Original Article http://dx.doi.org/997/jla.205.4..7 pissn 2287-2892 eissn 2288-256 JLA Consumption of Added Sugars and Lipid Profiles in Korean Population from a Cohort Study Sang Yeun Kim, Sun Ha Jee Department of Epidemiology and Health Promotion, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Korea 첨가당과혈청지질농도와의관련성에관한코호트연구 김상연, 지선하 연세대학교보건대학원역학건강증진학과, 국민건강증진연구소 Objectives: The purpose of the study was to examine the relationship between added sugar consumption and dyslipidemia. Methods: Final study subjects consisted of 8,73 participants after the exclusion of participants with dyslipidemia or under lipid lowering medications at baseline. Added sugar levels were categorized into tertiles [men: Low <8.0 g, Middle: 8.0-2.9 g, High 22.0 g; women: Low <6.0 g, Middle 6.0-4.9 g, High 5.0 g]. Dyslipidemia was analyzed based on two of the most recent guidelines identified from the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and the 2009 Korean Society of Lipidology and Atherosclerosis (KSLA). We used Kaplan-Meier and Cox proportional hazard models to estimate the hazard ratio (HR) with 95% confidence interval (CI) of dyslipidemia. Results: High added sugar was associated with hypercholesteremia (HR,.22; 95% CI,.06-.40), high LDL cholesterolemia (.29;.3-.48), and low HDL cholesterolemia (.26;.0-.44) based on the KSLA Standard in men. In women, the high added sugar was only related to the risk for hypercholesteremia (.26;.07-.49) based on the KSLA Standard. A similar trend was shown in both men and women with application of NCEP-ATP Ⅲ standard. Conclusion: In this study, an increase in added sugar consumption was associated with an increased risk of dyslipidemia in men. Additional studies assessing the association between cardiovascular and other diseases should be conducted in the future. Key Words: Added sugar, Lipid profiles, Dyslipidemia, Cohort study 서론 총당류는크게식품 ( 과일, 우유등 ) 자체에존재하는당과첨가당 (added sugar) 으로분류할수있다. 그중첨가당은식품의제조과정이나조리중에첨가되는당을가리키며설탕, 시럽, 꿀, 물엿등이포함되나우유의유당, 과일의과당, 감미료등은 포함되지않는다. 우리나라에서는 200년영양섭취기준개정판에처음으로영양성분중당류를추가하였다. 2 세계보건기구 (WH0) 는당을과잉섭취할경우영양불균형을초래하여심혈관질환, 암, 당뇨병, 비만등을야기할수있음을경고하고있으며, 당섭취를제한하는것이체중증가예방에기여함을강조하였다. 3 또한첨가당의섭취가증가할수록비만, 인슐린 Received: Revised: Accepted: May 4, 205 June 5, 205 June 9, 205 Corresponding Author: Sun Ha Jee, Department of Epidemiology and Health Promotion, Graduate School of Public Health, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 20-749, Korea Tel: +82-2-2228-523, Fax: +82-2-365-58, E-mail: jsunha@yuhs.ac This is an Open Access article distributed under the terms of the creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.lipid.or.kr Copyright c 205 The Korean Society of Lipidology and Atherosclerosis 7
