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1 Review Article J Clin Nutr 2016;8(2):45-50 pissn ㆍ eissn 경장영양액조성물에서다량영양소와미량영양소 ( 비타민, 무기질 ) 의원재료 김수희 대상 ( 주 ) 웰라이프식품사업총괄뉴트리션마케팅 Sources and Formulation of Macro- and Micro-Nutrients in Enteral Nutrition Formula Nutritional Food Business Unit, Daesang Corp. Enteral feeding therapy has existed since ancient Egypt, but most of the major advances in enteral nutrient techniques and formulas have taken place during the 20th century through the development of sources and ingredients This review provides a historical account of enteral nutrition (EN), including the sources and formulation of macro-and micro-nutrients in the formula and how to manufacture them. The formulas were improved by the development of raw materials that are easier to digest and the next formula is expected to develop functionality using more raw materials, such as -3, amino acid, and more functional ingredients to heal the disease. Key Words: Enteral feeding, Enteral nutrition, Enteral nutrition formula 서론 1. 환자용영양식 (medical enteral nutrition) 의역사경장영양 (enteral nutrition) 은영양공급뿐아니라소화기관의괴사를막고, 면역을증강시키는역할을한다. Gut is action, eat. 은경장영양의가이드라인을명쾌하게함축한문장이다. 고대이집트에서부터곡류와와인, 우유를원료로하여관을이용한피딩 (feeding) 을했다고알려져있으며, 1, 2차대전이후로튜브를이용한경장영양식의공급방법이더욱발전하였 고, 영양식의원료들도아미노산, 비타민과무기질등소화하기보다용이하게정제된다양한원료들을이용하였다. 1939년에보트엔로슨사 (Abott and Rawson) 에서페닐케토뇨증 (phenylketonuria) 환자를위한최초의상업적환자식이출시된이래로전세계약 10조원규모 (2010년) 로성장하였고, 에보트 (Abbott), 네슬레 (Nestle) 등 (Fig. 1) 의다국적회사들이전세계환자식시장의 50% 이상시장점유율을가지고있으며, 단순한식사대 Received Aug 11, 2016; Revised Aug 18, 2016; Accepted Aug 19, 2016 Correspondence to Nutritional Food Business Unit, Daesang Corp., 470 Myeonmok-ro, Jungnang-gu, Seoul 02154, Korea Tel: , Fax: , cosmos1018@daesang.com Conflict of interest: None. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Fig. 1. Clinic nutrition product, global strategic business report c 2016, The Korean Society for Parenteral and Enteral Nutrition. All Rights Reserved.

체를넘어면역및질환의개선및소화에용이한원료들이발전하며, 환자의질환및상태에맞춘다양한상업적환자식시장이형성되었다. 1 환자식 (medical food) 의발전은결국식품원료를소화및공급하기쉽게가공, 정제, 기능화하였느냐에의해발전해왔으며본론에서보다자세히환자식에사용되는원료들과영양학적의미에대해서알아보고자한다.

