대한비만학회지 : 제 17 권제 1 호 2008 원저 40 세이상성인에서비만지표가혈중지질수준과고지혈증발생에미치는영향 이화여자대학교의과대학예방의학교실, 이화의학글로발첼린지사업단 남상명 하은희 * 서영주 박혜숙 장문희 서주희 김병미 Effect of Obesity and Blood Lipid Profiles on Hyperlipidemia in Adults Aged Over 40 Years Sang-Myung Nam, Eun-Hee Ha *, Young-Ju Suh, Hyesook Park, Moon Hee Chang, Ju Hee Seo, Byung-Mi Kim Department of Preventive Medicine, BK21 Research Division for Medicine, School of Medicine, Ewha Womans University 요 약 연구배경 : 본연구는고지혈증과비만의관계를알아보고자비만지표중체질량지수 (BMI) 와체지방량 (%) 을사용한결과를비교하여한국인에게적합한비만지표를제시하고자하였다. 방법 : 2005년 6월부터 12월까지서울지역 E종합병원에서건강검진을수진한 40세이상의남녀중연구에동의한 1121명 ( 남자 420명, 여자 701명 ) 을연구대상자로하였다. 결과 : 체질량지수를비만기준으로한경우총콜레스테롤, LDL-콜레스테롤은비만을동반한군보다비만을동반하지않은군에서유의적으로높게나타났다. 체지방량 (%) 을비만기준으로한경우, 비만을동반한고지혈증군에서복부비만과상체비만이주로나타났으며체질량지수를기준으로한비만고지혈증군에비해 2배가까이높게분류되었다. 총콜레스테롤과 LDL-콜레스테롤은고지혈증군간에는차이를보이지않았으나동맥경화지수 (AI), HDL-콜레스테롤에대한총콜레스테롤의비율은비만을동반하지않은고지혈증군에비해비만을동반한고지혈증군에서매우높게나타났다. 보정교차비는두기준모두총콜레스테롤, LDL-콜레스테롤이증가할수록고지혈증의위험이증가하는것으로나타났으며특히동맥경화지수 (AI), HDL-콜레스테롤에대한총콜레스테롤의비율은비만을동반하지않은고지혈증군에비해비만을동반한고지혈증군에서매우높게나타나복부비만이고지혈증의위험요인임을알수있었다. 결론 : 한국인의고지혈증을진단하는비만지표로는체지방량 (%) 을이용하는것이비만특성을잘반영하며, 비만은고지혈증의위험수준을높이는것으로나타났다. ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 중심단어 : 체지방량 (%), 체질량지수, LDL-콜레스테롤, 고지혈증 서론 2001년발표된 1994년의우리나라의사망원인통계결과를보면암, 뇌혈관질환, 심장질환, 당뇨병등에기인한사망자가전체의 50.4% 를차지하여선진국형질병양상을보 여주고있다. 1) 관상동맥질환및뇌혈관질환의공통되는위험인자에는고지혈증, 고혈압, 당뇨, 흡연등이있다. 2) 특히 Frammingham 연구보고 3) 에따르면, 관상동맥질환의가장중요한위험인자인고지혈증은고지혈증을치료할경우관상동맥질환에의한사망률을 20~30% 까지감소시킬수있 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 교신저자 : 하은희, (158-710) 서울양천구목 6 동이화여자대학의과대학예방의학교실 Tel: 02)2650-5757, Fax: 02)2653-1086, E-mail: eunheeha@ewha.ac.kr, Mobile: 011-9189-2931-20 -
- 40 세이상성인에서비만지표가혈중지질수준과고지혈증발생에미치는영향 - 다고하였다. 관상동맥병변의연구에서도고지혈증의위험인자를조절하면급성관상동맥증후군을잘유발하지않는안정성반 (stable plaque) 으로변환될수있어병변의퇴행정도는미약하지만관상동맥질환의재발은임상적으로대폭감소시킴이관찰되었다고했다. 4,5) 죽상동맥경화의가장중요한독립인자인고지혈증은혈중콜레스테롤 (cholesterol) 이나중성지방 (triglyceride) 이정상이상으로높아진현상을말하다. 6) 고지혈증의경우특별한자각증상이없기때문에심혈관질환의예방에소홀할수있다. 고지혈증의위험요인으로는생활습관의서구화, 영양섭취량의증가, 동물성지방섭취량의증가, 평균체중의증가, 운동량감소, 스트레스증가, 평균수명의연장및노년층인구의증가등이있다. 7) 이요인들은주로식이및체중조절과관련되어있는데특히비만은콜레스테롤과지단백 (lipoprotein) 대사에이상을초래하여고지혈증의원인이된다고하였다. 과체중이거나비만한사람은혈장콜레스테롤이나중성지방이정상인보다높다고보고된바있다. 8) 관상동맥질환의위험도를잘나타내주는비만관련지표에는체질량지수 (body mass index: BMI), 체지방량 (%, Percent Body Fat: %BF), 허리둘레 (WC), 허리엉덩이둘레비율 (waist/hip ratio: WHR) 등이있는데 9,10) 외래에서간편하게신체계측을통해측정할수있는체질량지수와허리둘레가주로사용되어왔다. 그러나좀더정확한비만평가를위해비만지표와관련된국내연구들이진행되어왔다. 한국노인을대상으로한연구에의하면남자노인은허리둘레, 여자노인은체질량지수가심혈관질환의위험을선별하는데좋은지표가된다고하였다. 11) 그러나체질량지수를기준으로비만에속한다하더라도지방축적부위에따라당대사및지질대사에미치는영향이다른것으로보고되었으며 11) 특히복부비만은전체비만보다고혈압, 당뇨병, 고지혈증, 낮은 HDL( 고밀도지단백질 ) 콜레스테롤, 높은 LDL( 저밀도지단백질 ) 콜레스테롤과관련이있으며 12,13) 복부비만의증가는혈중지질조성의변화를가져와관상동맥질환의위험도를유의적으로높인다고하였다. 14) 최근의연구에서일본 15), 홍콩 16), 싱가폴 17) 등과같은아시아인들은서양인과달리비만치료로서같은기준의체질량지수를사용하였을때심혈관질환의위험성은높은데비해체질량지수는낮게나타나, 아시아인에게 WHO에서제시하는체질량지수의기준을적용하는것이타당한가에대한논의가있어왔다. 18) 아시아인에게적합한지표를위해국내에서도허리둘레 (WC), 허리엉덩이둘레비율 (WHR) 의타당도에대한연구들이진행되었으나 19) 체지방량 (%) 을기준으로한연구는아직까지미비한실정이다. 체질량지수와허리엉덩이둘레비율은측정방법이간단하여판단기준으로많이사용되지만인종에대한고려없이설정된기준을사용하여비만증의합병증의발생위험을평가하거나고지혈 증을진단함에있어오류를범하게될수있다. 