J Lipid Atheroscler 205;4():7-25 JOURNAL OF LIPID AND ATHEROSCLEROSIS 저항성, 이상지질혈증을증가시키고더나아가서허혈성심장질환과신장질환과의관련이높다고보고하고있다. 4,5,6 미국국민건강조사 (NHANES,999-2006) 에의하면전체섭취열량에대한첨가당의섭취비율이높아질수록심장질환의위험요인인이상지질혈증과밀접한관련성이있었고, 5 특히비만군에서첨가당섭취와인슐린저항성이양의상관성을보였다. 7 높은중성지방 / 고밀도지단백 (triglyceride, TG/high density lipoprotein, HDL) 콜레스테롤비는관상동맥질환의지표역할을하고있으며 8,9 이는인슐린저항성과도관련있는지표로활용되고있다. 0 203년보건복지부통계연보에따르면우리나라주요사망원인별사망률중암다음으로높은사망원인은뇌혈관질환과심장질환인것으로보고되었고, 특히심장질환은 2000년인구 0만명당 46.4명에서 202년 52.5명으로꾸준한증가추세를보이고있다. 우리나라식품의약품안전처가보고한최근 3년간가공식품으로의당섭취량은 2008년 9.3 g, 2009년 2 g, 200년 27.3 g으로증가추세를보였다. 특히가공식품에의한당섭취량은 2-49세에서약 50%, 50-65세 38%, 65세이상에서 39% 를차지하였다. 2 또한당뇨병을가진어린이와청소년의제2형당뇨병구성비가 990년에는 5.3%, 2000년에는 2.0% 로증가함을보고하였으며, 제2형당뇨병환아중 68% 가비만에속하였다. 3 또한소아및청소년을대상으로한연구에서이상지질혈증유병률은남아에서 25.2%, 여아에서 2.7% 로조사되었고특히과체중, 비만군에서유의한증가경향을보였다. 4 이와같이우리나라의경우가공식품으로의당섭취비율이증가하고있고, 성인에서심혈관질환의발생률또한증가하고있다. 그러나한국인을대상으로한대규모연구에서첨가당이심혈관위험도에미치는영향을알아볼수있는자료가거의없는실정이다. 994년에우리나라최초로개원한세브란스건강증진센터는건강검진에참여한검진자에게 998년부터간이법을이용한영양조사를실시하고있다. 세브란스건강증진센터의경우건강검진을받은대상자들중다수가반복적으로검진에참여하고있었다. 본연구팀은첨가당의섭취와이상지질혈증과관련성을전향적인코호트연구설계로알아보고자세브란스영양코호트를구축하였다. 세브란스영양코호트의궁극적인목적은식습관과만성질환과의관련성을알아보는것이며, 이중에서도첨가당의섭취가장기적으로심뇌혈관질환위험인자와의관련성을알아보고자하였다. 대상및방법. 연구대상자 이연구는후향적코호트로서 998년부터 2008년까지세브란스검진센터를내원하여건강검진을받은 20세이상검진자 77,264명중최초검진일이후 203년 2월까지 회이상재방문한 2,668명이포함되었다. 이중에서이상지질혈증이거나이상지질혈증약을복용하는경우 (N=380), 흡연력, 음주력, 수입에결측이있는경우 (N=2,570), 콜레스테롤, 혈당등기본자료에결측이있는경우 (N=5) 을제외한후, 최종 8,73명 ( 남자,39명, 여자 7,574명 ) 이최종분석에사용되었다. 본연구는세브란스병원임상연구심의위원회의승인을얻어시행하였다. 2. 연구자료수집 ) 영양자료이연구에서사용한간이법영양설문지는총 7개조사항목으로서고기 생선 두류, 달걀, 우유, 유제품, 채소류, 김치류, 밥 빵 국수, 감자 고구마, 첨가당, 탄산음료, 빵 과자, 과일, 유지류등의항목을포함하고있으며, 설문지의타당도와신뢰도에대한자세한내용은이미연세논총에발표되어있다. 5 연구기간 0년동안같은설문지를사용하였다. 이연구에조사된첨가당항목은 ) 주식으로빵을먹는경우쨈, 꿀을얼마나바르는지 (0,,.0), 2) 조리할때설탕, 꿀등을얼마나넣는지 (0,,.0), 3) 커피나홍차에설탕을얼마나넣는지 (0,,,) 의세문항의점수를합산하여조사하였고첨가당조사항목중점수화된설문항목은표준화하기위해서 200년개정된당뇨병식품교환표 6 에따라모든항목에대해서그램 (g) 으로환산하여표시하고분석에사용하였다. 이자료에서사용한간이법과 3일간 24시간회상법으로조사된식사일기를한국영양학회에서개발한 CAN-Pro 3.0 Nutrient database을이용하여분석한후총칼로리섭취량에대한상관성을보기위해 2가지방법을동시에수집한 60명 ( 남자 : 30명, 여자 : 30명 ) 의자료를분석하였다. 간이법과 24시간회상법간총칼로리섭취량에서높은상관성을보였다 (r=0032, p<.000). 7 2) 문진자료검진일 3-4일전에피검자에게자기기입식설문지가전달되어, 8 www.lipid.or.kr
