30 / 폐경전후여성의골밀도와골대사 인건강문제라고할수있다. 6) 골다공증의발생은다양한원인에의해나타나고여러종류의병인이관련되어있어그원인을간단히찾기는어려운질환이다. 7) 골다공증유병률을정확하게파악하고건강한뼈를유지하는데영향을미치는관련요인을규명하는것은노년기에골다공증으로인한골절을

한국영양학회지 (Korean J Nutr) 2011; 44 (1): 29 ~ 40 DOI 10.4163/kjn.2011.44.1.29 폐경전 후여성의골밀도및골대사지표에영향을미치는요인 박지연 1 최미연 2 이선희 1 최윤호 3 박유경 2,4 삼성서울병원건강의학센터, 1 경희대학교동서의학대학원의학영양학과, 2 성균관대학교의과대학삼성서울병원, 3 경희대학교임상영양연구소 4 The Association between Bone Mineral Density, Bone Turnover Markers, and Nutrient Intake in Pre- and Postmenopausal Women Park, Jiyoun 1 ㆍ Choi, Miyoun 2 ㆍ Lee, Seonheui 1 ㆍ Choi, Yoonho 3 ㆍ Park, Yookyoung 2,4 1 Center for Health Promotion, Samsung Medical Center, Seoul 135-710, Korea 2 Department of Medical Nutrition, Kyung Hee University, Yongin 446-701, Korea 3 Sungkyunkwan University School of Medicine, Seoul 136-720, Korea 4 Research Institute of Medical Nutrition, Kyunghee University, Seoul 130-701, Korea ABSTRACT The purpose of this study was to examine the association among bone mineral density (BMD), biochemical bone markers, nutrients, and salt intake in premenopausal and postmenopausal women. We evaluated 431 subjects who visited a health promotion center of a university hospital between January 2008 and July 2009. We excluded those who were taking medications or who had an endocrine disorder affecting osteoporosis. The subjects were divided into premenopausal (n = 283) and postmenopausal (n = 143) women. We evaluated the correlation among BMD of the lumbar spine, femoral neck, and total femoral, as well as biochemical bone markers, hormone, serum profiles, general characteristics, nutrient intakes, and food intake frequencies. From a stepwise multiple regression analysis, lumbar spine BMD was positively correlated with weight (p < 0.001) and negatively correlated with osteocalcin (OC)(p < 0.001), Femoral neck BMD was positively correlated with weight (p < 0.001) and negatively correlated with C-telopeptide (CTx) and alkaline phosphatase (ALP)(p < 0.001, p < 0.05). In premenopausal women, femoral total BMD was positively correlated with BMI (p < 0.001) and negatively correlated with CTx (p < 0.001). In postmenopausal women, lumbar spine BMD was positively correlated with calcium intake (p < 0.01) and negatively correlated with sodium intake (p < 0.01). Femoral neck and femoral total BMD were both positively correlated with weight (p < 0.001), and femoral neck BMD was negatively correlated with age and ALP (p < 0.001, p < 0.05). Femoral total BMD was negatively correlated with age and OC (p < 0.001, p < 0.01). These results suggest that reducing sodium intake may play an important role delaying bone resorption and preventing a decrease in BMD. (Korean J Nutr 2011; 44 (1): 29 ~ 40) KEY WORDS: bone mineral density (BMD), osteocalcin (OC), C-telopeptide (CTx), premenopausal women, KEY WORDS: postmenopausal women. 서 최근경제성장과함께소득수준이향상되면서의료기술의발달및개인의건강에대한관심이높아지고더불어삶의질도높아지고있다. 우리나라국민의평균수명은 2007 년 79.5 세로 2000년 76세에비해늘었으며 1) 65세이상노 접수일 :2010 년 9월 13일 / 수정일 :2010 년 12월 14일채택일 :2011년 2월 11일 To whom correspondence should be addressed. E-mail: ypark@khu.ac.kr 론 인인구는 2005년전체인구의 9.1% 로 2003년 8.3% 에비해증가하였다. 2) 전세계적으로노인인구가증가함에따라노인영양에대한연구가활발히진행되고있으며 3) 골다공증유병률이지속적으로높아지고사회경제적부담이증가됨으로써골밀도에관한건강문제가대두되고있다. 골다공증은그자체가문제가되는것은아니나골절이되면일상생활이불편해지고사망으로이어질수도있기때문에관심을가져야한다. 4) 특히골다공증은특정한예후가없기때문에 소리없는질병 이라고불려지기도한다. 5) 골다공증은주로노화와폐경으로인한고연령층여성들에게가장많이나타나는대표적 2011 The Korean Nutrition Society

30 / 폐경전후여성의골밀도와골대사 인건강문제라고할수있다. 6) 골다공증의발생은다양한원인에의해나타나고여러종류의병인이관련되어있어그원인을간단히찾기는어려운질환이다. 7) 골다공증유병률을정확하게파악하고건강한뼈를유지하는데영향을미치는관련요인을규명하는것은노년기에골다공증으로인한골절을예방하는데중요하다. 8) 정상적인골에서는골흡수와골형성이균형적으로일어나골의미세손상을치료하고오래된골조직을새로운골조직으로대치하게되어골의생체기능을유지하게되는데폐경후여성에게는골흡수가골형성을초과하게되면서골소실이일어나게된다. 9,10) 이는에스트로겐분비의감소로골형성은그대로이나골흡수가증가되기때문이다. 11) 따라서폐경은골다공증의가장중요한요소로간주된다. 12) 여성의경우골량은 30~35 세에최고치에달하며, 그이후의골대사는파골세포에의한골흡수와조골세포에의한골형성이균형을유지하면서지속적으로교체되는재형성과정으로유지되나, 재형성이흡수된골량을따라가지못하여골량이감소하게되어매년 1~2% 씩골밀도가감소하게된다. 13) 특히폐경기이후에는첫 3년동안연간평균 4~5% 의골량감소를보이며그이후에는연간 1~2% 의골량감소를보인다고한다. 이러한골소실의원인은증가된혈중난포자극호르몬 (Follicular stimulating hormone: FSH) 과감소된에스트로겐농도와연관된다. 최근골밀도와생화학적표지자에대한연구가많이이루어지고있다. 생화학적표지자는골재형성 (bone remodeling) 의속도를알수있으며혈액과소변으로검사한다. 생화학적표지자는골형성지표와골흡수지표로나누어진다. 골형성지표인 Total alkaline phosphatase는조골세포에서분비되는당단백질로임상에서가장흔히이용되는골형성지표이며비용적인면에서임상에서많이사용되어지고있고간장질환이나대사성질환이없는경우골대사지표로이용할수있다고보고되어지고있다. 14) 오스테오칼신 (osteocalcin: OC) 은골형성지표의하나로조골세포 (osteoblast) 로부터합성되는데폐경기및청소년기와같이골전환 (bone turnover) 이증가된시기에높다고알려져있다. 15) 또한최근에활발히측정되고소개되는 C-terminal telopeptide (CTx) 는뼈의손상이있을때혈중으로유리되어나오는콜라겐물질로써소변으로의농도측정은물론혈액검사를통해서도골흡수상태를측정할수있는측정법이다. 16) 골밀도에영향을미치는요인으로는유전, 17) 가족력, 성별, 18) 연령 19) 등수정불가능한요인과신체활동량, 영양상태, 20) 식습관, 21) 흡연, 22) 알코올및카페인섭취 23) 등수정가능한환경요인이있다. 2005년국민건강영양조사보고서에의하면 우리나라여성의 1일평균칼슘섭취량은 463.8 mg으로 1인권장량인 700 mg보다낮다. 골질량이축적되는시기에칼슘의섭취량이부족하면결국최대골질량을감소시켜성인기에골다공증을유발하는주요원인이된다. 24) 그리고국내연구에서골밀도를위하여폐경후여성들에게양질의단백질, 탄수화물과칼슘을보충시키고, 칼슘과인의균형을개선하는것이중요하다는보고도있다. 25) 골다공증의발생에있어서식생활및영양섭취상태가중요한인자로인식되고있으며나트륨은칼슘흡수에영향을주는것으로알려져있다. 일본의 20~40 세여성의경우고염분식사를하는여성은그렇지않은여성에비하여뼈의무기질함량이유의적으로낮았다는보고가있다. 26) 이는칼슘섭취가높은여성들이오히려낮은골밀도를보였는데, 작은생선으로부터섭취하는높은나트륨함량때문으로보인다고보고되어식품으로부터섭취하는무기질사이에도상호작용이일어나고있음을알수있다. 우리나라는김치류, 찌개류, 장아찌등절인식품빈도가높아 27) 골감소의위험률이더높을것이라생각된다. 폐경또한골대사에치명적인영향을미치는중요한요인 28) 으로본연구는폐경전후여성의골밀도에영향을미치는영양ㅇ소를찾아내어골감소예방을위한올바른영양교육의기초자료를마련하고자한다. 연구방법 연구대상본연구는 2008년 1월 2일부터 2009년 7월 17일까지서울소재대학병원건강검진센터에서건강검진을받은여성수진자중영양분석설문지를작성하고골밀도검사와골대사지표검사를시행한 615명을대상으로하였다. 폐경기여성의정의는마지막월경이있은후 1년이상월경이없고혈중 FSH (Follicle stimulating hormone) level 이 40 miu/ml 이상으로하였으며, ISCD ( 국제임상골밀도측정학회 ; The International society for Clinical Densitometry) 29) 에서주요위험요인으로정한고관절골절의모계력이있거나, 45세이후경한외상으로인해골절된과거력, 장기간스테로이드투여한대상자와골밀도에영향을주는것으로알려져있는질환 ( 갑상선기능항진증, 부갑성기능항진증, 기관지천식, 류마티스관절염, 만성피부질환, 당뇨병, 간경변증, 알코올중독, 말기신부전 ) 이나호르몬대체요법의과거력이있거나위암수술, 자궁및난소적출술시행의경험, 설문내용및검사결과가부정확한경우인 184명을제외한 431명을대상으로하였다. 폐경전여성은 283명 (65.17%) 폐경후여성은 148 명 (34.3%) 이었다.