따라서본연구에서는 40세이상의성인을대상으로체질량지수와체지방량 (%) 의두가지비만지표에따른혈중지질특성을분석하고비만과고지혈증발생과의관계를파악하여위험을평가하고자하였다. 방법 1. 연구대상연구대상자는 2005년 6월부터 2005년 12월까지건강검진수진자코호트에소속된서울지역 E종합병원에건강검진을수진한 40세이상의남녀중연구에동의한총 1,121 명 ( 남자 420명, 여자 701명 ) 으로하였다. 혈중지질의평가는미국국립보건원 20) (National Institutes of Health) 의진단과고지혈증관리지침 21) 에의해총콜레스테롤은정상 (< 200 mg/dl), 경계 (200~239 mg/dl), 위험 ( 240 mg/dl) 으로구분하였다. 중성지방은정상 (< 150 mg/dl), 경계 (150~199 mg/dl), 위험 ( 200 mg/dl) 으로구분하였다. 연구대상자는 3개의그룹으로분류하였다. 혈중농도를정상범위로한정상군 (Normal) 과경계수준과위험수준을포함하여총콜레스테롤이 200 mg/dl 이상이거나중성지방이 150 mg/dl 이상인경우를고지혈증 (Hyperlipidemia) 군으로분류하였다. 22) 또한고지혈증군은다시비만을동반하지않은정상고지혈증 (Normal + Hyper) 군과비만을동반한고지혈증 (Obesity + Hyper) 군으로분류하여비교하였다. 비만기준은체질량지수와체지방량 (%) 을이용하였다. 체질량지수는우리나라기준으로정상군은체질량지수 < 25 kg/m 2 로하였고비만군은체질량지수 25 kg/m 2 로하였다. 체지방량 (%) 은 WHO기준에따라남자의정상군은 < 20%, 비만군은 20% 로하였으며, 여자의정상군은 < 30%, 비만군 30% 로하였다. 23) 2. 신체계측및체성분분석신장과체중은신장-체중자동측정기를이용하여측정하였으며혈압을측정하였고, 신장과체중을측정하여체질량지수 (BMI; 체중 (kg)/ 신장 (m) 2 ) 를산출하였고, 체성분분석은생체전기저항분석법 (Bioelectrical impedence analysis, BIA) 방식의체성분분석기 (Zeus 9.9, Jawon, Korea) 를이용하여측정전소변을본후체지방량 (%) 과근육량 (kg) 을측정하였다. 허리둘레 (WC) 는직립자세에서최하위늑골하부와골반장골능과의중간부위를측정하였으며 (cm), 엉덩이둘레는대퇴골대전자부위의둘레를측정하였다. 허리둘레의기준치는세계보건기구서태평양지부의기준에따라남자에서는 90 cm 이상, 여성에서는 80 cm 이상일때복부비만으로정의하였다. 24) 상체비만 (upper body fat) 은허리엉덩이둘레비 (WHR) 로측정하였는데허리둘레 (cm) 를엉덩 - 21 -
- 대한비만학회지 : 제 17 권제 1 호 2008 - 이둘레 (cm) 로나눈값으로하였다. 남자는허리엉덩이둘레비 (WHR) > 0.90이고여자는허리엉덩이둘레비 (WHR) > 0.80일때상체형비만으로하였다. 25) 3. 사회인구학적관련요인사회인구학적요인과생활습관요인을살펴보기위하여설문조사에는성별, 나이, 교육수준, 음주습관 ( 과거음주, 현재음주, 비음주 ), 규칙적운동여부 ( 예, 아니오 ) 등이조사되었다. 4. 혈중지질분석혈중지질중중성지방과총콜레스테롤, HDL-콜레스테롤및 LDL-콜레스테롤은효소법으로비색정량하였다. 동맥경화지수 (Atherogenic index:ai) 는동맥경화의위험율을예측할수있는변인으로산출방식 26) 은 LDL-콜레스테롤 /HDL-콜레스테롤이며 Newman 등 27) 의기준에근거하여그값이 5.0 이하일때정상으로하였으며, 총콜레스테롤 /HDL- 콜레스테롤은 3.0 이하일때정상으로하였다. 5. 통계분석그룹별혈중지질분석과비만관련지표분석은 χ 2 -test와 ANOVA-test를이용하였다. 사후검정으로서, 개별집단간의차이를보기위해 P < 0.05 수준에서 Duncan's multiple test로비교분석을시행하였다. 비만지표에따른혈중지질및비만관련요인과고지혈증발생과의관계를보기위해교란변수로성별, 연령, 교육수준, 음주습관, 규칙적운동여부및총열량섭취를보정한후세집단에대한 multinomial logistic regression 분석을수행하였다. 통계분석은 SAS (version 9.0) 를이용하였다. Table 1. Distribution of study population characteristics in the hyperlipidemic groups with normal weight (BMI < 25 kg/m 2 ) and excess weight (BMI 25 kg/m 2 ) Characteristics Normal * Hyperlipidemia (n = 549) Normal + Hyper * Obesity + Hyper * (264) (n = 351) (n = 198 ) P-value Sex male 84 (31.84) 100 (28.49) 102 (51.12) female 180 (68.18) 251 (71.51) 96 (48.48) Waist(male) < 90 82 (97.62) 86 (86.00) 52 (50.98) 90 2 ( 2.38) 14 (14.00) 50 (49.02) Waist(female) < 80 158 (87.78) 200 (79.68) 36 (37.50) 80 22 (12.22) 51 (20.32) 60 (62.50) WHR(male) < 0.9 80 (95.24) 84 (84.00) 67 (65.69) 0.9 4 ( 4.76) 16 (16.00) 35 (34.31) WHR(female) < 0.8 128 (71.11) 145 (57.77) 37 (38.54) 0.8 52 (28.89) 106 (28.89) 59 (61.46) Age (yr) 49.17 ± 7.05 a 51.11 ± 7.02 b 52.85 ± 7.42 c Weight (kg) 59.34 ± 7.05 a 57.56 ± 7.50 a 71.35 ± 8.66 b Height (cm) 161.83 ± 7.49 ab 160.74 ± 6.89 a 161.94 ± 8.02 b (%) BF 25.52 ± 4.96 a 26.71 ± 4.53 a 31.19 ± 