Sang Yeun Kim, et al.: Added Sugars and Lipid Profile Table. Definition of dyslipidemia in the study Dyslipidemia *NCEP-ATP Ⅲ KSLA Hypercholesterolemia (mg/dl) Total Cholesterol 240 Total Cholesterol 230 High LDL-cholesterolemia (mg/dl) LDL-cholesterol 60 LDL-cholesterol 50 Low HDL-cholesterolemia (mg/dl) HDL-cholesterol <40 HDL-cholesterol <40 Hypertriglyceridemia (mg/dl) Triglyceride 200 Triglyceride 200 Elevated TG/HDL-cholesterol ratio >3.8 *National Cholesterol Education Program (NCEP) ATP III guideline KSLA; The Korean Society of Lipidology and Atherosclerosis. Dyslipidemia treatment guideline LDL; Low density Lipoprotein, HDL; High density Lipoprotein, TG; Triglyceride 스스로작성하게한후검진당일에제출하였다. 흡연력은 비흡연, 과거흡연, 현재흡연 으로구분하여조사한후현재흡연자는흡연량과흡연기간에대해서조사하였다. 음주력은 마신다, 안마신다 로구분하여조사한후, 마시는경우술의종류와빈도를조사하였다. 수입 (Income) 은월평균수입을만원단위로조사하였다. 과거력은과거또는현재이상지질혈증이있는경우, 약복용력은이상지질혈증으로약을복용하는경우를조사하였다. 3) 검진자료체질량지수 (body mass index, BMI) 는체중 (kg) 을신장 (m) 의제곱으로나눈값을사용하였다. 혈압은수은혈압계를사용하여수축기혈압과이완기혈압을각각 회측정하였다. 그리고 2시간이상동안공복상태를유지한후, 혈당, 총콜레스테롤, 고밀도지단백콜레스테롤, 중성지방을 Hitachi-7600 analyzer (Hitachi Ltd., Tokyo, Japan) 을사용하여분석하였다. 저밀도지단백 (Low Density Lipoprotein, LDL) 콜레스테롤은 Friedwald 법을이용하여계산하였다. 3. 결과변수 (outcome) 추적 998년 월부터 2008년 2월까지등록된연구대상자는 203년 2월까지추적되었다. 추적방법은연구대상자가자발적으로검진센터를재방문시얻어진검진데이터를사용하였다. 연구기간동안재방문의횟수는 회이상인연구대상자 8,73을추적하였고 회재방문자 8,337명 (44.6%), 2회재방문자 3,89명 (2%), 3회재방문자 2,243명 (2.0%), 4회재방문자,42 명 (7.6%), 5회재방문자 975명 (5.2%) 으로총 5회까지재방문한대상자가이연구에서추적관찰되었다. 추적기간동안이상지질혈증이발생되면, 관찰기간을인년 (person-year) 로계산하였다. 이상지질혈증은한국에서주로사용하는두가지기준인한국지질 동맥경화학회 (The Korean Society of Lipidology and Atherosclerosis, KSLA) 에서 2009년개정한이상지질혈증치료지침기준과수정된 National Cholesterol Education Program Adult Treatment Pannel III (NCEP ATP III) 기준을함께사용하였다. 8,9 이연구에서사용한이상지질혈증의정의는 Table 과같다. 4. 분석방법연구시작시점에서대상자가 NECP-ATP III 기준혹은한국지질 동맥경화학회정의에서이상지질혈증을가지고있는경우는분석에서제외되었다. 주요노출변수인첨가당섭취량 (g/day) 은전체대상자의값을남녀별로삼분위수 (tertile) 로나누었다 ( 남자 : T <8.0 g, T2 8.0-2.9 g, T3 22.0 g, 여자 : T <6.0 g, T2 6.0-4.9 g, T3 5.0 g). 첨가당과이상지질혈증과의관련성은첨가당의가장낮은섭취군 (T) 을기준으로 T2, T3에서이상지질혈증의발생위험도를위험비 (hazard ratio) 와 95% 신뢰구간으로보였다. 통계분석은 Cox의비례모형 (proportional hazards model) 과 Kaplan-Meier 생존분석을사용하였고, SAS 9.2 program (SAS Institute, Cary, NC) 을사용하였다. 본연구자료는첨가당의삼분위수에따라비례모형가정을만족하였다. 결과 첨가당섭취량의삼분위분류에따른성별일반적특성은 Table 2에나타내었다. 남성의경우평균연령은가장낮은삼분위 (T) 의 46.세에비해가장높은삼분위 (T3) 에서 44.4세로유의하게낮았다. 이밖에체질량지수, 총콜레스테롤, LDL 콜레스테롤, HDL 콜레스테롤, 공복시혈당, 수입도삼분위군간유의한차이를보였다. www.lipid.or.kr 9