2 체를넘어면역및질환의개선및소화에용이한원료들이발전하며, 환자의질환및상태에맞춘다양한상업적환자식시장이형성되었다. 1 환자식 (medical food) 의발전은결국식품원료를소화및공급하기쉽게가공, 정제, 기능화하였느냐에의해발전해왔으며본론에서보다자세히환자식에사용되는원료들과영양학적의미에대해서알아보고자한다. 원료가엄격히정해져있고, 식품위생법에따라사용한모든원료를제품표시기준에맞추어소비자에게공개해야한다 ( 완전표시제 ) (Fig. 2). 상업적환자용영양식 (commercial medical enteral nutrition) 은각영양소원료뿐아니라및소화력개선및적응증을증대하기위한원료뿐아니라제조 / 유통중안정성을더하기위해 50여가지가넘는다양한원료들이사용된다. 2 본론 1. 환자용영양식제조및가공규격 1911년 CODEX (Codex Alimentarius Commission, 국제식품규격위원회 ) 에서는환자용식품에대한정의및표시지침및사용원료에대해회원국들에게제시하였고, 우리나라에서는식품공전내 특수의료용도등식품 의규격에따라제조, 가공, 관리, 유통되고있다. 국내에도특수의료용도등식품은식품공전상 환자용균형영양식, 당뇨, 시장, 장질환, 열량및영양공급용, 선천성대사질환, 영유아환자용, 연하곤란자용 으로 8가지규격기준에따라제조가공되며, 원료및함량등도공전상사용할수있는식품 2. 환자용영양식원료 1) 단백질 (protein) 주요한대량영양소 (macro nutrient) 로서단백질은대량으로생산이가능하며안정적인공급이되는단백질인우유유래한단백질과콩단백질을소화하기쉽도록정제, 가공한원료들을사용한다. 우유에는카제인 (casein) 과유청 (whey) 이라는두가지형태의단백질이약 80:20의비율로함유되어있는데 (Table 1) 소 Fig. 2. The labelling requirement of medical food complying with the rule of Korea Food and Drug Administration. Fig. 3. The milk based proteins and functional material. WPC = whey protein concentrate; WPI = whey protein isolate; WPH = whey protein hydrate, GOS = galactooligosaccharide; MPC = milk protein concentrate; MPI = milk protein isolate. Table 1. The general characteristics of milk protein sources Product Heat stability Solubility Viscosity Taste Color in 10% solution WPC80 Neutral/dairy Cream WPI Neutral/dairy Cream Hydrolyzed Protein Bland Cream/light yellow Esprion300 Milky White/cream Calcium caseinate Bland/neutral Milky Sodium caseinate Bland/neutral White MPC85 Milky White MCI88 Milky White Total milk protein Full/milky White/cream WPC = whey protein concentrate; WPI = whey protein isolate; MPC = milk protein concentrate; MCI = micellar casein isolates. 46 Journal of Clinical Nutrition

Sources and Formulation of Macro- and Micro-Nutrients in EN Formula 화흡수속도및열안정성, 아미노산조성및맛등에차이가있어, 단백질의종류및비율, 유당및지방의함량을조절하여정제가공한뒤, 환자식뿐만아니라유가공식품의원료로사용한다 (Fig. 3).

concentrate/whey protein isolate) 가분말용환자식의원료로사용된다.