4.88 a 0.15 SBP (mmhg) 120.59 ± 15.68 a 1 27.58 ± 18.16 b 138.06 ± 16.37 c DBP (mmhg) 74.49 ± 10.18 a 78.12 ± 10.70 b 84.97 ± 9.66 c FBS (mg/dl) 92.30 ± 12.71 a 96.29 ± 15.97 a 107.55 ± 32.60 b Total Cholesterol (mg/dl) 172.55 ± 18.76 a 2 21.85 ± 32.23 b 215.80 ± 30.94 c HDL-Cholesterol (mg/dl) 57.64 ± 12.20 a 61.75 ± 15.02 b 51.89 ± 11.77 c LDL-Cholesterol (mg/dl) 98.57 ± 17.60 a 1 33.90 ± 33.36 b 127.28 ± 32.03 c Triglyceride (mg/dl) 81.91 ± 29.75 a 1 36.06 ± 89.73 b 187.63 ± 106.13 c Atherogenic index 1.80 ± 0.64 a 2.29 ± 0.78 b 2.54 ± 0.74 c T-Chol/HDL-Chol-ratio 3.10 ± 0.62 a 3.78 ± 0.96 b 4.32 ± 0.95 c * Normal : BMI < 25 and total cholesterol < 200 mg/dl and triglyceride < 150 mg/dl. Normal + Hyper : BMI < 25 and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Obesity + Hyper : BMI 25 and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Number(%). Mean ± SD. Values within a column with different superscript letters such as a, b, c are significantly different at P < 0.05. χ 2 -test. ANOVA test. WHR, Waist to hip ratio; BMI, Body mass index; (%) BF, bodyfat (%); SBP, Systolic blood pressure; DBP, Diastolic blood pressure; FBS, Fasting blood glucose; Atherogenic index, LDL-cholesterol/HDL-cholesterol; T-Chol/HDL-Chol-ratio, Total cholesterol /HDL-cholesterol. - 22 -
- 40 세이상성인에서비만지표가혈중지질수준과고지혈증발생에미치는영향 - 결 1. 체질량지수와체지방량 (%) 에따른일반특성과혈액조성변화 체질량지수를비만기준으로하였을경우 Table 1과같이비만을동반한고지혈증군은여성에비해남성의분포가높게나타났으며, 복부비만과 WHR은비만을동반한고지혈증군에서남, 여모두높게나타났다 (P < 0.001). 비만을동반한고지혈증군의평균몸무게는유의적으로높게나타났다. 수축기혈압 (SBP) 및이완기혈압 (DBP) 은고지혈증군이정상군에비해, 특히비만을동반한고지혈증군에서유의하게높았다. 혈당은비만을동반한고지혈증군에서유의적으로높았으며정상기준인 70~100 mg/dl보다다소높았다. 각군의혈중지질특성을보면세군간의유의적인차 과 이를보였는데, 총콜레스테롤, LDL-콜레스테롤은비만을동반한군보다비만을동반하지않은고지혈증군에서더높게나타났다. HDL-콜레스테롤은비만을동반하지않은고지혈증군에서높게나타났으며, 중성지방은비만을동반한고지혈증군에서유의적으로높았다. 동맥경화지수 (AI) 는두군모두정상범위인 5.0 이하에속하였으나, HDL-콜레스테롤에대한총콜레스테롤의비율은비만을동반한고지혈증군에서 4.0 이상으로심혈관질환위험군으로나타났다. 한편, 비만기준을체지방량 (%) 으로하였을경우 Table 2 와같이비만을동반한고지혈증군은 370명으로체질량지수를기준으로산정한비만을동반한고지혈증군 198명에비해두배에가깝게비만수가증가된것을볼수있었다. 또한성별분포에서도체질량지수에의한분류와는달리비만을동반한고지혈증군에서여성의분포가다소높게나타 Table 2. Distribution of study population characteristics in the hyperlipidemic groups with normal weight and excess weight (BF%) Characteristics Normal * Hyperlipidemia (n = 550) Normal + Hyper * Obesity + Hyper * (n = 164) (n = 180) (n = 370) P-value Sex male 35 (21.34) 23 (12.78) 179 (48.38) female 129 (78.66) 157 (87.22) 191 (51.62) Waist (male) < 90 (95.35) 49 (89.09) 29 (51.79) 90 6(4.65) 6 (10.91) 27 (48.21) Waist (female) < 80 82 (98.8) 21 (95.45) 74 (59.68) 80 1 (1.2) 1 (4.55) 50 (40.32) WHR (male) < 0.9 35 (100.0) 20 (86.96) 131 (73.18) 0.9 0 (0.0) 3 (13.04) 48 (26.82) WHR (female) < 0.8 0.8 95 (73.64) 34 (26.36) 106 (67.52) 51 (32.48) 77 (40.31) 114 (59.69) Age (yr) 48.22 ± 6.37 a 49.37 ± 6.04 a 52.88 ± 7.44 b Weight (kg) 54.75 ± 6.51 a 53.73 ± 5.73 a 66.61 ± 9.39 b Height (cm) 161.04 ±7.23 a 159.77 ± 5.30 a 161.83 ± 8.03 b 0.02 BMI 21.22 ± 1.62 a 21.19 ± 1.76 a 25.34 ± 2.46 b SBP (mmhg) 119.61 ± 16.32 a 123.13 ± 18.32 a 