한국영양학회지 (Korean J Nutr) 2011; 44(1): 29 ~ 40 / 31 일반사항, 신체계측및혈압측정일반사항은조사대상자의가정혹은직장으로우편배달 된문진이나건강검진당일에받은문진에대해수진자가직접작성해온정보로이루어졌다. 일반사항조사내용으로는연령, 폐경유무등이있다. 수진자의신장및체중, 체지방률, 근육량등의신체구성성분은자동신체계측기 (Biospace의 Inbody 3.0; Korea) 를이용하여검사가운을입은가벼운옷차림상태에서신발을벗고측정하였다. 체질량지수 (BMI) 는체중을신장의제곱으로나눈값을산출하였다 [BMI = 체중 (kg)/ 신장 (m 2 )]. 허리둘레는줄자를이용하여수진자가숨을내쉰상태에서배꼽위 2.5 cm 부위를측정하였다. 혈압은안정된상태에서의자에앉은수진자의왼쪽팔에자동혈압측정기를이용하여수축기혈압 (Systolic blood pressure, SBP) 과이완기혈압 (Diastolic blood pressure, DBP) 을측정하였다. 채혈및혈액성분분석혈액검사는건강검진전날저녁부터다음날검사시까지 12시간이상공복상태에서주사기로채취한혈액에대하여이루어졌다. 총콜레스테롤은 (Total cholesterol) 과중성지방 (triglyceride) 은 Modular Analytics SWA (Roche Dignostics GmbH, Mannheim, Germany) 를이용하여측정하였고, HDL-C와 LDL-C는균질효소비색법 (Homogeneous Enzymic Colorimetry Method) 으로분석하였으며, TG는효소법 (Enzymic Colorimetry Method) 으로분석하였다. 모든생화학검사는 Hitachi-7600 (hitach, Japan) 검사장비로측정하였다. 여성호르몬지표인 FSH (Follicular stimulating hormone) 와 E2 (estradiol) 는 RIA 법을이용하여 Gamma counter에서측정하였다. 골형성지표인혈중 Osteocalcin (OC), Alkalinephosphatase (ALP) 과골흡수지표인 C-telopeptide (CTx) 는효소면역측정법 (ELISA) 으로측정하였다. 골밀도측정및분석골밀도측정은이중에너지방사선골밀도측정기 (Dual Energy X-ray Absorptiometry, DXA: Lunar Radiation Corp, USA) 를이용하여골다공증의주요지표가되는요추 (Lumbar spine: L1-L4) 와왼쪽대퇴경부 (Left femoral Neck), 왼쪽대퇴전체 (Left femoral total) 에서골밀도를측정하였다. 요추골밀도는해면골 (trabecular bone) 이풍부하여대사율이높다고알려져있으며, 측정값의정밀도향상을위하여제 1요추에서제 4요추까지의골밀도평균치를사용하였다. 30) 본연구는세계보건기구 (WHO) 의기준에따라요추및대퇴골 T-score가 -1.0 보다크면 normal group, -1.0 에서 -2.4 이면 osteopenia group, -2.5 이하이면 osteoporosis group으로설정하였다. 식이섭취조사식이섭취조사는삼성서울병원건강의학센터영양상담실에서 2001년에개발한식품섭취빈도조사지를이용하였다. 식품구성항목은총 113종으로곡류 19종, 국 & 찌개 5종, 김치 6종, 육류 10종, 생선류 15종, 콩 & 두부 3종, 채소류 9 종, 나물 13종, 과일류 18종, 우유및유제품 3종, 유지류 4종, 술 5종이였으며, 1998년국민영양조사결과와삼성서울병원건강의학센터에서 2000년 1년동안건강검진을한 17,162 명을대상으로조사된식품항목및섭취빈도를고려하여구성하였다. 각식품의섭취빈도는 Block 등 31) 이미국국립암연구소 (National Cancer Institute) 에서개발한 HHHQ (Health Habits and History Questionnaire) 을참고하여최근 3개월간의평균섭취빈도를기준으로작성하도록하였다. 식품섭취빈도설문지의타당도검증은김등 32) 과백등 33) 의식품섭취빈도설문지의타당도검증연구등을참고하여 2001년 3월에 3일간의 24시간식사기록지 ( 주중 2일, 주말 1일 ) 와식품빈도조사를 Paired t-test하여이루어졌으며그결과열량, 단백질, 철분, 아연, 비타민 A, 비타민 C, 베타카로틴, 비타민 B 1, 비타민 B 2, 나이아신, 칼슘등주요영양소들의평균차이가없어수진자들의영양섭취평가도구로서타당한식품섭취빈도조사지였다. 34) 통계분석모든통계분석은폐경전여성과폐경후여성으로나누어시행하였다. 두군간의일반적특성, 영양소섭취량, 혈액검사, 골밀도검사등이들특성의차이를알아보기위해 t-test을하였고, 단순상관분석 (simple correlation analysis) 을이용하여골밀도와상관성이있는요인을알아내었다. 또한나이, 체중, 신장을공변량으로통제한후골밀도와제요인과의상관성을확인하기위하여편상관분석 (partial correlation coefficients analysis) 을실시하였으며, 골밀도와상관성이있는요인들중골밀도를예측할수있는인자를찾기위해다중선형회귀분석 (multiple linear regression) 을시행하였다. 모든통계처리는 PASW (predictive Analytics Software) 17.0 을이용하였으며, 통계적유의성은 p < 0.05 를기준으로검정하였다. 결 대상자의일반적인특성본연구에참여한대상자들의일반적인특성은다음과같 과

32 / 폐경전후여성의골밀도와골대사 다 (Table 1). 전체대상자들의연령평균은 48.4 ± 6.3세였으며신장은평균 159.3 ± 5.2 cm이었으며, 폐경후여성의연령은폐정전여성보다유의하게높았고, 신장은유의하게낮았다 (p < 0.001). 평균허리둘레는 74.7 ± 6.5 cm, 체지방률 29.1 ± 5.3%, 체질량지수 (BMI) 21.9 ± 2.4 kg/ m 2 으로평균허리둘레, 체지방률 (p < 0.001) 체질량지수 (p < 0.01) 모두폐경후여성에서유의하게높았다. 폐경후여성의평균폐경나이는 50.3 ± 3.1세였고, 평균폐경경과기간은 5.17 ± 5.16 년이었다. 평균수축기혈압 (SBP) 은 113.4 ± 17.3 mmhg로폐경후여성에서유의하게높았으며 (p < 0.001) 가나타났고, 이완기혈압 (DBP) 또한, 69.4 ± 10.8 mmhg로폐경후여성에서유의하게 (p < 0.01) 높았다. 신체계측을통해본연구의대상자들은건강하다고평가할수있었다. 골밀도및골대사지표전체연구대상의요추평균골밀도는 0.006 ± 1.37 이고, 대퇴경부의평균골밀도는 -0.371 ± 0.96이고, 대퇴전체의평균골밀도는 -0.174 ± 1.02, 평균혈청 OC의농도는 17.14 ± 7.34 ng/m이었다 (Table 2). 폐경전 후여성에서평균혈청 OC 농도는폐경후여성이폐경전여성보다유의하게높았으며 (13.58 ± 3.80 ng/ml vs 23.94 ± 7.69 ng/ml, p < 0.001), 마찬가지로혈청 CTx 농도 (0.28 ± 0.13 ng/ ml vs 0.65 ± 0.24 ng/ml, p < 0.001), 혈청 ALP 농도 (51.55 ± 13.05 U/L vs 74.43 ± 17.94 U/L, p < 0.001) 또한폐경전여성과비교하여폐경후여성이유의하게높았다 (Table 2). 골밀도의분포는요추골밀도를기준으로 2.8% 가 osteoporosis group이었고, 21.8% 는 osteopenia group이었으며 75.4% 가 normal group이었다. 대퇴경부골밀도를기준으로는 1.0% 가 osteoporosis group이었고, 25.5% 가 osteopenia group이었으며, 73.5% 가 normal group이었다 (Table 3). 대퇴전체골밀도에서는 0.5% 가 osteoporosis group이었고, 20.6% 는 osteopenia group이었으며 78.9% 가 normal group이었다. 폐경전후의요추, 대퇴경부, 대퇴전체에서의골밀도분포는폐경전여성에서폐경후여성보다유의하게높았다 (p < 0.001)(Table 3). 골밀도, 골대사지표및여성호르몬지표와의상관관계연구대상자들의골밀도, 골대사지표및여성호르몬지표와의상관관계에대한결과는 Table 4와같다. LS (Lumbar spine) 의평균골밀도는 FN (Left femoral neck), FT (Left femoral total) 의평균골밀도와서로양의상관관계를보였다 (p < 0.001, p < 0.001). 