3 Sources and Formulation of Macro- and Micro-Nutrients in EN Formula 화흡수속도및열안정성, 아미노산조성및맛등에차이가있어, 단백질의종류및비율, 유당및지방의함량을조절하여정제가공한뒤, 환자식뿐만아니라유가공식품의원료로사용한다 (Fig. 3). 카제인나트륨과카제인칼슘은단백질함량이 90% 이상으로, 우유가공단백질중가장단백질함량이높고, 열안정성과유화력이좋아지방원료와함께사용해야하는액상타입의상업적환자용영양식에주요단백질원료로가장많이사용되며, 이외에도맛이뛰어난농축유단백 (milk protein concentrate) 과소화흡수속도는높지만멸균시열안정성이떨어지는유청단백질류 (whey protein concentrate/whey protein isolate) 가분말용환자식의원료로사용된다. 3 최근에는콩에서유래한분리대두단백 (isolated soy protein, ISP) 이란원료도상업적환자용영양식의단백질급원으로많이사용되는데식물성단백질임에도단백질품질평가법 (protein digestibility corrected amino acid score, PDCAAS) 수치가 1 이상으로정제한완전단백질로서, 특히글루타민과아르기닌의함량이높고, 최근문제가되는탄소배출량도적어미래단백질로각광받고있다 (Fig. 4). 3 특히, 상업적환자용영양식에 ISP와우유유래단백질을섞어서사용할경우에아미노산조합이보다풍부해지며, 포만감의시간을늘려줄수있는등다양한이점이보고되고있다 (Table 2). 4 2) 지방 (fat) 또다른대량영양소인지방은주로대두유, 옥배유, 유채씨유, 올리브유등불포화지방산함량이높은식물성유지를주요원료로사용하며일가불포화지방산 (monounsaturated fatty acid, MUFA) 과다가불포화지방산 (polyunsaturated fatty acid, PUFA), 포화지방산 (saturated fatty acid, SFA) 의적절한비율에맞춰조성물을만든다 (Fig. 5). 5 PUFA인오메가-3 DHA/EPA는원료인정제어유특유의비린취로일반식품에다량으로사용하기어려움이있으나, 최근식품가공법의발달로상업적환자용영양식에일부사용중이다. 그러나환자의상태와임상방법에다양한논의가있으며, 섭취량의가이드라인도조금씩다르다 (Table 3). 지방은불포화지방산의급원이자열량을내는영양소이지만, Fig. 5. The fatty acid composition of vegetable oils. 5 Table 3. Recommended daily allowance of ω-3 based the diffrent institutions Fig. 4. Protein quality of commonly consumed proteins and usable protein per acre of farmland. 3 Institution British Nutrition Foundation UK Department of Health Committee on Medical Aspect of Food and Nutrition Policy (COMA) Health and Welfare Canada International Society for the Study of Fatty Acids and Lipids (ISSFAL) National Nutrition Council (Norway) German Nutrition Society American Heart Association Recommended allowance 1.2 g/day DHA/EPA g/day DHA/EPA g/day DHA/EPA g DHA/EPA/LNA 0.44 g DHA/EPA 1.2 g/day Omega-3 FA g/day Omega-3 FA 900 mg day DHA/EPA Table 2. Protein blend benefits for athletes and active individuals 4 Protein Compete protein Digestion rate Lean body mass gains High in leucine High in arginine & glutamine Antioxidant activity Whey O Fast O O Soy O Intermediate O O O Casein O Slow O Combined O Prolonged O O O O Volume 8, Number 2, August