135.03 ± 16.92 b DBP (mmhg) 73.69 ± 10.32 a 75.94 ± 11.10 a 82.64 ± 10.04 b FBS (mg/dl) 92.10 ± 10.05 a 93.28 ± 10.69 a 103.42 ± 27.08 b Total Cholesterol (mg/dl) 172.57 ± 18.36 a 222.26 ± 333.69 b 218.47 ± 30.91 b HDL-Cholesterol (mg/dl) 58.65 ± 12.26 a 65.57 ± 15.16 b 54.62 ± 13.05 c LDL-Cholesterol (mg/dl) 98.19 ± 18.21 a 133.88 ± 35.52 b 130.64 ± 31.66 b Triglyceride (mg/dl) 78.93 ± 29.84 a 114.29 ± 64.24 b 174.22 ± 106.70 c Atherogenic index 1.76 ± 0.56 a 2.16 ± 0.82 b 2.49 ± 0.73 c T-Chol/HDL-Chol-ratio 3.05 ± 0.64 a 2.56 ± 0.94 b 4.18 ± 0.95 c * Normal: BF < 20% for man, BF < 30% for woman and total cholesterol < 200mg/dL and triglyceride < 150 mg/dl. Normal+Hyper: BF < 20% for man, BF < 30% for woman (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Obesity+Hyper: BF 20% for man, BF 30% for woman and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Number(%). Mean ± SD. Values within a column with different superscript letters such as a, b, c are significantly different at P < 0.05. χ 2 -test. ANOVA test. WHR, Waist to hip ratio; BMI, Body mass index; (%) BF, bodyfat (%); SBP, :Systolic blood pressure; DBP, Diastolic blood pressure; FBS, Fasting blood glucose; Atherogenic index, LDL-cholesterol/HDL-cholesterol; T-Chol/HDL-Chol-ratio, Total cholesterol /HDL-cholesterol. - 23 -
- 대한비만학회지 : 제 17 권제 1 호 2008 - 났다 (P < 0.001). 복부비만 (WC) 은남자, 여자모두비만을동반한고지혈증군에서상대적으로높게나타났으며, 남자의경우에는정상군과비만을동반하지않은군에서는거의나타나지않았다. 상체비만 (WHR) 은남녀모두비만을동반한고지혈증군에서상대적으로높게나타났으며남자의경우정상군은상체비만자가없었으며비만을동반하지않은고지혈증군은 3명뿐이었다. 세군간의평균연령, 평균몸무게는비만을동반한고지혈증군에서유의하게높았다. 평균체질량지수는정상군과비만을동반하지않은고지혈증군은 25 kg/m 2 이하로정상의범위에속했다. 수축기혈압 (SBP) 및이완기혈압 (DBP) 은비만을동반한고지혈증군에서통계적으로유의하게높았다. 혈당또한혈압과유사한경향을보였다. 체지방량 (%) 분류에의한혈중지질특성을보면총콜레스테롤, LDL-콜레스테롤은고지혈증군간에는유의한차이를보이지않았다. 반면 HDL-콜레스테롤과중성지방은세군모두유의한차이를보였다. 동맥경화지수는고지혈증군모두정상범위였으며 HDL-콜레스테롤에대한총콜레스테롤의비율은심혈관질환위험범위에속하였으며비만을동반한고지혈증군에서가장높았다. 2. 체질량지수, 체지방량 (%) 에따른고지혈증위험요인의분석 체질량지수를비만지표로사용하여정상군과비만을동반하지않은고지혈증군, 비만을동반한고지혈증군의고지혈증발생위험을비교한결과는 Table 3과같다. 성별, 연령, 교육수준, 음주습관, 규칙적운동여부, 총열량섭취를통제한결과, 총콜레스테롤, LDL-콜레스테롤과중성지방함량이증가할수록고지혈증위험도가증가하는것으로나타났다. 특히동맥경화지수와 HDL-콜레스테롤에대한총콜레스테롤의비율은비만을동반한고지혈증군에서매우높게나타났다. HDL-콜레스테롤함량은비만을동반하지않은고지혈증군에서는위험요인으로작용하였으나비만을동반한군에서는보정교차비가 0.97 (95% CI = 0.96-0.99) 로비만을동반한고지혈증에대하여보호효과를나타내었다. 비만관련요인에따른고지혈증위험률을보면, 허리둘레는비만하지않은고지혈증군과비만을동반한고지혈증군모두에서혼란변수들의통제후보정교차비가유의하여복부비만이증가할수록고지혈증위험도가큰것으로나타났다. Table 4는체지방량 (%) 을비만지표로하여정상군에대 Table 3. Odds ratios of risk factors on hyperlipidemia with excess weight (BMI 25 kg/m 2 ) Characteristics Normal + Hyper * vs Normal * Obesity + Hyper * vs Normal * adjusted OR 95% CI adjusted OR 95% CI Total cholesterol (mg/dl) 1.12 (1.10~1.15) 1.10 (1.08~1.12) HDL-cholesterol (mg/dl) 1.03 (1.02~1.05) 0.97 (0.96~0.99) LDL-cholesterol (mg/dl) 1.07 (1.05~1.08) 1.06 (1.04~1.07) Triglyceride (mg/dl) 1.02 (1.02~1.03) 1.03 (1.02~1.04) Atherogenic index 3.14 (2.26~4.32) 5.59 (3.66~8.53) T-Chol/HDL-Chol-ratio 3.13 (2.35~4.16) 6.92 (4.58~11.47) Waist (cm) 1.07 (1.03~1.11) 1.53 (1.38~1.71) * Normal: BMI < 25 and total