불량을예방하기위해징후와증상에대한모니터링을하도록권장하고있다 [19]. (2) 탄수화물 (carbohydrate): 수술후정확한권장량은없으나, 중심신경계의충분한포도당을제공하기위해서 1일 130 g 의탄수화물을제시하고있다. 수술후환자들에게는전곡류, 콩류, 저지방유제품, 및과일등영양밀도가높은복합탄수화물을 6

4 백희준 : 권장하고있으며, 그에비해첨가당 ( 정제당 ) 이높은식품은체중증가, 덤핑증후군, 및고혈당증의원인이될수있으므로제한하도록한다 [23]. 특히 RYGB환자는정제당함량이높은식품의섭취로인하여덤핑증후군을경험할수있으며, 덤핑증후군을예방하기위한일반적인식사원칙은다음과같다 : (1) 단순당 ( 예, 설탕 ) 을피하고복합당질과섬유소를섭취한다 ; (2) 고형식을섭취하기전 30분안에액상형태의음식을섭취하지않는다 ; (3) 소량씩자주섭취한다 [5]. (3) 지방 (fat): 수술후에는저지방저열량의식사를권장하고있다. 그러나필수지방산의섭취는심혈관질환의위험감소와필수지방산의공급을위해서권장되고있다 [24]. 특히 BPD/DS 수술을받은후지방의흡수불량이총열량의 72% 까지될수있다고하며, 이와같은지방흡수불량이모든방법에서발생하는것은아니라고한다. 따라서 BPD/DS와같은수술방법에의한체중감량의효과는거의지방과단백질흡수불량에의한것이다. 장에서의지방흡수불량은지용성비타민과무기질 ( 특히, 아연 ) 의결핍위험을증가시킨다는점도고려해야한다 [19]. (4) 수분 (fluid): 적절한수분섭취는비만수술후매우중요하다. 수술후환자는 1일평균 1.5 L를마실것을권장하고있다. 수술첫날에는물을매우소량적시는수준으로시작하여점진적으로증량하며, 식후 30분후천천히마시도록한다. 식후 30분후에마시는것은식사후발생될수있는위장관증상과충분한 수분섭취를위한공간을확보하기위한것이다 [5,19]. 3) 수술후단계별식사요법비만수술후식사요법은몇주에서몇달까지단계별로진행되며, 체중조절을도모하는동안발생될수있는메스꺼움, 구토, 역류, 및설사등의합병증을최소화하기위해서천천히진행하도록한다 [23]. 일반적으로수술후제공되는식사는다음과같은단계로진행된다 [19]. (1) 1단계 : 수술방법의종류에상관없이 24시간안에맑은유동식 (clear liquid diet) 을시작할수있으나, 전문의와전문영양사와의협의가필요하다. 맑은유동식은거의열량이없는식사이며, 카페인과탄산함유식품은소화관의불쾌감의원인이되므로제한한다. (2) 2단계 : 이단계에서는고단백전유동식 (full liquid diet) 을제공하게되는데상처회복을위한에너지와단백질 (60-80 g/ 일 ) 이공급되어야한다. 단백질필요량은약 240 ml의단백질유동식을하루에 3-5회정도섭취하면충족할수있다. 단백질유동식에는 1회섭취시약 15 g 정도단백질과탄수화물 g을포함하여 kcal 정도에너지를공급하게된다. 환자에따라다르나이단계는최소 10일이상지속한다. (3) 3단계 : 이단계부터는반고형식 (semisolid diet) 이제공되며, 환자는수술후처음질감이있는식사를접하게된다. 따라서이시기에는식품에대한불내성을최소화할수있도록향후실 Table 2. Diet progression after bariatric surgery a Type of diet Duration Meal pattern Clear liquid diet 1-2 d Sip ml throughout the day Consist mostly of water Broth, 100% fruit juice, sugar-free gelatin Full liquid diet 1 d Sip 60 ml throughout the day Consist of Liquid and semiliquid at room temperature 100% fruit juice, low-fat milk, strained cream soup, smooth cooked cereal, and low-fat, sugar-free, or no sugar added pudding and custard Pureed diet 3-4 wk 6 small meals per day (60-90 ml/meal) Consist of smooth paste or thick liquid with no distinct pieces Strained, pureed, and liquid foods that are low in fat and sugar The amount per meal is based on volume (ie, fluid ounces) Mechanical soft diet 4 wk 5 small meals per day ( ml/meal) Consist of very small, tender, moist, easily chewed pieces Meat must be ground or flaked. Other foods must be chopped or mashed Foods and liquids should be low in fat and sugar Soft diet 4 wk 4 small meals per day ( ml/meal) Consist of small, tender, easily chewed pieces Foods must be chopped or diced Foods and liquids should be low in fat and sugar Regular diet Usually initiated at 3-mo follow-up a Data based on McMahon et al. [25]. 3 meals per day ( ml/meal) Consist of food of regular consistency and firmer texture as tolerated Foods of any consistency may be tried carefully Continue to choose foods and liquids low in fat and sugar 7