J Lipid Atheroscler 205;4():7-25 JOURNAL OF LIPID AND ATHEROSCLEROSIS Table 2. Characteristics of study participants at baseline (998-2008) in accordance with added sugar consumptions, the Severance Nutrition Cohort Study Men (n=,39) Women (n=7,574) <8.0 g/day (n=3,407) 8.0-2.9 g/day (n=3,826) 22.0 g/day (n=3,906) p value <6.0 g/day (n=2,548) 6.0-4.9 g/day (n=2,307) 5.0 g/day (n=2,79) p value Age (year) 46.± 46.± 44.4±9.2 <0.000 45.6± 45.0±. 42.9±9.4 <0.000 Body Mass Index (kg/m 2 ) 24.3±2.7 24.5±2.8 24.6±2.8 <0.000 22.8±3.0 22.7±3.0 22.7±3.0 530 Total cholesterol (mg/dl) 93.0±34.2 94.9±32.0 96.7±33.2 <0.000 9.2±35.9 9±33.6 89.0±34.3 0.066 LDL-cholesterol (mg/dl) 4.±3.4 6.4±29.6 9.3±3 <0.000 2.3±32. 2.3±30.0 2.2±3 84 HDL-cholesterol (mg/dl) 50.0±.8 49.2±.6 48.0± <0.000 57.5±3.2 57.5±2.7 58.2±2.8 0.0552 Triglyceride (mg/dl) 55.9±05.3 59.0±97. 60.0±98.6 038 3.0±8 09.0±68.8 ±6 <0.000 TG/HDL-cholesterol ratio 3.5±3.2 3.6±3.0 3.7±2.8 0.0548 2.2±2.3 2.±.8.9±.6 <0.000 Systolic Blood Pressure 22.5±6.4 22.±5.8 9.6±5.5 <0.000 6.2±8.3 5.6±8.4 2.8±6.6 <0.000 (mmhg) Fasting glucose (mg/dl) 99.0±24.7 95.5±9.4 93.7±6.8 <0.000 9.9±2. 89.3±3.7 88.±2.4 <0.000 Income (ten thousand won) 40±59.8 4±55.6 39.4±53.0 0.0076 372.4±7.2 367.6±69.0 389.9±66.0 <0.000 Total calorie intake (kcal/day) 907.3±293.9 946.5±285.0 996.±294.4 <0.000 647.5±290. 699.2±287.6 79.6±289.0 <0.000 Added Sugars (g/day) 4.±.7 4.9±4. 33.4±2.7 <0.000 3.5±.2 0.±2.5 23.±8.7 <0.000 Cigarette smoking Former (%) 38.5 37.4 27.8 2.6 2.3 2.7 Current (%) 32. 37.5 58.6 <0.000 3.3 3. 5.3 0.0005 Alcohol drinking (%) 86.6 88.2 85.9 0.05 32.4 33.3 39.9 <0.000 Obesity (BMI 25) (%) 38.5 4.7 42.6 0.00 2 2 2 802 LDL; Low density Lipoprotein, HDL; High density Lipoprotein, TG; Triglyceride Data presented mean±sd 여성의경우평균연령은가장낮은삼분위 (T) 의 45.6세에비해가장높은삼분위 (T3) 에서 42.9세로유의하게낮았다. 또한중성지방, TG/HDL 콜레스테롤비, 수축기혈압, 공복시혈당, 수입도첨가당섭취량의삼분위간유의한차이를보였다. 남녀모두에서첨가당섭취량이높아질수록총칼로리섭취량도증가하였다. 현재흡연율은첨가당섭취량이많은군에서남성 (58.6%) 과여성 (5.3%) 모두유의하게높았고, 여성의음주율은첨가당섭취량이가장많은군 (T3) 에서 39.3% 로유의하게높았다 (Table 2). 첨가당섭취량삼분위에따른이상지질혈증각항목별발생위험도를성별에따라평가하였다 (Table 3, 4). 남성의경우 NCEP-ATP Ⅲ 기준으로이상지질혈증발생을진단한경우고콜레스테롤혈증발생위험은흡연, 음주, 수입, 총칼로리섭취량을통제한상태에서가장낮은 T (<8.0 g) 에비해 T3 ( 22.0 g) 에서.7배, 고LDL 콜레스테롤혈증발생위험은 T3 ( 22.0 g) 에서.24배, KSLA 이상지질혈증치료지침과진단기준이같은저HDL 콜레스테롤혈증의발생위험은 T3 ( 22.0 g) 에서.26배유의하게증가하는경향을보였지만고중성지방혈증발생위험은차이를보이지않았다 (Table 3). 또다른기준인 KSLA 치료지침을기준으로이상지질혈증발생을진단한경우에도흡연, 음주, 수입, 총칼로리섭취량을통제한상태에서고콜레스테롤혈증발생위험은가장낮은 T (<8.0 g) 에비해 T3 ( 22.0 g) 에서.22배유의하게증가하는경향을보였고고LDL콜레스테롤혈증발생위험도 T2 (8.0-2.9 g) 에서.9배, T3 ( 22.0 g) 에서.29배로유의하게증가하는경향을보였다. 고 TG/HDL 콜레스테롤비율도흡연, 음주, 수입, 총칼로리섭취량을통제한상태에서첨가당섭취량이가장낮은 T (<8.0 g) 에비해 T2 (8.0-2.9 g) 에서.4배, T3 ( 22.0 g) 에서.5 배로유의하게증가하는경향을보였다. 여성의경우 NCEP-ATP Ⅲ 기준으로고콜레스테롤혈증발생위험은흡연, 음주, 수입, 총칼로리섭취량을통제한상태에서첨가당섭취량이가장적은 T (<6.0 g) 에비해 T2 (6.0-4.9 g) 에서.29배, T3 ( 5.0 g) 에서.36배로유의하게증가하는경향을보였다 (Table 4). 20 www.lipid.or.kr