cholesterol < 200 mg/dl and triglyceride < 150 mg/dl. Normal + Hyper: BMI < 25 and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Obesity + Hyper: BMI 25 and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Adjusted for age, sex, education level, alcohol drinking, regular exercise and energy intake. Table 4. Odds ratios of risk factors on hyperlipidemia with excess weight (BF%) Characteristics Normal + Hyper * vs Normal * Obesity + Hyper * vs Normal * adjusted OR 95% CI adjusted OR 95% CI Total Cholesterol (mg/dl) 1.14 (1.11~1.18) 1.08 (1.06~1.10) HDL-cholesterol (mg/dl) 1.05 (1.03~1.07) 0.99 (0.97~1.01) LDL-dholesterol (mg/dl) 1.07 (1.05~1.09) 1.05 (1.04~1.06) Triglyceride (mg/dl) 1.02 (1.01~1.03) 1.03 (1.02~1.04) Atherogenic index 2.35 (1.56~3.54) 5.18 (3.32~8.09) T-Chol/HDL-Chol-ratio 2.15 (1.52~3.04) 5.83 (3.83~8.88) Waist (cm) 1.07 (1.00~-1.12) 1.35 (1.25~1.46) * Normal: BF < 20% for man, BF < 30% for woman and total cholesterol < 200 mg/dl and triglyceride < 150 mg/dl. Normal + Hyper: BF < 20% for man, BF < 30% for woman and (total cholesterol 200 mg/dl or triglyceride 150 mg/dl). Obesity + Hyper: BF 20% for man, BF 30% for woman and (total cholesterol 200 mg/dl or triglyceride 150 mg/ dl). Adjusted for age, sex, education level, alcohol drinking, regular exercise and energy intake. - 24 -
- 40 세이상성인에서비만지표가혈중지질수준과고지혈증발생에미치는영향 - 한고지혈증위험률을분석한결과이다. 성, 연령, 교육수준, 음주습관, 규칙적운동여부및총열량섭취를통제한결과 HDL-콜레스테롤은비만을동반하지않은고지혈증군에서는위험요인으로작용하였으나비만을동반한고지혈증군에서는유의하지않았다. 총콜레스테롤과 LDL-콜레스테롤은비만을동반하지않은고지혈증군의보정교차비에비해비만을동반한고지혈증군에서다소감소하였으나, 유의성은확보되었다. 동맥경화지수와 HDL-콜레스테롤에대한총콜레스테롤의비는혼란변수보정후두고지혈증군에서교차비가유의하게증가하여고지혈증발생과관련성이매우높은것으로나타났으며특히비만을동반한고지혈증군에서의고지혈증위험도가매우크게나타났다. 비만관련요인에따른고지혈증위험률을보면성, 연령, 교육수준, 음주습관, 규칙적운동여부및총열량섭취를통제한결과비만을동반한고지혈증군에서복부비만이증가할수록고지혈증위험성이증가하는것으로나타났다. 고찰본연구에서는심혈관질환의주요인자인비만지표에따른지질조성을체질량지수와체지방량 (%) 의두가지비만지표를사용하여, 비만지표별비만의특성과비만지표에따른고지혈증의위험요인을살펴보았다. 일반적으로사용되는비만의판정지표는체질량지수와허리둘레, 허리와엉덩이비율, 허벅지둘레등이사용되는데이들이인종, 연령등에따라진단결과가다르게나타나는것으로보고되고있다. 9-11) 본연구에서도이에기초하여한국인에게적합한비만지표를선별하기위하여체질량지수와체지방량 (%) 의두가지비만지표를사용해비만을판정하였다. 체질량지수를기준으로했을때비만을동반한고지혈증군의비율은전체고지혈군의 24%(n = 198) 인것에비해체지방량 (%) 으로분류할경우 52%(n = 370) 로좀더많은분포를나타내어체지방으로분류하는경우좀더많은사람이비만자로판정받게된다. 또한비만을동반한고지혈증군의성별분포가다르게나타났는데, 특히여성은체질량지수로비만을판정하는것보다는체지방량 (%) 으로판정하는것이비만으로판정되는수가많아졌다. Kook 등의 28) 결과에서도여성이남성에비해낮은체질량지수 (BMI) 에도체지방량 (%) 은더높게나타났다. 이는여성이남성에비해서근육량보다체지방량을더많이가지고있어외형적으로판정되는경우보다는체지방량 (%) 으로판정될때더많은수가나타난것으로생각되며, 여성은체지방량 (%) 으로비만을판정하는것이바람직하다고사료된다. 이에여성의체질량지수가좀더낮게적용되어야할것으로생각된다. 싱가폴인들을대상으로한연구 29) 에서도과체중과비만기준인체질량지수 25 kg/m 2 는 23 kg/m 2 로, 30 kg/m 2 는 27 kg/m 2 로낮 춰져야한다고했으며홍콩인들 18) 은 23 kg/m 2, 26 kg/m 2 이적당하다고제시되었다. 반면흑인이나카프카시안사람들에게는비만의기준치로서체질량지수 25 kg/m 2 와 30 kg/m 2 가질병률과사망률증가의위험요인으로서적절한지표 30) 라고한결과를볼때비만기준으로서체질량지수는인종에따라다르게적용되어야하며, 한국인은한국인에게적합한체질량지수기준을위해좀더연구가되어야할것이다. 비만을여러형태로분류할때체질량지수로판정하는경우비만형태가분명하게분류되지않아비만을동반하지않는고지혈증군에서복부비만을가진사람들이분류되어있으므로이로인해혈액조성의오류를가져올수있다. 그러나체지방량 (%) 으로판정하는경우복부비만과상체비만은정상군과비만을동반하지않는고지혈증군에비해비만을동반한군에서주로분포되어좀더명확한결과를보여주고있다. 본연구결과를볼때체지방량 (%) 이일관된지질조성과비만도를보여주므로비만지표로서더효율적이라고생각된다. 