반면에 LS, FN, FT의평균 Table 1. Anthropometric measurements of subjects Premenopause (n = 283) Postmenopause (n = 148) Total (n = 431) p-value 5) Age (y) 44.79 ± 2.79 1) 55.22 ± 5.340 48.4 ± 6.30 0.000*** Height (cm) 160.20 ± 4.8400 157.58 ± 5.3500 159.3 ± 5.200 0.000*** Weight (kg) 55.60 ± 6.560 55.50 ± 6.170 55.6 ± 6.40 0.874 WC (cm) 2) 73.93 ± 6.590 76.26 ± 6.160 74.7 ± 6.50 0.000*** BMI (kg/m 2 ) 21.67 ± 2.430 22.35 ± 2.210 21.9 ± 2.40 0.005** % Body fat 28.25 ± 5.260 30.79 ± 5.130 29.1 ± 5.30 0.000*** Age at menopause (yr) - 50.3 ± 3.10 - Yrs since menopause - 5.17 ± 5.16 - SBP (mmhg) 3) 110.80 ± 15.080 118.36 ± 20.130 113.4 ± 17.30 0.000*** DBP (mmhg) 4) 68.41 ± 10.46 71.23 ± 11.11 69.4 ± 10.8 0.01** 1) Mean ± standard deviation 2) WC: waist circumference 3) SBP: Systolic Blood pressure 4) DBP: Diastolic Blood pressure 5) Significantly different between premenopausal and postmenopausal women by Student t-test ( ** : p < 0.01, *** : p < 0.001) Table 2. Bone turnover markers and BMD of subjects Bone variables Premenopause (n = 283) Postmenopause (n = 148) Total (n = 431) Significance 5) Lumbar spine BMD (T-score) 0.48 ± 01.20 1) -0.91 ± 01.22 0.006 ± 01.37 0.000*** Femur neck BMD (T-score) -0.13 ± 00.89 1) -0.84 ± 00.91-0.371 ± 00.96 0.000*** Femur total BMD (T-score) 0.07 ± 00.97 1) -0.64 ± 00.96-0.174 ± 01.02 0.000*** OC (ng/ml) 2) 13.58 ± 03.80 1) 23.94 ± 07.69 17.14 ± 07.34 0.000*** s-ctx (ng/ml) 3) 0.28 ± 00.13 1) 0.65 ± 00.24 0.41 ± 00.25 0.000*** Total ALP (U/L) 4) 51.55 ± 13.05 1) 74.43 ± 17.94 59.40 ± 18.44 0.000*** 1) Mean ± standard deviation 2) OC: osteocalcin 3) s-ctx: serum C-telopeptide 4) Total ALP: total serum alkaline phosphatase 5) Significantly different between premenopausal and postmenopausal women by Student t-test ( *** : p < 0.001)

한국영양학회지 (Korean J Nutr) 2011; 44(1): 29 ~ 40 / 33 골밀도와골대사지표인 OC, CTx, ALP, 여성호르몬인 FSH 의평균농도에서는음의상관관계를보였다 (p < 0.001, p < 0.001, p < 0.001, p < 0.001). 그리고여성호르몬인 E2 는 LS, FN의평균골밀도와는양의상관관계를나타냈다 (p < 0.001). 마찬가지로 FT의평균골밀도는여성호르몬인 E2와양의상관관계를보였다 (p < 0.01). 골대사지표인 OC와 CTx, ALP는각각양의상관관계를보였고 (p < 0.001, p < 0.001) 여성호르몬인 FSH와는양의상관관계 (p < 0.001), E2와는음의상관관계를보였다 (p < 0.001). E2의평균농도는 LS, FN, FT의평균골밀도와유의한양의상관관계가있었으며 (p < 0.001, p < 0.001, p < 0.01), 골대사지표인 OC, CTx, ALP 및여성호르몬 FSH에서는유 Table 3. Comparison of BMD between premenopausal and postmenopausal women Premenopause (n = 283) Postmenopause (n = 148) χ 2 value 5) p-value LS 2) Normal 254 (89.8) 1) 71 (48) 93.943 0.000*** Osteopenia 029 (10.2) 65 (43.9) Osteoporosis 000 (00) 12 (08.1) FN 3) Normal 234 (82.7) 83 (56.1) 36.989 0.000*** Osteopenia 049 (17.3) 61 (41.2) Osteoporosis 000 (00) 04 (02.7) FT 4) Normal 241 (85.2) 99 (66.9) 20.187 0.000*** Osteopenia 042 (14.8) 47 (31.8) Osteoporosis 000 (00) 02 (01.4) 1) N (%) 2) LS: Lumbar spine 3) FN: Left femoral Neck 4) FT: Left femoral total 5) χ 2 value: significance as determined by chisquare test *** : p < 0.001 Table 4. Pearson correlation coefficients among bone mineral density, bone turnover markers and female hormone of subjects (n = 431) Bone mineral density Bone turnover markers Female hormone LS FN FT OC s-ctx ALP FSH E2 Lumbar spine BMD (T-score) 1 0.717*** 0.738*** -0.447*** -0.438*** -0.367*** -0.405*** 0.277*** Femur neck BMD (T-score) 0.717*** 1 0.918*** -0.336*** -0.342*** -0.329*** -0.309*** 0.179*** Femur total BMD (T-score) 0.738*** 0.918*** 1-0.350*** -0.352*** -0.296*** -0.285*** 0.139** OC (ng/ml) -0.447*** -0.336*** -0.350*** 1 0.805*** 0.596*** 0.605*** -0.372*** s-ctx (ng/ml) -0.438*** -0.342*** -0.352*** 0.805*** 1 0.634*** 0.645*** -0.381*** ALP (U/L) -0.367*** -0.329*** -0.296*** 0.596*** 0.634*** 1 0.530*** -0.310*** FSH (miu/ml) -0.405*** -0.309*** -0.285*** 0.605*** 0.645*** 0.530*** 1-0.520*** E2 (pg/ml) 0.277*** 0.179*** 0.139*** -0.372*** -0.381*** -0.310*** -0.520*** 1 * : p < 0.05, ** : p < 0.01, *** : p < 0.001 Table 5. Serum lipid & mineral levels in pre and postmenopausal women Parameters Premenopause (n = 283) Postmenopause (n = 148) p-value 6) TG (mg/dl) 2) 094.63 ± 45.47 1) 110.88 ± 59.03 0.004** TC (mg/dl) 3) 193.17 ± 31.25 208.81 ± 35.39 0.000*** HDL-C (mg/dl) 4) 062.04 ± 14.63 60.82±14.18 0.406 LDL-C (mg/dl) 5) 115.02 ± 28.15 129.09±32.97 0.000*** Ca (mg/dl) 009.11 ± 00.33 9.38 ± 00.40 0.000*** P (mg/dl) 003.48 ± 00.42 3.88 ± 00.43 0.000*** Na (mg/dl) 141.53 ± 01.60 143.44 ± 01.21 0.000*** K (mg/dl) 004.15 ± 00.34 4.20 ± 00.29 0.127 Cl (mg/dl) 103.14 ± 01.65 103.56 ± 01.79 0.016* 1) Mean ± standard deviation 2) TG: Triglyceride 3) TC: Total cholesterol 4) HDL-C: High density lipoprotein-cholesterol 5) LDL- C: Low density lipoprotein-cholesterol 6) Significantly different between premenopausal and postmenopausal women by Student t-test ( * : p < 0.05, ** : p < 0.01, *** : p < 0.001)