Sang Yeun Kim, et al.: Added Sugars and Lipid Profile Table 3. Adjusted hazard ratios (HR, 95% CI)* for dyslipidemia according to added sugar consumptions in men High LDL cholesterolemia Low HDL cholesterolemia Elevated TG/HDL cholesterol ratio T (<8.0 g) T2 (8.0-2.9 g) T3 ( 22.0 g) (mg/dl) Case HR HR Case (95% CI) (95% CI) p value Case HR P for p value (95% CI) trend Total Cholesterol 240 278/306.0 297/349.0 88 363/3542.7 0.0563 0.000 (6-.9) (.00-.38) Total Cholesterol 230 35/294.0 426/3295.4 0.0692 477/336.22 0.007 <0.000 (9-.32) (.06-.40) LDL-cholesterol 60 27/347.0 300/3556.02 958 39/3565.24 0.0088 <0.000 (7-.2) (.06-.46) LDL-cholesterol 50 376/2996.0 456/3345.9 (.04-.37) 0.028 528/334.29 (.3-.48) 0.0002 <0.000 HDL-cholesterol <40 368/2772.0 42/3062.0 88 544/3090.26 0.000 <0.000 (6-.27) (.0-.44) Triglyceride 200 588/3463.0 459/2509.02 665 506/2650.0 872 595 (0-.5) (9-.4) >3.8 627/3069.0 497/28.4 0.0272 585/2260.5 0.099 0.0007 (.02-.29) (.02-.30) *Model; adjusted for age, smoking status, alcohol intake, income and total calories intake, HR; hazard ratio, 95% CI; 95% confidence interval National Cholesterol Education Program (NCEP) ATP III treatment guideline The Korean Society of Lipidology and Atherosclerosis. Dyslipidemia treatment guideline Added sugars (g/day); T (<8.0), T2 (8.0-2.9), T3 ( 22.0) LDL; Low density Lipoprotein, HDL; High density Lipoprotein, TG; Triglyceride Table 4. Adjusted hazard ratios (HR, 95% CI)* for dyslipidemia according to added sugar consumptions in women T (<6.0 g) T2 (6.0-4.9 g) T3 ( 5.0 g) (mg/dl) Case HR HR Case (95% CI) (95% CI) p value Case HR p value P for (95% CI) trend Total Cholesterol 240 203/2305.0 209/226.29 0.0095 236/254.36 0.008 0.002 (.07-.57) (.2-.64) Total Cholesterol 230 277/275.0 279/202.20 0.035 308/240.26 0.0066 0.0030 (.02-.42) (.07-.49) High LDL LDL-cholesterol 60 95/2340.0 79/254.08 cholesterolemia LDL-cholesterol 50 268/2229.0 249/204.5 (7-.37) 836 203/2539.7 0 0.0274 (8-.32) (6-.43) 4 283/2428.7 0.077 0.06 (9-.39) Low HDL HDL-cholesterol <40 74/355.0 9/902.04 84 94/2033. cholesterolemia (0-.34) (6-.45) Hypercholesterolemia Hypertriglyceridemia Hypercholesterolemia Hypertriglyceridemia Triglyceride 200 273/30.0 8/860 0.0522 6/2027 3 (5-.00) (7-.04) Elevated >3.8 279/2986.0 43/803 6 737 48/979.04 TG/HDL (8-.7) (5-.27) cholesterol ratio 258 496 0.03 0.0338 239 879 *Model; adjusted for age, smoking status, alcohol