4 소화가잘되지않는다는단점이있다. Medium chain triglyceride (MCT oil의경우간문맥으로흡수되므로일반적인식이지방보다흡수가빠르고에너지효율 (8.3 kcal/g) 이좋아서지방흡수불량환자들에게효과적으로열량을공급할수있으며, 케톤식이요법이필요한환자와질병등으로대사량이높아진환자 ( 외상, 화상, 암등이화상태환자 ) 에게주요열량급원으로사용되기도한다. 3) 탄수화물 (carbohydrate) 탄수화물은단당류, 이당률, 올리고당, 다당류, 당알콜등으로나뉘나이소스를사용할경우삼투압이증가하면서설사등소화, 흡수와관련된다양한부작용이발생하게된다. 특히과민성대장질환 (inflammatory bowel disease, IBD) 환자의경우최근포디맵 (FODMAP) 으로통칭되는탄수화물에의한대사질환에문제가제기되고있다. 그러므로대부분의상업적환자식에는복합당질인콘시럽 ( 또는말토덱스트린 ) 을사용하며, 글루코스의중합체형태인말토덱스트린은일반적으로옥수수의스타치 (starch) 에서정제하여만드는데, dextrose equivalent (DE) 에따라다양한물성적특성을보이고 (Fig. 6), 삼투압 mosm/kg인인체의삼투압에맞추기위해 DE=11 18 분포를가진말토덱스트린을사용한다. DE의분포도가보다기준값에밀집된포물선을가질수록품질이우수하며, 목적하는삼투 압을맞출수가있기때문에스타치의정제공정이중요하다. 또한 DE 분포는최종제품의텍스처 (texture) 와색상에영향을끼친다. 5 4) 식이섬유 (fiber) 식이섬유는비영양소 (non-nutrient) 로분류되었으나, 장내융모기능을개선시키고, 체내콜레스테롤및지질을낮추고, 설사및변비개선, 혈당개선, 무기질흡수촉진등다양한건강상의잇점으로, 일반적인환자용영양식제품에질환개선효과를주는기능성원료이다. 전통적인분류법으로수용성과불용성식이섬유로나누었으나, 최근에는식품가공기술의발달로이경계가무너져, 두가지식이섬유의특징과기능성효과를가진원료들이개발되어, 경관급식시발생하는설사및변비개선에도움을주고있다. 6 환자용영양식에가장많이사용하는수용성식이섬유는치커리에서추출한이눌린, 스타치에서합성한폴리덱스트로스또는난소화성식이섬유가가장많이사용되는원료이고, 최근네슬레나에보트 (Abbott) 사의제비티 (Jevity) 나네슬레 (Nestle) 사의부스트 (Boost) 에사용하는 Sunfiber와 Soyfiber라는원료는구아검과대두에있는불용성식이섬유성분을가수분해하여분자사이즈를 20,000까지낮춰불용성화이바의특징인수분함습효과와변량개선효과를주어설사및변비를개선하면서도수용성식이섬유가가지는프리바이오틱 (perbiotics) 의효과와혈당개선의효과가있다 (Table 4). 7 Fig. 6. The change of meterial property according of dextrose equivalent. 5) 비타민 / 무기질 (vitamins& minerals) 비타민과무기질은미량영양소 (mircro nutrient) 로국가마다허용된원료에차이가있다. 그래서해외에서판매되는환자용영양식제품중국내에서유통이어려운경우도있다. 비타민의경우생산공정중가장많이파괴되는영양성분이므로생산및유통중파괴율을감안하여첨가용량을설정한다 (Fig. 7). 일반적으로액상타입의상업적멸균식은생산공정중배합과열공정이있기때문에산화또는열에의한파괴율을 Table 4. Clinical test about functionality of various fibers Sunfiber Poly dextrose Indigestible dextrin Inulin Improve constipation In volunteer test In volunteer test In volunteer test In volunteer test Improved tolerance and bifidobacteria use In volunteer test In animal/volunteer test In volunteer test In volunteer test Reduced the cholesterol and fat In animal/volunteer test In animal/volunteer test In animal/volunteer test In animal/volunteer test Improved glycaemic response In animal/volunteer test In volunteer test In animal/volunteer test In animal/volunteer test Increasing electrolyte absorption In animal test In animal test Improved chorionic ileum In animal test Reduced days with diarrhoea In volunteer test 48 Journal of Clinical Nutrition