혈액의지질분석결과, 고지혈증군들은정상군에비해비만지수및복부비만이더높았으며혈중콜레스테롤, LDL-콜레스테롤및중성지방증가, HDL-콜레스테롤감소, 동맥경화지수증가, 수축기및이완기혈압증가등이관찰되었다. 비만기준으로체질량지수를사용하는경우혈중총콜레스테롤과 LDL-콜레스테롤은다른비만관련요인들과는달리비만을동반하지않은고지혈증군에서비만을동반한고지혈증군에비해유의적으로높게나타났다. 특히비만을동반하지않은고지혈증군에서의 LDL-콜레스테롤함량은정상범위인 130 mg/dl를초과하여위험범위였으나비만을동반한고지혈증군은오히려정상범위에속해모순된결과를보여주었다. 이는 Iwao 15) 의연구에서도체질량지수를측정했을때일본인들은서양인에비해체질량지수는낮으나총콜레스테롤이나 LDL-콜레스테롤농도는매우높게나타났다고한결과와일치했다. 그러나체지방량 (%) 으로판정하는경우 LDL-콜레스테롤은비만을동반하지않은고지혈증군과비만을동반한고지혈증군모두정상범위를초과하여위험범위였다. 따라서비만을판정하는지표에의해서혈중지질의형태가다르게나타남을알수있었다. Ko 31) 의연구결과에서도체질량지수와체지방량 (%) 에따라혈중지질에대한진단결과가달라질수있으며체지방량 (%) 을사용했을때모든변인들의변화경향이더일관적이었다고하였다. 중성지방은두기준모두비만을동반한고지혈증군에서매우높게나타났는데, 최근연구 32,33) 에의하면, 중성지방농도의증가는 HDL-콜레스테롤감소와관련이있으며, HDL-콜레스테롤에대한중성지방의비율은심혈관질환의중요한요인이다. 중성지방은비만과직접적인상관관계가 - 25 -
- 대한비만학회지 : 제 17 권제 1 호 2008 - 있으며인슐린저항성과연관된다. 고지혈증의위험요인으로두기준체질량지수와체지방량 (%) 모두혈중총콜레스테롤, LDL-콜레스테롤및중성지방증가는고지혈증발생을증가시키는위험요인으로작용하였다. 특히비만을동반한고지혈증은동맥경화지수와 HDL-콜레스테롤에대한총콜레스테롤의비와매우높은관계를보였다. 위의결과들을볼때비만지표로서체지방량 (%) 이좀더일관된결과들을보여주고있으며, 체질량지수로분석하는경우다소낮은기준치를적용하는것이적합하다고생각된다. 또한본연구를통하여비만을동반한고지혈증자가비만하지않은고지혈증자보다높은동맥경화지수와 HDL- 콜레스테롤에대한총콜레스테롤의비를나타낸것으로보아비만이고지혈증발생의위험을증가시키는인자임을알수있었다. 본연구는단면연구이기에고지혈증과비만의원인적연관성에대한선후관계의규명이어려우며, 성별에따른남녀간의특성과위험비의차이를고려하지못했다는것과폐경기이후여성의고콜레스테롤발생에대한점을고려하지못한제한점을갖는다. 그러나본연구를통하여한국인에게적합한비만지표를선정한다는면에서매우의미가있다고생각되며비만이고지혈증의위험을증가시키는요인임을밝혔다. 이에향후세밀한연구를통하여한국인의특성을고려한비만지표별기준치설정하는한편, 비만한고지혈증자에게있어비만으로인한심혈관질환의발생위험을감소시키기위해지질섭취의제한이나운동등의적절한조치를통해복부비만에대한관리가이루어져야할것이다. ABSTRACT Effect of Obesity and Blood Lipid Profiles on Hyperlipidemia in Adults Aged Over 40 Years Background: This study was conducted to investigate the relationship between the indices of obesity and risk of hyperlipidemia, and also to recommend healthy Body mass index (BMI) and percent body fat (BF %), that would be appropriate for Korean adults. Methods: A cross-sectional study was carried out in Ewha hospital since June 2005 until December 2005. Subjects (n = 1121) were recruited from the participants of the biannual health examination (provided for those over 40 years old) who consented to participate in this study. Results: When using BMI as a criterion for obesity, total and LDL-cholesterol levels of hyperlipidemic and normal body weight group were much higher than hyperlipidemic obesity group. However, when applying BF (%) as a criterion for obesity, total and LDL-cholesterol levels of hyperlipidemic obesity group were not different from those of normal group. But serum lipid levels in the hyperlipidemic obesity group were significantly higher than those in the hyperlipidemic and normal body weight group. Adjusted odds ratio of HDL-cholesterol to total cholesterol of hyperlipidemic obesity group was higher than that of hyperlipidemic and normal body weight group by using BF (%). The atherosclerotic index (AI) and the ratio of HDL to total cholesterol of the hyperlipidemic obesity group were significantly higher than those of the hyperlipidemic and normal body weight group. Conclusion: This study shows that the criterion of BMI, according to the WHO standard for obesity, is not valid for Koreans, instead BF (%) is valid and is an adequate predictor for obesity rather than BMI. We conclude that obesity is one of the factors that increase the risk for hyperlipidemia. Key words: Body Fat (BF), Body Mass Index (BMI), LDL-cholesterol, Hyperlipidemia 참고문헌 1. Korean statistical association. 