intake, income and total calories intake, HR; hazard ratio, 95% CI; 95% confidence interval National Cholesterol Education Program (NCEP) ATP III treatment guideline, The Korean Society of Lipidology and Atherosclerosis. Dyslipidemia treatment guideline Added sugars (g/day); T (<6.0), T2 (6.0-4.9), T3 ( 5.0) LDL; Low density Lipoprotein, HDL; High density Lipoprotein, TG; Triglyceride www.lipid.or.kr 2
J Lipid Atheroscler 205;4():7-25 JOURNAL OF LIPID AND ATHEROSCLEROSIS Hypercholesterolemia (Total Cholesterol 230 mg/dl) High LDL-cholesterolemia (LDL-cholesterol 50 mg/dl) T2(8-2.9 g) T2(8-2.9 g) 2 3 4 5 6 7 8 9 0 2 3 4 2 3 4 5 6 7 8 9 0 2 3 4 Low HDL-cholesterolemia (HDL-cholesterol <40 mg/dl) Hypertriglyceridemia (Triglyceride 200 mg/dl) T2(8-2.9 g) T2(8-2.9 g) 2 3 4 5 6 7 8 9 0 2 3 4 2 3 4 5 6 7 8 9 0 2 3 4 Fig.. Distribution of dyslipidemia incidence according to added sugar consumptions and medical treatment guidance in men. Added sugars (g/day); T (<8.0), T2 (8.0-2.9), T3 ( 22.0), LDL; Low density Lipoprotein, HDL; High density Lipoprotein, TG; Triglyceride, ; Cum survival 고LDL 콜레스테롤혈증발생위험은세그룹간유의한차이를보이진않았지만첨가당섭취량이증가하며고LDL 콜레스테롤혈증발생위험이증가하는경향을보였다 (P for trend, 0.0274). 또한 KSLA 기준으로고콜레스테롤혈증발생위험은흡연, 음주, 수입, 총칼로리섭취량을통제한상태에서첨가당섭취량이가장적은 T (<6.0 g) 에비해 T2 (6.0-4.9 g) 에서.20배, T3 ( 5.0 g) 에서.26 배로유의하게증가하는경향을보였고, 고LDL 콜레스테롤혈증발생위험은세그룹간유의한차이를보이진않았지만첨가당섭취량이증가하며고LDL 콜레스테롤혈증발생위험이증가하는경향을보였다 (P for trend, 0.06). Elevated TG/HDL-cholesterol ratio>3.8 T2(8-2.9 g) 2 3 4 5 6 7 8 9 0 2 3 4 남자에서첨가당섭취량을삼분위로나누어약 5년간관찰한후이상지질혈증각항목별발생위험도와고TG/HDL 콜레스테롤발생위험도를생존곡선으로보여주었다 (Fig., 2). 첨가당섭취량이많은 T3 (22 g 이상 ) 의생존곡선이이상지질 Fig. 2. Distribution of Elevated TG/HDL cholesterol ratio incidence according to added sugar consumptions in men. Added sugars (g/day): T (<8.0), T2 (8.0-2.9), T3 ( 22.0), HDL; High density Lipoprotein, TG; Triglyceride, ; Cum survival 22 www.lipid.or.kr
Sang Yeun Kim, et al.: Added Sugars and Lipid Profile 혈증 ( 고콜레스테롤, 고LDL 콜레스테롤혈증, 저HDL 콜레스테롤혈증 ) 과고TG/HDL 콜레스테롤비에서뚜렷이감소되어있음을확인할수있었다. 고찰 한국인을대상으로 5년간추적한세브란스영양코호트연구에서첨가당섭취량을삼분위로나누어 NCEP-ATP Ⅲ 기준과 KSLA 기준에따라진단된이상지질혈증의발생을비교한경우, 두기준모두에서남자에서는첨가당섭취량이낮은 T (<8.0 g) 에비해 T3 ( 22.0 g) 에서이상지질혈증 ( 고콜레스테롤, 고LDL 콜레스테롤혈증, 저HDL 콜레스테롤혈증 ) 과고TG/HDL 콜레스테롤비위험이유의하게증가하는경향을보여주었고, 여자에서는 NCEP-ATP Ⅲ 기준과 KSLA 기준에따라첨가당섭취량이낮은 T (<6.0 g) 에비해 T2 (6.0-4.9 g) 서부터 T3 ( 5.0 g) 까지이상지질혈증중고콜레스테롤혈증발생위험만유의하게증가하는경향을보여주었다. 첨가당과이상지질혈증의발생을보는이연구에서연령, 흡연력, 음주력, 총칼로리를통제하였고, BMI를통제하지않았다. 왜냐하면, 첨가당은 BMI를증가시키고, BMI 는이상지혈증을증가시키는 pathway 상에있기때문이다. 