34 / 폐경전후여성의골밀도와골대사 의한음의상관관계를보였다 (p < 0.001, p < 0.001, p < 0.001, p < 0.001). 나이와키, 체중을보정했을때여성호르몬 FSH와 E2는대퇴골경부와대퇴골전체골밀도와유의한상관관계는없었다 (data not shown). 혈액분석폐경전 후여성의생화학분석자료를 Table 5에제시하였다. TG, TC, LDL-콜레스테롤의농도는폐경후여성에서유의적으로높았다 (p < 0.01, p < 0.001, p < 0.001). HDL- 콜레스테롤의농도는두군간에유의적인차이가없었으며승 35) 의연구결과와같이혈청 Ca 농도는폐경후여성에서유의하게높았다 (p < 0.001). 그리고혈청내 P, Na, Cl의농도는폐경후여성이유의적으로높았다 (p < 0.001, p < 0.001, p < 0.05). 혈청 K의농도는두그룹간유의적인차이는없었다. 영양섭취상태대상자들의영양소섭취상태를비교한결과는 Table 6에나타냈다. 연구대상자들의 1일평균열량섭취량은폐경전여성과폐경후여성에서각각 1679.4 ± 370.6 kcal/day, 1,621.40 ± 352.11 kcal/day 로폐경전여성이폐경후여성보다높은경향이었으나유의적인차이는없었다. 탄수화물섭취는두군간유의적인차이를보이지않았고, 단백질섭취는폐경전여성과폐경후여성각각 75.58 ± 20.43 g/day, 70.89 ± 17.62 g/day 로폐경전여성에서유의적으로높았다 (p < 0.05). 콜레스테롤섭취는폐경전여성과폐경후여성에서각각 238.2 ± 116.4 mg/day, 191.3 ± 99.3 g/day 로폐경전여성보다폐경후여성이유의하게낮았다 (p < 0.001). 전체대상자들의평균콜레스테롤섭취량은 222.08 ± 112.96 mg/day로관상동맥질환예방을위한수준인 300 mg 보다낮은수준이었다. 식이섬유섭취는각각 22.93 ± 7.58 g/day, 24.74 ± 7.38 g/day 로폐경후여성에서유의적으로높았고 (p < 0.05), 칼륨섭취는 3,134.62 ± 938.90 mg/day, 3,362.38 ± 1,038.92 mg/day로폐경후여성에서유의적으로높게나타났다 (p < 0.05). 칼슘, 철분, 비타민 A, 베타카로틴, 비타민 B 1, 비타민 B 2, 비타민 C, 나이아신, 엽산의섭취량과두군간의유의한차이는보이지않았다. 또한칼슘흡수에영향을미치는인과신장에서재흡수기전을칼슘과공유하고있는나트륨의섭취량은두군간에차이를보이지않았다. 전체에너지중열량영양소의섭취기여비율은 C : P : F 이폐경전과후 58 : 18 : 24와 61 : 18 : 21로폐경전여성에서폐경후여성보다탄수화물섭취비율이낮고지방섭취비율은높게나타났다. 골밀도, 골대사지표, 여성호르몬및신체특성과의관계폐경전후여성의골밀도, 골대사지표, 여성호르몬및신체계측지표와의상관관계는 Table 7과같다. 폐경전여성의 Table 6. Mean daily energy and nutrient intakes of subjects Nutrients Premenopause (n = 283) Postmenopause (n = 148) Significance 2) Calorie (kcal) 1679.44 ± 370.590 1621.40 ± 352.110 0.117 Carbohydrate (g) 240.95 ± 56.4900 248.55 ± 63.5500 0.205 Protein (g) 75.58 ± 20.4300 70.89 ± 17.6200 0.018* Fat (g) 44.41 ± 15.7800 37.59 ± 13.1200 0.000*** CHO : Pro : Fat ratio (%) 57.4 : 18.0 : 23.8 61.3 : 17.5 : 20.9 - Fiber (g) 22.93 ± 7.58000 24.74 ± 7.38000 0.018* Cholesterol (mg) 238.20 ± 116.430 191.29 ± 99.3000 0.000*** Calcium (mg) 689.84 ± 274.590 698.46 ± 258.660 0.753 Phosphorus (mg) 1131.69 ± 307.860 1109.09 ± 279.710 0.456 Iron (mg) 12.83 ± 3.87000 12.94 ± 3.36000 0.754 Na (mg) 3402.21 ± 1418.28 3247.71 ± 1389.02 0.280 K (mg) 3134.62 ± 938.900 3362.38 ± 1038.92 0.022* Vitamin A (µg R.E) 680.89 ± 401.700 676.61 ± 334.320 0.495 β-carotene (µg) 3080.11 ± 2181.44 3223.87 ± 1855.10 0.911 Vitamin B1 (mg) 1.07 ± 0.36000 1.05 ± 0.33000 0.498 Vitamin B2 (mg) 1.19 ± 0.40000 1.18 ± 0.35000 0.744 Vitamin C (mg) 148.56 ± 87.7600 161.67 ± 96.1200 0.155 Niacin (mgne) 17.95 ± 5.04000 17.02 ± 4.31000 0.057 Folic acid (µg) 307.72 ± 110.070 328.12 ± 110.020 0.068 1) Mean ± standard deviation 2) Significantly different between premenopausal and postmenopausal women by Student t-test ( * : p < 0.05, ** : p < 0.01, *** : p < 0.001)

한국영양학회지 (Korean J Nutr) 2011; 44(1): 29 ~ 40 / 35 Table 7. Correlation among BMD, bone turnover markers, hormone and anthropometric factors in premenopausal (n = 283) and postmenopausal women (n = 148) Premenopausal women (n = 283) Postmenopausea women (n = 148) Variables LS FN FT OC CTx ALP FSH E2 LS FN FT OC CTx ALP FSH E2 Age -0.062-0.061-0.041 0.016-0.074 v0.078-0.226*** -0.050-0.311*** -0.355*** -0.283*** -0.087-0.032-0.085-0.253** -0.105 Height -0.083-0.110-0.012 0.016-0.029-0.092-0.102-0.048-0.355*** -0.321*** -0.179* -0.151-0.049-0.017-0.036-0.074 Weight -0.277*** -0.325*** -0.355*** 0.009-0.037-0.154** -0.036-0.069-0.276*** -0.202* -0.196* -0.114-0.037-0.041-0.150-0.058 WC 1) -0.190*** -0.259*** -0.313*** 0.020-0.012-0.206*** -0.002-0.040-0.029-0.031-0.013-0.140-0.006-0.085-0.267*** -0.064 BMI -0.250*** -0.283*** -0.372*** 0.006-0.022-0.214*** -0.017-0.046-0.064-0.003-0.090-0.234** -0.078-0.055-0.142-0.114 BFM 2) -0.095-0.086-0.165** 0.051-0.006-0.307*** -0.080-0.049-0.013-0.081-0.024-0.253** -0.145-0.003-0.078-0.022 SBP 3) -0.127* -0.119* -0.159** 0.053-0.075-0.182** -0.107-0.031-0.010-0.076-0.088-0.110-0.041-0.029-0.046-0.007 DBP 4) -0.004-0.064-0.096 0.063-0.085-0.114-0.084-0.037-0.072-0.032-0.038-0.022-0.062-0.086-0.075-0.098 1) WC: waist circumference 2) BFM: body fat mass 3) SBP: Systolic Blood pressure 4) DBP: Diastolic Blood pressure * : p < 0.05, ** : p < 0.01, *** : p < 0.001 요추골밀도와대퇴경부골밀도는체중 (r = 0.277,0.325, p < 0.001), 허리둘레 (r = 0.190, 0.259, p < 0.001), BMI (r = 0.250, 0.283, p < 0.001), SBP (r = 0.127, 0.119, p < 0.05) 와유의적인양의상관관계를나타냈다. 그리고대퇴전체골밀도는체중 (r = 0.355, p < 0.001), 허리둘레 (r -0.313, p < 0.001), BMI (r = 0.214, p < 0.001), 체지방률 (r = 0.165, p < 0.01), SBP (r = 0.159, p < 0.01) 과양의상관관계를나타냈다. 골대사지표중하나인 ALP는몸무게 (r = 0.154, p < 0.01), 허리둘레 (r = 0.206, p < 0.001), BMI (r = 0.214, p < 0.001), 체지방률 (r = 0.307, p < 0.001), SBP (r = 0.182, p < 0.01) 와양의상관관계를나타냈으며, 여성호르몬인 FSH는나이 (r = 0.226, p < 0.001) 와양의상관관계를나타냈다. 폐경후여성의요추골밀도, 대퇴경부골밀도, 대퇴전체골밀도는나이 (r = -0.311, p < 0.001) 와음의상관관계를나타내었고신장 (r = 0.355, p < 0.001) 이나체중 (r = 0.276, p < 0.001) 과는양의상관관계를나타냈다. 골대사지표인 OC는 BMI (r = -0.234, p < 0.01) 와체지방률 (r = -0.253, p < 0.01) 과음의상관관계를나타냈다. 여성호르몬인 FSH는나이 (r = -0.253, p < 0.01) 와허리둘레 (r = -0.267, p < 0.01) 에서음의상관관계를나타냈다. 폐경전과폐경후여성에서골밀도의예측인자폐경전과폐경후여성에서요추골밀도및대퇴경부골밀도는 Table 8과같다. 요추골밀도예측인자로는폐경전여성에서체중, OC, 혈청인및식이성칼륨이예측인자로나타났으며총설명력은 17.1% 였다. 폐경전여성에서체중이상대적으로다른인자들보다더큰영향을미치며긍정적인영향을주는것으로나타났다. OC, 혈청인, 식이칼륨은폐경전여성의요추골밀도에부정적인영향을주는것으로나타났다. 그리고폐경후여성에서요추골밀도를예측할수있는인자로는키, 나이, OC, 혈청칼슘, 혈청나트륨, 식이지방, 식이나트륨, 식이칼슘이 36% 로요추골밀도를예측할수있는것으로나타났다. 특히폐경후여성에서는식이칼슘이다른인자들보다더큰영향을미치는것으로나타났으며긍정적인영향을주는것으로나타났고, 또한혈청칼슘, 혈청나트륨, 식이지방은긍정적영향을주는것으로나타났다. 반면에나이, OC, 식이나트륨은폐경후여성에서요추골밀도에부정적인영향을주는것으로나타났다. 대퇴경부골밀도는폐경전여성에서키, 체중, 체지방률, CTx, ALP, 혈청염소, 식이칼륨이 22.8% 로나타났다. 특히체중이대퇴경부골밀도에있어상대적으로다른인자들보다더큰영향을미쳤고, 긍정적인영향을주는것으로나타났다. 키, 체지방률, CTx, ALP, 혈청염소, 식이칼륨은대퇴