Sources and Formulation of Macro- and Micro-Nutrients in EN Formula Fig. 7. The stability of vitamins. Fig. 9. The accident agreement of medical food, Nucare. 3.

국내특수의료용도등식품에의무적으로첨가해야하는비타민은비타민 A, B1, B2, B6, C, D, E, 나이아신, 엽산으로총 9가지이지만, 시판되는환자식의대부분이인체에필요한모든비타민류를고함량으로함유하고있다.

무기질또한국내에서규격으로첨가해야하는것은칼슘, 철, 아연으로 3가지이지만인체에필요한모든무기질및극미량무기질인셀렌, 몰리브댄, 크롬까지함유한제품이판매되고있다.

5 Sources and Formulation of Macro- and Micro-Nutrients in EN Formula Fig. 7. The stability of vitamins. Fig. 9. The accident agreement of medical food, Nucare. 3. 환자용영양식의제조공정이런다양한원료들을정확히계량하고, 혼입하고, 배합및유화공정을거쳐서멸균하여위생적인상업적환자용영양식이만들어진다. 프로세싱후에도유통중제품이안정성및맛테스트를통해제품이소비자에게제공된다 (Fig. 9). Fig. 8. The different proterty accoiding the calcium salts. 결 론 가장많이고려한다. 국내특수의료용도등식품에의무적으로첨가해야하는비타민은비타민 A, B1, B2, B6, C, D, E, 나이아신, 엽산으로총 9가지이지만, 시판되는환자식의대부분이인체에필요한모든비타민류를고함량으로함유하고있다. 국내비타민류의시험법은식품공전에 Association of Official Analytical Chemists (AOAC) 등국제적으로공인된다양한분석방법을이용하여분석하나, 다양한매트릭스에서시험법의적용성을평가한연구결과가부족하여분석의오차가가장많은영양소중하나로서오랜기간제품의생산및관리, 분석방법을보유하여야만비타민의함량을제대로첨가할수있는노하우를보유할수있다. 무기질또한국내에서규격으로첨가해야하는것은칼슘, 철, 아연으로 3가지이지만인체에필요한모든무기질및극미량무기질인셀렌, 몰리브댄, 크롬까지함유한제품이판매되고있다. 무기질의경우는제품에첨가시공정중에다른영양소, 특히단백질등과반응하여침전및크리밍을만들기도하고, 비타민을산화시키는등까다로운원료이므로최대한다른영양소와반응하지않는원료를선정하고, 또한맛과색깔에도영향을미치므로이런특성을고려하여원료를선정한다. 예를들어칼슘의경우에도다양한원료가있으나, 이중제품의생산공정및다른영양원료의특성을고려하여제품개발시투입할원료를선정한다 (Fig. 8). 보다기능적이고질환개선에도움을주는제품을만들기위해선행되어야하는것은바로기능성원료를상업적환자용영양식조성에적용하는것이다. 최근엔슈어는근손실을방지해주는제품에 HMB ( -hydroxy- -methylbutyrate) 라는원료를적용하여, 보다기능적인제품인 Revigor라는신제품을출시하였다. 최근새로개발된감미료인 Xtend라는원료는탄수화물분해속도를줄여주면서글루코스및인슐린반응속도를저하시켜당뇨환자에게좋은원료를공급하고있으나, 국내에서는이런기능성원료들의허가가되어있지않아질환용환자들에게보다도움을주는상업적환자용영양식제품개발에어려움이있다. 보다효과적이고다양한질환제품을개발하는데걸림돌이되고있으므로선행해서풀어야하는부분중하나이다. 고령화속도가빠른우리나라에서도다양한기능성원료들이 2006 년부터건강기능식품의원료로서질환을예방또는개선할수있는원료들이개발및허가되고있으나, 환자용영양식에적용하기에는아직인체적용시험및다른영양소와의상관관계에대한연구가부족하여적용하기에어려움이있어, 국내외적으로보다다양한연구가필요하다. REFERENCES 1. Harkness L. The history of enteral nutrition therapy: from raw Volume 8, Number 2, August

6 eggs and nasal tubes to purified amino acids and early postoperative jejunal delivery. J Am Diet Assoc 2002;102(3): Institute of Medicine of the National Academies. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Washington, DC:The National Academies Press; Hughes GJ, Ryan DJ, Mukherjea R, Schasteen CS. Protein digestibility-corrected amino acid scores (PDCAAS) for soy protein isolates and concentrate: criteria for evaluation. J Agric Food Chem 2011;59(23): Paul GL. The rationale for consuming protein blends in sports nutrition. J Am Coll Nutr 2009;28(Suppl):464S-472S. 5. Alimentarius, Codex. Codex standard for named vegetable oils. Codex Stan 210;1999. Available from: pdf/180/ pdf. 6. Marchal LM, Beeftink HH, Tramper J. Towards a rational design of commercial maltodextrins. Trends in Food Sci Technol 1999;10(11): European Food Safety Authority. Scientific Opinion of the Panel on Dietetic Products, Nutrition and Allergies on a request from the EC on population references intakes for carbohydrates and dietary fibre. EFSA J 2008;894: Journal of Clinical Nutrition

어린이기호식품1회제공량표시-결과보고서-줄임.hwp

어린이기호식품1회제공량표시-결과보고서-줄임.hwp 우리는소비자와함께행복한세상을만든다 어린이기호식품 1 회제공량표시조사보고서 2010. 11 식품미생물팀 차례 Ⅰ. 조사개요 1 1. 추진배경 1 2. 조사기간및조사내용 2 Ⅱ. 조사결과 2 1. 어린이기호식품 2 2. 가공식품의영양표시제도 4 3. 1회제공량표시 9 4. 영양성분앞면표시제 12 5. 신호등표시제 14 6. 고열량 저영양식품 16 7. 어린이기호식품품질인증