1994. Death of cause statical annual report (2001). 2. Castella WP. Cardiovascular disease and multifactorial risk. Challenge of the 1980s. Am Heart J 1983;106(5 Pt 2):1191-200. 3. Sytkowski PA, Kannel WB, D'Agostino RB. Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham heart study. N Engl J Med 1990;322(23):1635-41. 4. Kim CJ. Hyperlipidemia. Korean J. Med 2002; 62(1):44-57. 5. Austin MA, Hokanson JE, Edwards KL. Hypertriglyceridemia as a cardiovascular risk factor. Am J Cardiol 1998;81(4A):7B-12B. 6. Hauner H, Stangl D, Schmatz C, Burger K, Blomer H, Pfeiffer EF. Body fat distribution in men with angiographically confirmed coronary artery disease. Atherosclerosis 1990;85(2-3):203-10. 7. 손숙미. 산업보건에서의건강과식이 -Ⅱ 고지혈증. 산업보건 2003;180:51-8. - 26 -
- 40 세이상성인에서비만지표가혈중지질수준과고지혈증발생에미치는영향 - 8. Hwang GH, Huh YR. A study of hyperlipidemia in koreans-Ⅰ. Specially related to physical characteristics and it's risk factors for hypercholesterolemia. Korean J Food Nutr 1999;12(3):279-89. 9. Turcato E, Bosello O, Harris T, Zoico E, Bissoli, Fracassi E, et al. Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors. Int J Obes Relat Metab Disord 2000;24(8):1005-10. 10. Bray GA. Classification and evaluation of the obesity. Med Clin North Am 1989;73(1):161-84. 11. Moon HK, Kim EG. Comparing validity of Body Mass Index, Waist to Hip Ratio, and Waist Circumference to Cardiovascular Disease Risk Factors in Korean Elderly. Korean J Nutr 2005;38(6):445-54. 12. Thomas GN, Ho SY, Lam KS, Janus ED, Hedley AJ, Lam TH. Hong Kong Cardiovascular Risk Factor Prevalence Study Steering Committee. Impact of obesity and body fat distribution on cardiovascular risk factors in Hong Kong Chinese. Obes Res 2004;12(11):1805-13. 13. Gus M, Fuchs SC, Moreira LB, Moraes RS, Wiehe M, silva AF, et al. Association between different measurements of obesity and the incidence of hypertension. Am J Hypertens 2004;17(1):50-3. 14. Suh YK, Kim HS, Kim JS, Choi HM. Plasma LDL particle size affect the blood lipid profile and dietary intakes among korean adults. Korean J Community Nutr 2004;9(1):58-65. 15. Iwao N, Iwao S, Muller DC, Koda M, Ando F, Shimokata H, et al: Differences in the relationship between CHD risk factors and body composition in Caucasians and Japanese. Int J Obes 2005;29(9):228-35. 16. Ko GT, Tang J, Chan JC, Sung R, Wu MM, Wai HP, et al. Lower BMI cut-off value to define obesity in Hong Kong Chinese: an analysis based on body fat assessment by bioelectrical impedance. Br J Nutr 2001;85(2):239-42. 17. Deurenberg-Yap M, Schmidt G, van Steveren WA, Deurenberg P. Paradox of low BMI and high body fat percentage among Singaporean. Int J Obes Relat Metab Disord 2000;24(8):1011-17. 18. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363(9403): 157-63. 19. 이득주, 김상만, 이은주, 권혁찬, 조남한, 정윤석. 여성에서허리둔부둘레비와비만관련질환의예측. 대한비만학회지 1996;5(1):41-8. 20. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106(25):3143-421. 21. Shin HH. Korean guidelines of hyperlipidemia treatment for prevention of atherosclerosis. Korea Soc of Lipidol Atherosclerosis 2002;12(3):226-8. 22. Ckoi MJ. Relations of life style, nutrient and blood lipids in middle-aged men with borderline hyperlipidemia. Korean J Community Nutr 2005;10(3):281-9. 23. Goh VH, Tain CF, Tong TY, Mok HP, Wong MT. Are BMI and other anthropometric measures appropriate as indices for obesity? A study in an Asian population. J Lipid Res 2004;45(10):1892-8. 24. Lee WY, Park JS, Noh SY, Rhee EJ, Kim SW, Zimmer PZ. Prevalence of the metabolic syndrome among 40,698 Korean metropolitan subjects. Diabetes Res Clin Prac 2004;65:143-9. 25. Savva SC, Tornaritis M, Savva ME, Kourides Y, Panagi A, Silikiotou N, et al: Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord 2000;24(11):1453-8. 26. Lemieux I, Lamarche B, Couillard C, Pascot A, Cantin B, Bergeron J, et al. Total cholesterol/hdl cholesterol ratio vs LDL cholesterol/hdl cholesterol ratio as indices of ischemic heart disease risk in men: the Quebec Cardiovascular Study. Arch Intern Med 2001;161(22):2685-92. 27. Newman WP 3rd, Freedman DS, Voors AW, Gard PD, Srinivasan SR, Cresanta JL, et al: Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis. The Bogalusa Heart Study. N. Engl J Med 1986;314(3):138-44. 28. Kook SR, Park YS, Ko YK, Kim SM, Lee DJ, Kang HC, et al: Relationship of body fat, lipid, blood pressure, glucose in serum to waist-hip ratio between - 27 -
- 대한비만학회지 : 제 17 권제 1 호 2008 - obese and normal body mass index group. J Korean Acad Fam Med 1997;18(3):317-27. 29. Deurenberg-Yap M, Chew SK, Deurenberg P. Elevated body fat percentage and cardiovascular risks at low body mass index levels among Singaporean Chinese, Malays and Indians. Obes Rev 2002;3(3):209-15. 30. Luke A, Durazo-Arvizu R, Rotimi C, Prewitt TE, Forrester T, Wilks R, et al. Relation between body mass index and body fat in black population samples from Nigeria, Jamaica, and the United States. Am J Epidemiol 1997;145(7):620-8. 31. Ko SK. Blood lipoprotein level and morbidity of hyperlipidemia according to VO2max, BMI and %Fat in adult women. Korean Sport Res 2006;17(1):355-64. 32. Shearman AM, Ordovas JM, Cupples LA, Schaefer EJ, Harmon MD, Shao Y, et al. Evidence for a gene influencing the TG/HDL-C ratio on chromosome 7q32.3 qter: a genome-wide scan in the Framingham Study. Human Molecular Genetics 2000;9(9):1315-20. 33. Ballantyne CM, Olsson AG, Cook TJ, Mercuri MF, Pedersen TR, Kjekshus J. Pedersen and John Kjekshus. Influence of low high-density lipoprotein cholesterol and elevated triglyceride on coronary heart disease events and Response to Simvastatin Therapy in 4S. Circulation 2001;104(25). - 28 -