36 / 폐경전후여성의골밀도와골대사 경부골밀도에부정적인영향을미치는것으로나타났다. 폐경후여성에서대퇴경부골밀도에영향을주는예측인자로는나이, 체중, ATP가있었다. 특히나이가대퇴경부골밀도에있어상대적으로다른인자들보다더큰영향을미쳤고부정적인영향을미치는것으로나타났다. 체중은긍정적인영향을, ALP는부정적인영향을미치는것으로나타났다. 대퇴전체골밀도는 Table 9와같다. 폐경전여성에서는 BMI, 체지방률, CTx, 혈청염소, 식이칼륨이 27.7% 로대퇴전체골밀도를예측할수있는것으로나타났다. 특히 BMI 가대퇴전체골밀도에있어상대적으로다른인자들보다더 큰영향을미친것으로나타났고긍정적인영향을주는것으로나타났다. 체지방률, CTx, 혈청염소, 식이칼륨은폐경전여성에게부정적인영향을주는것으로나타났다. 폐경후여성에서대퇴전체골밀도를예측할수있는인자로는나이, 체중, 혈청인, OC로 17.5% 의설명력을나타내는것으로나타났고, 특히나이가대퇴전체골밀도에있어상대적으로다른인자들보다더큰영향을미치는것으로나타났으며부정적인영향을주는것으로나타났다. 체중, 혈청인은대퇴전체골밀도에긍정적인영향을주는것으로나타났고, OC 는부정적인영향을주는것으로나타났다 Table 8. Stepwise multiple regression analysis of the relation of variables on spine BMD, neck BMD in pre and postmenopausal women after adjusting by age, height, weight Independent variable R 2 B SE Beta* p-value R 2 B SE Beta* p-value (Constant) 0.242 0.815 0.767 0.242 0.815 0.767 Premenopausal women Postmenopausal women Weight 0.054 0.010 0.295 0.000 0.054 0.010 0.295 0.000 OC 0.171-0.080 0.017-0.254 0.000 0.171-0.080 0.017-0.254 0.000 P (serum) -0.330 0.156-0.116 0.035-0.330 0.156-0.116 0.035 K (diet) 0.000 0.000-0.130 0.019 0.000 0.000-0.130 0.019 (Constant) -32.229 11.007 0.004-32.229 11.007 0.004 Height 0.056 0.018 0.246 0.002 0.056 0.018 0.246 0.002 Age -0.052 0.017-0.226 0.003-0.052 0.017-0.226 0.003 OC -0.037 0.011-0.235 0.001-0.037 0.011-0.235 0.001 Ca (serum) 0.360 0.510 0.215 0.167 0.019 0.360 0.510 0.215 0.167 0.019 Na (serum) 0.147 0.069 0.146 0.035 0.147 0.069 0.146 0.035 Fat (diet) 0.147 0.069 0.146 0.035 0.147 0.069 0.146 0.035 Na (diet) 0.000 0.000-0.241 0.006 0.000 0.000-0.241 0.006 Ca (diet) 0.001 0.000 0.273 0.005 0.001 0.000 0.273 0.005 *: β unstandardized coefficients, : SE standard error. Regession equations, Premenopausal women y = 0.242 + 0.054 weight-0.080 OC-0.330 P (serum) + 0.000 K (diet), Postmenopausal women: y = -32.229 + 0.056 Height-0.052 Age-0.037 OC + 0.510 Ca (serum) + 0.147 Na (serum) + 0.147 Fat (diet) + 0.000 Na (diet) + 0.001 Ca (diet) Table 9. Stepwise multiple regression analysis of the relation of variables on Left femoral Total BMD in pre and postmenopausal women Premenopausal women Postmenopausal women Independent variable R 2 B SE Beta* p-value (Constant) 3.861 3.190 0.227 BMI 0.252 0.032 0.630 0.000 Body fat mass -0.060 0.015-0.325 0.000 0.277 CTx -1.947 0.385-0.259 0.000 Cl (serum) -0.063 0.030-0.107 0.039 K (diet) 0.000 0.000-0.159 0.002 (Constant) -0.451 1.363 0.741 Age -0.050 0.014-0.279 0.000 Weight 0.175 0.032 0.012 0.207 0.008 P (serum) 0.378 0.184 0.169 0.041 OC -0.028 0.010-0.225 0.006 * : β unstandardized coefficients, : SE standard error. Regession equations, Premenopausal women: y = 3.861 + 0.252 BMI-0.060 Body fat mass -1.947 CTx-0.063 Cl (serum) + 0.000 K (diet) Postmenopausal women: y = -0.451-0.050 Age + 0.032 Weight + 0.378 P (serum)-0.028 OC

한국영양학회지 (Korean J Nutr) 2011; 44(1): 29 ~ 40 / 37 고찰 골다공증은골형성의감소와골파괴의증가로인하여골량이감소되는질환으로골다공증의발생에는골세포의기능을조절하는다양한국소적인조절인자와전신적인조절인자들의상호작용이작용하며, 이런조절기전에는여러가지호르몬, 사이토카인, 유전자들이관여한다. 36) 골은매우활동적인기관으로조골세포의골형성과파골세포의골흡수가지속적으로일어나는골개조작용을특징으로하고골량은조골세포와파골세포활동의균형에따라좌우된다. 37) 골질을평가하는방법으로는침습적인검사방법이일반적이므로골밀도나골절에영향을미칠수있는위험요인을사전에파악하여골절의위험성을예측하고이를예방하는것이무엇보다중요하다. 38) 이에본연구에서는폐경전과폐경후여성을대상으로골밀도, 골대사지표, 여성호르몬및영양소와의관련성에대해연구하여궁극적으로골다공증예방프로그램및교육의기초자료를마련하고자수행되었다. 여성에서의골밀도는호르몬과연관이많으며, 폐경에의한에스트로겐의결핍이중요한요인으로생각되고있다. 39) 여성호르몬은골조직에서주작용이골흡수의감소이며, 조골세포계통및파골세포계통의세포에서여성호르몬수용체에높은친화력을가지고있기때문에골조직에직접적으로작용하며, 40) 여성호르몬의골흡수에대한예방효과는조골세포에서분비되어지는측분비 (paracrine) 인자를통하여이루어진다. 41) 본연구결과, 폐경전여성보다폐경후여성에서여성호르몬인 FSH의농도가높고 E2의농도가낮게보여져, 폐경후여성에서골감소의위험률이높아지고있다는것을확일할수있었다 (data not shown). 골밀도는 30세에최대골량에도달한후유지되다가폐경이되면서골량이급격히감소하여대부분의여성이 70세에는골다공증의수준에다다르게되는것으로알려져있다. 42) 특히폐경기여성에서는에스트로겐결핍으로인해파골세포의세포사망이감소하고, 조골세포의세포사망이증가하여조골세포의수가점점감소함으로써이들의불균형에의해골소실이발생하여골다공증의위험이높아지게된다. 43) 본연구에서도폐경전과폐경후여성의골밀도분포는폐경전과후여성에서는 normal group이폐경후여성에서는 osteopenia group, osteoporosis group의비율이유의하게높았다. 즉, 폐경후여성이골밀도의감소가더많다는것을볼수있었는데이러한결과는 Kim 44) 의폐경후지역사회성인여성을대상으로한연구에서연령과골밀도 사이에음의상관관계를나타냈다고보고한연구와일치한다. 또한, 폐경후에골소실을의미하는골표지자인 OC와 ALP, CTx가폐경전보다증가하는것으로관찰되어폐경후여성에서골다공증의위험이증가하리라는것이입증되었다. 이는골대사지표가골밀도를반영하는좋은지표가될수있고폐경후여성에게있어골대사지표의증가는골대사가빠르다는것을의미하기때문에오히려골대사지표의증가가골밀도감소의위험요인으로해석될수도있다. 체중과골량은서로밀접한상관성이있어폐경후여성에서체질량지수가낮은경우골량이적고골소실또한증가되며, 비만한여성에서골밀도는높게나타나는경향이있다. 