본연구의코호트에포함된 998년부터 2008년까지남녀별첨가당섭취량을보면남성에서 998년 6. g에서 2008년 2 g으로평균섭취량이꾸준히증가된것으로조사되었고, 여성에서도 998년.3 g에서 2008년 4.8 g으로증가된것으로조사되었다. Table에서제시되진않았으나남자에서는첨가당을 22 g 이상섭취하는군에서 8 g 미만의낮은섭취군에비해비만위험이.30 배유의하게높은것으로, 여자에서는첨가당을 5 g 이상섭취하는군에서 6 g 미만의낮은섭취군에비해비만위험에차이가없는것으로조사되었다. Minnesota heart study의 27년간의첨가당섭취량조사에의하면남자는 980년대에총칼로리섭취량중 %, 2000년대에는 5.% 를여자는 980년대에 9.5%, 2000년대에는 2.8% 를첨가당으로섭취하는것으로보고되었는데특히남녀모두에서 BMI가증가하면서첨가당섭취량도증가하였고 2002년이후첨가당섭취가다소감소하기는하였으나미국권고기준인전체섭취량의 5-5% 를넘는수준을보였다. 20 첨가당섭취의절대값의차이는있지만서구의연구와함께우리연구에서도연도별첨가당섭취가 증가되고있고첨가당섭취량이증가할수록비만의위험이함께높아지는것을볼수있었다. 이는증가된첨가당의섭취가비만을야기시키고이상지질혈증의대표적인혈중중성지방과 LDL 콜레스테롤농도를높이고 HDL 콜레스테롤농도를낮추기때문인것으로추정되며지방분포의변화와인슐린저항성의증가도중요요인일것으로이해된다. 2,22,23 비만하거나지방조직의인슐린저항성으로인해지방세포의지방산을저장하는능력이떨어지게되면지방분해로인해혈중유리지방산이증가하고간의지방생합성으로이어지며중성지방이축적된초저밀도지단백콜레스테롤을생성분비하게되고이는고중성지방혈증을초래하게된다. 24,25 또한인슐린저항성이있는경우 LDL 콜레스테롤, HDL 콜레스테롤의핵심지질인콜레스테릴에스터는콜레스테롤에스터프로테인 (cholesteryl ester transfer protein, CETP) 에의해중성지방이풍부한 HDL 콜레스테롤생성되고분해효소인 Hepatic lipase 의작용에의해분해되거나작아져혈중 HDL 콜레스테롤은감소하고 LDL 콜레스테롤은증가하게된다. 25,26,27 인슐린저항성과관련있는지표로알려져있는 TG/HDL 콜레스테롤비도 0,28 다른이상지질혈증지표와함께첨가당의섭취량이많은군에서유의하게높아지는것으로조사되었다. WHO 에서는만성질환을위한 일당섭취목표량을총열량의 0% 미만으로권고하였고 (2,000 kcal 기준시 200 kcal, 약 50 g에해당 ) 3 200년개정된 Dietary Guidelines for Americans 에따르면고형지방과첨가당으로의열량섭취가전체열량의 5-5% 를넘지않을것을권장하고있다. 7 또한미국심장학회에따르면남자에서는하루섭취량중설탕이첨가된음료까지포함하여첨가당으로의섭취가 50 kcal, 여자에서는 00 kcal를넘기지않도록권고하고있으며이는전체칼로리섭취량중 5% 정도에해당된다. 29 그러나이들이권고한첨가당에는설탕이첨가된음료까지포함되어있고한국인의평균섭취량보다높은것을볼수있다. 한국영양학회의 200년영양섭취기준개정판에의하면권장식사패턴을고려하여식사를섭취하는경우총당류의섭취기준을에너지섭취의 0-20% 로권장하고있으며, 이는하루에 2,000 kcal를섭취하는경우 200-400 kcal에해당되며당류 g당 4 kcal를내므로약 50-00 g에해당된다. 2 총당류중첨가당의섭취는특별한권고사항이없지만 0% 미만으로섭취할것을권장하고있다. 식약처조사에의한전체당섭취중가공식품으로 www.lipid.or.kr 23
J Lipid Atheroscler 205;4():7-25 JOURNAL OF LIPID AND ATHEROSCLEROSIS 의당섭취가약 50% 이상을차지하는대상자는 2세에서 49세까지로보고되었고 2 국민건강영양조사자료를바탕으로한소아및청소년기의이상지질혈증유병률은과체중에서는 37-40%, 비만에서는 53-56% 로비만할수록이상지질혈증의유병이증가하는것을볼수있다. 4 이러한유의한증가는성인기의심혈관질환의위험을더욱증가시킬것으로사료되어성인의첨가당과이상지질혈증의결과를토대로어린이에서도이상지질혈증의적절한관리및제안이필요할것으로생각된다. 이연구는영양설문문항이제한적이어서자세한섭취조사가이루어지지않고어린이와청소년에서는조사가이루어지지않은제한점이있지만동일한조사방법으로대규모로오랜기간조사된한국인코호트자료로서의미있는자료라사료된다. 우리나라에서도매년전연령대에서첨가당의섭취가증가되고있음을고려해볼때이연구에서확인된첨가당섭취로인한이상지질혈증발생뿐아니라심혈관계질환및여러질환발생과의연관성입증을위한추가적인역학연구가계속진행되어야할것으로생각된다. ACKNOWLEDGEMENT 본연구는보건복지부보건의료연구개발사업지원으로이루어진것임 (HI4C2686). 참고문헌. Dietary Guidelines Advisory Committee; United States Department of Agriculture, Agricultural Research Service. Dietary guidelines for Americans. Washington, D.C.: United States Department of Agriculture; 2000. 2. The Korean Nutrition Society. Korean dietary reference intakes for Korean. Seoul: The Korean Nutrition Society; 200. 3. Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser 2003;96:i-viii, -49. 4. Collino M. High dietary fructose intake: sweet or bitter life? World J Diabetes 20;2:77-8. 5. Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA 200;303:490-497. 6. Tappy L, Lê KA, Tran C, Paquot N. Fructose and metabolic diseases: new findings, new questions. Nutrition 200;26:044-049. 7. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption of added sugars is decreasing in the United States. Am J Clin Nutr 20;94:726-734. 8. Hanak V, Munoz J, Teague J, Stanley A Jr, Bittner V. Accuracy of the triglyceride to high-density lipoprotein cholesterol ratio for prediction of the low-density lipoprotein phenotype B. Am J Cardiol 2004;94:29-222. 9. da Luz PL, Favarato D, Faria-Neto JR Jr, Lemos P, Chagas AC. High ratio of triglycerides to HDL-cholesterol predicts extensive coronary disease. Clinics (Sao Paulo) 2008;63: 427-432. 0. Kim JS, Kang HT, Shim JY, Lee HR. The association between the triglyceride to high-density lipoprotein cholesterol ratio with insulin resistance (HOMA-IR) in the general Korean population: based on the National Health and Nutrition Examination Survey in 2007-2009. Diabetes Res Clin Pract 202;97:32-38.. Ministry of Health and Welfare (KR). Ministry of Health and Welfare statistical year book 203. Seoul: Ministry of Health and Welfare; 203. 2. Ministry of Food and Drug Safety. Total sugar intake survey 202 [Internet]. Cheongju: Ministry of Food and Drug Safety; 202 [cited 204 Jul 6]. Available from: http://www.mfds.go.kr/index.do?mid=675&seq=788 &cmd=v. 3. Park JM, Yoo EG, Kim DH. Type 2 diabetes mellitus in children. J Korean Pediatr Soc 2002;45:646-653. 4. Kim SH, Ahn BC, Joung H, Park MJ. Lipid profiles and prevalence of dyslipidemia in Korean adolescents. Endocrinol Metab 202;27:208-26. 5. Moon SJ, Lee KY, Kim SY. Application of convenient method for the study of nutritional status of middleaged Korean women. Yonsei Nonchong 980;7:203-28. 6. Korean Dietetic Association. Diabetes management [Internet]. Seoul: Korean Dietetic Association; 200 [cited 203 Jun 0]. Available from: http://www.dietitian.or.kr/ sub5_4_08.asp. 7. Lim H, Kim SY, Wang Y, Lee SJ, Oh K, Sohn CY, et al. Preservation of a traditional Korean dietary pattern and emergence of a fruit and dairy dietary pattern among adults in South Korea: secular transitions in dietary 24 www.lipid.or.kr
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