5 Vol. 5, No. 1, 2016 천해야하는새로운식행동에대해서교육하는것이중요하다. 이단계는최소 7-14일간지속되며, 두부, 갈아서만든생선이나닭고기, 치즈, 및요쿠르트와같이부드럽고수분이많은단백질식품과과일이나채소퓨레 (puree) 을섭취하게된다. (4) 4단계 : 최소 2주간반고형식을잘적응하면부드러운고형식 (soft solid diet) 즉, 갈거나다진육류, 통조림과일, 부드러운생과일, 부드러운채소, 계란과곡류등을섭취할수있다. 이단계에서목표로하는단백질섭취량과부드러운고형식에잘적응할때까지다음단계로의진행을권장하지않는다. (5) 5단계 : 수술후식사진행의마지막단계로우선단백질공급을중심으로채소, 과일, 전곡류등이포함된균형잡힌상식 (regular diet) 이제공된다. 이시기에는다양한식품과새로운질감의음식을천천히시도를해야한다. 비만수술후식사요법이기관별로차이가있다하더라도수술후일정기간수분과단백질공급은매우중요하며, 비만수술후식사진행단계는의료기관에따라다양하게나눌수있다 (Table 2) [25]. 대부분의국내의료기관경우수술직후수분을매우소량적시는수준의초기단계를제외한유동식, 연식, 상식등의 3 단계의식사진행으로진행되고있으며, 비만수술후단계별로활용할수있는식품은다음과같다. 수술후처음시작하는유동식의경우쌀미음과조미음, 탈지우유, 저지방우유, 무가당주스, 및무카페인음료와단백질보충제를공급하며, 다음단계인연식의경우흰죽과저지방의담백한영양죽, 연두부찜, 부드러운생선살, 계란찜, 다진살코기, 익힌채소, 무가당주스, 저지방우유및저열량의차 (tea), 그리고단백질보충제등이제공된다. 마지막단계인상식의경우수분이촉촉한흰쌀밥을주식으로연식에서제공되었던식품이외에부드러운생과일, 질긴지않은채소, 및살코기와단백질보충제등을섭취할수있으며, 이단계에서도카페인함유음료와탄산음료, 술, 및단당류를포함한아이스크림, 꿀, 설탕등은제한하도록한다. 3. 장기적체중감량을위한영양관리 (nutritional management for long-term weight loss) 일반적으로비만수술의성공은 2년후과잉체중 (excess weight) 의 50% 이상감량되는것이다. 그러나장기간에걸친 Magro 등 [26] 의연구에서비만수술 2년안에 50% 이상이다시체중이증가되었으며, 초고도비만그룹에서더높았다고한다. Freire 등 [27] 의연구에서는비만수술후 5년안에적절하게체중을유지하지못했는데그주요요인으로낮은질의식사, 신체활동의부족, 및지속적인영양관리의결여등을제시하고있다. 수술후목표이하의체중감소의주요원인은과다한에너지섭취이며 [28], 수술후식행동이수술과정과전반적인장기적인체중감량에있어서차이를보이는주요한요소라고한다 [29]. 따라서장기간에 걸친성공적인체중감량을위해환자의식사패턴에대한평가와개별화된영양관리는매우중요하다. 1) 수술후체중증가와관련된주요식사패턴체중증가와관련된식사패턴으로다음과같이 3가지로나누어생각해볼수있다. 첫번째식사패턴은가당음료수 (sweetened drinks) 와같이고열량음료수를선호하는패턴으로이와같은음식은수술한위에압력을최소한가하여포만감에거의영향을미치지않으므로고형식섭취시나타날수있는위장관증후군을피할수있다. 궁극적으로고열량의액상식품은에너지섭취량을증가시켜체중증가를초래한다. 실제 Brolin 등 [29] 은 50% 이하체중이감소된환자의과반수이상이고열량의음료를섭취하는것으로보고하였으며, 이와같은식사패턴이부적절한체중감량의주요원인으로설명하고있다. 이러한현상은 LAGB를하는경우에더욱높게나타나며, 그이유는 LAGB 이후고열량음료가변화된위장관구조에쉽게적응할수있기때문이라고한다. 따라서수술전부터환자의음료섭취습관을평가하는것이매우중요하다. 체중증가와관련된두번째패턴으로수술후고형음식물을잘씹지않아음식물섭취에의한통증, 구토, 메스꺼움등의경험으로고형식으로전환하는것을두려워하여퓨레식의섭취를그대로유지하는것이다. 그러나퓨레식은적절한포만감을제공하지못하므로체중감량에있어서도움이되지않는다. 장기간에걸친체중감량과유지를위해과일, 채소, 살코기, 가금류, 해조류, 전곡류, 및저지방의유제품등점진적인고형식을권장한다 [30]. 따라서수술후성공적인체중조절을위한영양교육과상담에서고열량음료수를선호하는습관에대한교정과동시에고형식을충분히씹는습관을갖도록교육하는것이반드시포함되어야한다 [31]. 세번째체중증가의주요원인으로과다한간식을섭취하는패턴 (Glazing) 을들수있으며, 이와같은식습관은비만수술전후환자들에게가장문제되었던습관으로, 매우소량의음식을지속적이면서도장시간섭취하는패턴이다. 한연구에서비만수술후지속적인간식을섭취하는습관의유병률이 31% 이상으로보고되었다 [32]. 특히작업환경주위에간식을섭취할수기회가많은것은가장주요한위험요인으로제시하고있다. 간식은배고픔 (hunger) 과관련된사항으로 RYGB 와 SG (sleeve gastrectomy) 의경우 ghrelin의감소로식욕이감소되는것을볼수있지만 LAGB술의경우그렇지않으므로더욱주의관찰이필요하다 [33]. 따라서비만수술후잘계획된균형식과식사와간식의적절한배분은포만감을느끼는데도움이되므로수술후식사계획시반드시고려되어야한다 [34]. 그외에도김등 [35] 에의한비만수술후영양교육기준에관한연구에서수술방법에따라체중감량에영향을미치는식사패 8