45) 이는체중이늘어나게되면근육에가해지는부하가늘어나고골에더많은기계적스트레스를주면서골량이유지되거나, 46) 폐경후여성의지방세포에서 androstenedion 이 estrone으로의변환이증가되어혈중에스트로겐이증가됨에따라골량이보존됨으로써긍정적인효과를보인것으로추측된다. 47) 본연구에서도폐경전여성과폐경후여성의체질량지수는 21.67 ± 2.43 kg/ m2, 22.35 ± 2.21 kg/ m 2 로폐경후여성이폐경전여성보다유의하게높았고체지방률또한 28.25 ± 5.26%, 30.79 ± 5.13% 로폐경후여성에서유의하게높았다. 이연구에서체중은폐경전과폐경후여성모두에서요추골밀도, 대퇴경부골밀도, 대퇴전체골밀도와양의상관관계를나타냈지만체지방률, ALP 는폐경전여성에서만대퇴전체골밀도와양의상관관계를나타냈고, 폐경후여성에서는골밀도와는유의한관계를나타내지않았지만 OC와음의상관관계를보였다. 이는골대사지표와체지방률간의관련성에대한암시로볼수있다. 앞에서언급했듯이비록체질량지수와골량은양의상관관계를나타내지만폐경후여성에서의복부비만은에스트로겐의감소와상관성이있고, 48) 복부지방의증가로인슐린저항성과유리지방산의농도가증가하여아포지방단백질 B 의분비를증가시켜고중성지방혈증과간지방효소의활성도를증가시켜 LDL-콜레스테롤은증가시키고 HDL-콜레스테롤은감소시켜심혈관위험을높이므로 49) 이를고려해야한다. 폐경전여성과폐경후여성의혈중중성지방농도는각각 193.17 ± 31.25 mg/dl 와 208.81 ± 35.39 mg/dl로폐경후여성에서유의하게높게나왔으며, LDL-콜레스테롤역시 115.02 ± 28.15 mg/dl, 129.09 ± 32.97 mg/dl 로폐경후여성에서유의하게높게나타났다. Yamaguchi 등 50) 은 LDL-콜레스테롤이요추부골밀도를감소시키고중성지방농도가척추골절의결정인자임을보고하였다. Parhami 등 51) 은시험관내실험에서 LDL-콜레스테롤이골수기질세포내

38 / 폐경전후여성의골밀도와골대사 에서골형성은억제하고지방생성을촉진한다고하였다. 혈압은수축기혈압이폐경전여성보다폐경후여성에서유의하게높게나왔으며폐경전여성에서골밀도와수축기혈압은유의적인양의상관관계를나타냈고폐경후여성에서는골밀도와수축기혈압은관계가없었다. 영양소섭취량의경우골밀도에영향을미치는나이, 키, 체중을보정한후에는폐경후여성이폐경전여성보다탄수화물, 섬유소, 칼륨섭취량이유의적으로높았고, 비타민 B 2 섭취량은유의적으로낮게나왔다 (data not shown). 전체대상자평균열량은폐경전과후각각 KDRIs의 88.3%, 85.3% 로알맞게섭취하고있었으나단백질섭취는각각 167.9%, 157.5% 로높게섭취하고있었고, KDRIs와비교하여나트륨섭취상태를또한각각 226.8%, 216.5% 로과잉으로섭취하고있음을알수있었다. 고나트륨섭취는칼슘배설의주요인중하나로, 식이나트륨섭취를증가시키면소변으로칼슘배설이증가 52) 하게되고, 소변중나트륨배설량이디옥시피리디놀린 ( 소변의골대사지표 ) 및칼슘의배설량과유의적인양의상관성을나타내어결국나트륨의과잉섭취는골밀도에부정적인영향을주게된다. 53) 칼륨섭취량은폐경전과폐경후여성에서 KDRIs와비교했을때, 66.7%, 71.5% 로매우부족한양을섭취하고있었는데본연구에서요추골밀도와칼륨섭취와의상관성을살펴보면폐경전여성에서음의상관관계를나타내어 Choi & Kim 54) 연구와같이요추골밀도에부정적인영향을미치는예측인자로나타났다. 평균인섭취량은폐경전여성 1,131.69 mg, 폐경후여성 1,109.09 mg으로권장량의 161%, 158% 를섭취하고있었으며, 폐경후여성을대상으로한 Lee 등 55) 의연구결과인 892.5 mg 보다높았다. 폐경전여성과폐경후여성의칼슘섭취량은한국인권장량 98.4%, 87.3% 였으며, 이는다른여러보고 56,57) 와비교했을때폐경전여성은충분하게칼슘을섭취하고있었으나폐경후여성은한국인권장량보다칼슘섭취량이부족하다는것을알수있다. 비록혈청내평균칼슘농도가골형성의좋은생화학적지표는아니지만, 칼슘섭취량은나이, 키, 체중을보정했을때폐경후여성에서요추골밀도와양의상관성을나타냈다. 폐경과더불어체내칼슘흡수능력은급격히떨어지므로 58) 골밀도유지를위해이시기의적절한칼슘섭취가중요하다고할수있다. 59) 이를반영하듯이, 미국의 NIH Consensus Conference 에서는에스트로겐대체요법을사용하는폐경후여성에게는칼슘균형을위해 1일 1,000 mg의칼슘을권장하고에스트로겐대체요법을사용하지않는여성에게는 1,500 mg의칼슘을권장하고있다. 60) 폐경전여성에서는골대사지표와영양소섭취사이에상 관성이나타나지않았지만폐경후여성에서 OC와나이아신은음의상관성을나타냈고 CTx는열량, 지방, 탄수화물, 철분, 칼륨과음의상관성을나타냈다. 폐경전여성보다폐경후여성에서골대사지표와영양소섭취사이의연관성을더잘반영한다는것을알수있었다. 폐경후여성에서요추골밀도를예측할수있는인자로는키, 나이, 61) OC, 혈청칼슘, 혈청나트륨, 식이지방, 식이나트륨, 식이칼슘이 36% 로요추골밀도를예측할수있는것으로나타났으며, 폐경전, 후모두 OC가부정적인영향을미치는것을알수있었고상대적으로다른인자들보다영향력이있었다. 대퇴골골밀도를예측하는인자로폐경전여성은 CTx, ALP가부정적인영향을미쳤고폐경후여성은 ALP가부정적인영향을주는것을알수있었고상대적으로다른인자들보다영향력이있었다. 대퇴전체골밀도를예측하는인자로는폐경전 CTx, 혈청염소가부정적인영향을미치는것으로나타났는데, 혈청염소와대퇴전체골밀도의관계는선행연구에서찾아볼수없었다. 또한, 폐경후여성에서 OC는부정적인영향을미치는것으로나타났고상대적으로다른인자들보다영향력이있는것으로나타났다. 이는골대사지표가골밀도를반영하는좋은지표가될수있고폐경후여성에게있어골대사지표의증가는골대사가빠르다는것을의미하기때문에오히려골대사지표의증가가골밀도감소의위험요인으로해석되어지기도한다. 요약 본연구는서울소재대학병원에서건강검진을한폐경전 (283 명 ) 과폐경후 (143 명 ) 여성총 431명을대상으로골밀도, 골대사지표, 여성호르몬및영양소와의관련성에대해알아보고자실시하였으며그결과를요약하면다음과같다. 연구대상자의평균나이는 48.4 세였고, 폐경후여성의평균폐경나이는 50.3 세였으며, 폐경후경과기간은 5.17 년이었다. 대상자의평균신장 체중 허리둘레 체질량지수 체지방률은각각 159.2 cm, 55.6 kg, 74.4 cm, 21.9 kg/ m2, 29.1% 이었으며, 폐경후여성의나이, 신장, 허리둘레, BMI, 체지방률이폐경전여성보다유의하게높았다 (p < 0.001, p < 0.001, p < 0.001, p < 0.01, p < 0.001). 평균수축기혈압과이완기혈압은각각 113.5 mmhg, 69.4 mmhg었으며폐경후여성에서유의적으로높았다 (p < 0.001, p < 0.01). 연구대상자의골밀도를살펴본결과폐경후여성이폐경전여성보다요추, 대퇴경부, 대퇴전체골밀도가유의하게감소되어있었고 (p < 0.001) OC, CTx, ALP 지표는폐경전여성보다폐경후여성이유의하게높은것으로나타

한국영양학회지 (Korean J Nutr) 2011; 44(1): 29 ~ 40 / 39 났다 (p < 0.001). 평균열량섭취량은폐경전여성 1,679.4 kcal, 폐경후 여성 1,621 kcal로권장량의 93.2%, 90.05% 이었으며탄수화물, 단백질, 지방섭취량의에너지기여비율은각각 58 : 18 : 24, 61 : 18 : 21 이었다, 단백질, 지방, 콜레스테롤섭취량이폐경전여성보다폐경후여성에서유의하게높았다 (p < 0.05, p < 0.001, p < 0.001). 일반영양소섭취량중에서특히칼륨섭취량 ( 폐경전 후여성의칼륨섭취량은권장량의 66.69%, 71.54%) 이권장량에많이부족한반면나트륨섭취량 ( 폐경전 후여성의나트륨섭취량은권장량의 226.8%, 216.5%) 은권장량보다훨씬높았으며섬유소, 칼륨의섭취량은폐경전여성이폐경후여성보다유의하게높게나타났다 (p < 0.05, p < 0.05). 폐경전여성은요추골밀도와칼륨섭취량사이에서음의상관관계를, 폐경후여성에서는요추골밀도와칼슘섭취량사이에서양의상관관계를나타냈고 CTx와열량, 지방, 탄수화물, 철분, 칼륨, 비타민 A, 베타카로틴, 나이아신, 엽산, 섬유소섭취량과음의상관관계를나타냈으며 OC와나이아신섭취량사이에서음의상관관계를나타났다. 요추골밀도는단백질, 지방, 칼슘과양의상관관계를나타냈고 FSH 또한지방, 나이아신섭취량사이에서양의상관관계를나타냈다. 이상의결과를종합해볼때폐경전과폐경후여성에서골표지자인 OC, CTx, ALP 지표는골밀도와여성호르몬농도와연관되어, 체내의골대사에관련된중요한중재자의하나임을재확인하였고, 골밀도를예측하는인자는다소차이가있었지만폐경전여성에서체중, BMI, 폐경후여성에서는칼슘섭취량, 나이등이다른인자들보다중요도및예측에있어상대적인영향이더큰것을알수있었다. 또한, 영양섭취상태는폐경전과폐경후여성에서열량섭취는권장량과비교하였을때양호한편이었으나그에반해, 칼륨, 칼슘섭취는부족, 나트륨은과잉섭취를하고있었다. 따라서폐경후골다공증을예방하고골감소를최소화하기위해서는골밀도에긍정적영향을미친다고판단된혈청칼슘의충분한섭취와적절한체중유지가중요하며반대로부정적영향을미친나트륨섭취감소는골밀도의감소를예방하는데중요한역할을할수도있다고제안한다. Literature cited 1) Korea National Statistical Office, Annual report of mortality statistics, Seoul; 2005 2) Korea National Statistical Office, Population projection for Korea, Seoul; 2007 3) Won HS. Effects of age-related changes in taste perception on nutritional status and validation of food frequency questionnaire for the Korean elderly [dissertation]: Seoul: Ewha Womans University; 1996 4) Choi SN, Lee SY, Chung NY. Bone density and processed food intake behavior if middle aged and elderly women in the Seoul area. Korean J Food Cult 2008; 23(6): 681-692 5) Avioli LV. The osteoporotic syndrome; Detection, prevention and treatment. 4th ed: Orlando, FL: Academic press; 2000. 6) Lee NJ. Age, Body weight, physical activity, dietary patterns, and acculturation may affect osteoporosis risk in postmenopausal Korean and Korean American women. Korean J Phys Educ 2008; 47(2): 361-369 7) Kim MS, Koo JO. Comparative analysis of food habits and bone density risk factors between normal and risk women living in the seoul area. Korean J Community Nutr 2008; 13(1): 125-133 8) Jang SN, Choi YH, Chol MG, Kang SH, Jeong JY, Choi YJ, Kim DH. Prevalance and associated factors of osteoporosis postmenopausal women in Chuncheon: HAS. J Prev Med Public Health 2006; 39(5): 389-396 9) Kim YS, Yoon BK, Kim JY, Choi DS, Lee JH, Kim JH, Kim KW, Min YK. Effect of hormone replacement therapy on bone mineral density in Korean postmenopausal women over age of 60. J Korean Soc Menopause 2007; 13(2): 114-122 10) Eastell R, Delmas PD, Hodgson SF, Eriksen EF, Mann KG, Riggs BL. Bone formation rate in older nomal women: concurrent assessment with bone histomorphometry, calcium kinetics and biochemical markers. J Clin Endocrinol Metab 1988; 67: 741-748 11) Lee HS, Baik IK, Hong ES. Effect of nutrients intakes on development of osteoporosis in Korean postmenopausal women. J Korean Diet Assoc 1996; 2(1): 38-48 12) Ribot C, Pouilles JM, Bonneu M, Tremollieres F. Assessment of the risk of post-menopausal osteoporosis using clinical factors. Clin Endocrinol (Oxf) 1992; 36: 225-228 13) Chung YJ, Lee KM, Park JW, Chung SP. Fators which are related with BMD in premenopausal women. J Korean Acad Fam Med 2001; 22: 363-370 14) Johansen JS, Riis BJ, Delmas PD, Christiansen C. Plasma BGP. An indicator of spontaneous bone loss and of effect of estrogen treatment in postmenopausal women. Eur J Clin Invest 1998; 18: 191-195 15) Lee KM, Han SB, Kim JS, Baik KJ, Hong SB, Moon KH, Kang JS, Yoon SH. Bone mineral density and bone turnover makers in patients with femur fracture who visited the emergency department. J Korean Soc Traumatol 2005; 18(2): 87-93 16) Lee CS, Yoon SC. The significance of serum C-telopeptide as a bone marker in chronic hemodialysis patients. Korean J Med 2009; 76(4): 443-450 17) Mckay HA, Petit MA, Khan KM, Schutz RW. Lifestyle determinants of bone mineral: a comparison between prepubertal Asian- and Caucasian-Canadian boys and girls. Calcif Tissue Int 2000; 66 (5): 320-324 18) NOF. OBRD~NRC; 1998 19) Riggs BL, Melton LJ. The prevention and treatment of osteoporosis. N Engl J Med 1992; 327: 620-627 20) Kakudo K. Introduction for special issue of calcitonin and calcitonin receptor. Cell Mol Biol 2006; 1552(3): 1-2 21) Mcguigan FE, Murray L, Gallagher A, Davey-Smith G, Neville CE, Van t Hof R, Boreham C, Ralston SH. Genetic and environmental determinants of peak bone mass in young man and women. J Bone Miner Res 2002; 17(7): 1273-1279 22) Anderson JJB. Nutritional advances in human bone metabolism introduction. J Nutr 1996; 126: 1150S-1152S

40 / 폐경전후여성의골밀도와골대사 23) Lamichhane AP. Osteoporosis-an update. J Nepal Med Assoc 2005; 44(158): 60-66 24) Slemenda CW, Christian JC, Reed T, Reister TK, Williams CJ, Johnston CC Jr. Longterm bone loss in men: effects of genetic and environmental factors. Ann Intern Med 1992; 117(4): 286-291 25) Yu CH, Kim HS, Lee JS, Kim JY. A study on Ca and P balance in Korean adult women. Korean J Nutr 2001; 34 (1); 54-61 26) Lee KS, Kim JM. Comparison of nutrients intake, bone density, total cholesterol and blood glucose in women living in Taegu City. J Korean Diet Assoc 2003; 9(1): 81-93 27) Mizushima S, Tsuchida K, Yamori Y. Preventive nutritional factors in epidemiology: interaction between sodium and calcium. Clin Exp Pharmacol Physiol 1999; 26: 573-575 28) Son SM, Heo KY. Salt intake and nutritional problems in Korea. Korean J Community Nutr 2002; 7(3): 381-390 29) Metka M, Holzer G, Heytmanek G, Huber J. Hypergonadotropic hypogonadonadic amenorrfea and osteoporosis. Fertil Steril 1992; 57: 37-41 30) Hamdy RC, Petak SM, Lenchik L. Which central dual X-ray absorptiometry skeletal sites and regions of interest should be used to determine the diagnosis of osteoporosis. J Clin Densitom 2002; 5(Suppl): S11-S18 31) Block G, Coyle LM, Hartman AM, Scoppa SM. HHHQ-DIET- SYS analysis software, Ver.3.0 National Cancer Institute, Bethesda, MD; 1993 32) Kim HY, Yang EJ. A Study on development and validation of food frequency