6 백희준 : 턴에차이를보이므로그에따른차별화된영양교육이이루어져야한다고한다. 2) 기타식행동관리법비만수술후성공적인체중감량과유지를위해새로운바람직한식행동에대한방법을인지하고실천하는것이중요하다. 식사는편안한환경에서천천히하며, 주위를산만하게하는환경즉, 텔레비전시청, 독서, 작업을하면서식사를하는것은피하도록한다. 다른작업을하면서식사를섭취하는경우포만감을느끼고식사를중단해야하는시기를인지하지못하고과식할수있게되기때문에주의해야한다. 또한식기는일정한크기의식기를사용하는것이섭취한음식의종류와섭취량을확인하는데도움이되며, 가능하면작은크기의식기를사용하는것이식사량조절에도움이될수있다 [9,30]. 그밖에도한연구에서비만수술이계획되어있는사람들의 50% 가주 2회패스트푸드 (fast food) 를섭취하고주 4회외식을한다고한다. 잦은외식은체중감량에도움이되지않으므로주의해야하며, 외식을하는경우주가되는식사의양을조절하고저지방과당의함량이적은식사를선택하며, 밥, 빵류및고열량음료등은기본제공량이외에추가로섭취하는습관은버리도록권장하고있다 [36]. 이상과같이관련된문헌들은검토해볼때고도비만환자의성공적인체중감량과장기간의걸친감량된체중을유지하기위해서는체계적인영양관리가지속적으로수행되어야한다. 결론 고도비만환자는행동요법및약물요법에의해서효과적으로목표체중과바람직한건강결과에도달하지못한경우수술요법이권장된다. 비만수술은짧은기간안에목표체중감량및동반질환의개선등장점이있지만시행되는수술방법의특성으로인한영양결핍을비롯한다양한영양문제가발생될수있으므로이에대한영양관리가철저하게이루어져야한다. 또한수술후일정기간이후다시체중이증가되는경향도있으므로성공적인체중감량과유지를위해비만관리를수행하는영양관리자는전문적인지식을갖고고도비만치료전과정에걸쳐주기적인영양상태평가와영양상담을실시해야한다. REFERENCES 1. Available at: en/accessed January, Available at: October 6, Available at: November 9, Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 2003;289: Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013;9: Kushner RF. Weight loss strategies for treatment of obesity. Prog Cardiovasc Dis 2014;56: Lee JH. Bariatric surgery. Korean J Med 2013;84: Heo YS, Park JM, Kim YJ, et al. Bariatric surgery versus conventional therapy in obese Korea patients: a multicenter retrospective cohort study. J Korean Surg Soc 2012;83: Kim MJ, Hur KY. Perioperative management of patients after bariatric surgery. J Metab Bariatr Surg 2012;1: Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic Association. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2009;109: American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Obesity Expert Panel, Executive summary: Guidelines (2013) for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the Obesity Society and American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Based on a systematic review from the The Obesity Expert Panel, Obesity (Silver Spring) 2014;22 Suppl 2:S Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009;56: Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294: Tarnoff M, Kaplan LM, Shikora S. An evidenced-based assessment of preoperative weight loss in bariatric surgery. Obes Surg 2008;18: Fris RJ. Preoperative low energy diet diminishes liver size. Obes Surg 2004;14: Rickers L, McSherry C. Bariatric surgery: nutritional considerations for patients. Nurs Stand 2012;26: Adrianzén Vargas M, Cassinello Fernández N, Ortega Serrano J. Preoperative weight loss in patients with indication of bariatric surgery: which is the best method? Nutr Hosp 2011;26: Hite AH, Berkowitz VG, Berkowitz K. Low-carbohydrate diet review: shifting the paradigm. Nutr Clin Pract 2011;26: Allied Health Sciences Section Ad Hoc Nutrition Committee, Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the surgical weight loss patient. Surg Obes Relat Dis 2008;4:S Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138: Isom KA, Andromalos L, Ariagno M, et al. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract 2014;29: Scopinaro N. Biliopancreatic diversion: mechanisms of action and long-term results. Obes Surg 2006;16: Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for pa- 9

7 Vol. 5, No. 1, 2016 tients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc 2010;110: Moizé VL, Pi-Sunyer X, Mochari H, Vidal J. Nutritional pyramid for post-gastric bypass patients. Obes Surg 2010;20: McMahon MM, Sarr MG, Clark MM, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc 2006;81:S Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg 2008;18: Freire RH, Borges MC, Alvarez-Leite JI, Toulson Davisson Correia MI. Food quality, physical activity, and nutritional follow-up as determinant of weight regain after Roux-en-Y gastric bypass. Nutrition 2012;28: Conason A, Teixeira J, Hsu CH, Puma L, Knafo D, Geliebter A. Substance use following bariatric weight loss surgery. JAMA Surg 2013;148: Brolin RE, Robertson LB, Kenler HA, Cody RP. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg 1994;220: Parkes E. Nutritional management of patients after bariatric surgery. Am J Med Sci 2006;331: Ahn SH. Nutritional management of bariatric surgery. J Korean Diabetes 2013;14: Colles SL, Dixon JB, O'Brien PE. Loss of control is central to psychological disturbance associated with binge eating disorder. Obesity (Silver Spring) 2008;16: Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252: McGrice M, Don Paul K. Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions. Diabetes Metab Syndr Obes 2015;8: Kim HJ, Namgung SA, Hong JI, Mok HJ. A study on the standards of medical-nutritional-education by the type of bariatric surgery in morbid-obesity patients. J Korean Diet Assoc 2010;16: Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord 2015;48:

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