questionnaire for Koreans. Korean J Nutr 1998; 31(2): 220-230 33) Paek HY, Ryu JY, Choi JS, An YJ, Mun HK, Park YS, Lee HG, Kim YI. Development and validation of food frequency questionnaire for dietary assessment of Korean adults in rural area. Korean J Nutr 1995; 28(9); 914-922 34) Lee SH. The association between dietary patterns and the risk of metabolic syndrome; 2005 35) Sung CJ, Choi YH, Kim MH, Choi SH, Cho KO. A study of nutrient intake and serum levels of osteocalcin, Ca, P, and Mg and their correlation to bone mineral density in Korean postmenopausal women residing in rural areas. Korean J Community Nutr 2002; 7(1); 111-112 36) Yu CH, Lee YS, Lee L, Kim SH, Lee SS, Jung Ik. Nutritional factors related to bone mineral density in the different age groups of Korean women. Korean J Nutr 2002; 35(7): 779-790 37) Lee HJ, Lee HO. A study on the bone meniral density and related factors in Korean postmenopausal women. Korean J Nutr 1999; 32(2): 197-203 38) Leon S, Marc AF. Clinical gynecologic endocrinology and infertility. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p.652 39) Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J Clin Invest 2005; 115: 3318-3325 40) Choi SH, Hwang DK, Song HR, Noh HJ, Kang JY, Choi DH, Choi HJ. Predictors for Lumbar bone mineral density in premenopausal and postmenopausal women in Korea. J Korean Soc Menopause 2009; 15(2): 101-109 41) Riggs BL, Melton LJ 3rd. The prevention and treatment of osteoporosis. N Engl J Med 1992; 327: 620-627 42) Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison s principles of internalmedicine, 15th ed. The McGraw-Hill Companies, Inc; 2001. p.2226-2227 43) Weinstein RS, Manolagas SC. Apoptosis and osteoporosis. Am J Med 2000; 108: 153-164 44) Turner RT, Riggs BL, Spelsberg TC. Skeletal effects of estrogen. Endocr Rev 1994; 15: 275-300 45) Pacifici R. Estrogen, cytokines, and pathogenesis of postmenopausal osteoporosis. J Bone Miner Res 1996; 11: 1043-1051 46) Felson DT, Zhang Y, Hannan MT, Anderson JJ. Effects of weight and body mass index on bone mineral density in men and women: the Framingham study. J Bone Miner Res 1993; 8: 567-573 47) Frost HM. Obesity, and bone strength and mass : A tutorial based on insights from a new paradigm. Bone 1997; 21: 211-214 48) Hoover PA, Webber CE, Beaumont LF, Blake JM. Postmenopausal bone mineral density: Relationship to calcium intake, calcium absorption, residual estrogen, body composition, and physical activity. Can J Physiol Pharmacol 1996; 74: 911-917 49) Rebuffé-Scrive M, Eldh J, Hafström LO, Björntorp P. Metabolism of mammary, abdominal, and femoral adipocytes in women before and after menopause. Metabolism 1986; 35: 792-797 50) Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab 2003; 88: 2404-2411 51) Koo JO, Ahn HS, Yoo SY. Study of bone mineral density, body composition and dietary habits of 20-30 years women. Korean J Community Nutr 2008; 13(4): 489-498 52) Yamaguchi T, Sugimoto T, Yano S, Yamauchi M, Sowa H, Chen Q. Plasma lipids and osteoporosis in postmenopausal women. Endocr J 2002; 49: 211-217 53) Parhami F, Jackson SM, Tintut Y, Le V, Balucan JP, Territo M. Atherogenic diet and minimally oxidized low density lipoprotein inhibit osteogenic and promote adipogenic differentiation of marrow stromal cells. J Bone Miner Res 1999; 14: 2067-2078 54) Choi, JH, Kim SK. Comparison of the dietary factors between normal and osteopenia groups by bone mineral density in Korean female college students. J Korean Soc Food Sci Nutr 2008; 37 (7): 815-958 55) Lee BK, Chang YK, Choi KS. Effect of nutrient intake on bone mineral density in postmenopausal women. Korean J Nutr 1992; 25(7): 642-655 56) Gruchow HW, Sobocinski KA, Barboriak JJ. Calcium intake and the relationship of dietary sodium And potassium to blood pressure. Am J Clin Nutr 1988; 48: 1463-1470 57) Jones G, Beard T, Parameswaran V, Greenaway T, Von Witt R. Apopulation-based study if the relationship between salt intake, bone resorption and bone mass. Eur J Clin Nutr 1997; 51(8): 561-565 58) Kim JH. Determinants of bone mineral density in adult women living in community dwellings [Masterthesis]. Bucheon: The Catholic University; 2002 59) Heaney RP, Recker RR, Stegman MR, Moy AJ. Calcium absorption in women: relationships to calcium intake, estrogen status, and age. J Bone Miner Res 1989; 4(4): 469-475 60) Heaney RP. Nutritional factors in bone health in elderly subjects: methodological and contextual problems. Am J Clin Nutr 1989; 50: 1182-1189 61) Yang YS, Noh HT. Predictors for Lumbar bone mineral density in premenopausal and postmenopausal women in Korea. Korean J Obstet Gynecol 2008; 51: 429-440