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대한지역사회영양학회지 18(2) : 101~111, 2013 Korean J Community Nutr 18(2) : 101~111, 2013 http://dx.doi.org/10.5720/kjcn.2013.18.2.101 제 1 형당뇨병소아청소년의영양지식, 식태도, 식행동에대한실태조사 노나연 남소영 강희숙 1) 이지은 2) 이수경 인하대학교식품영양학과, 1) 인하대병원소아청소년과, 2) 인하대학교의과대학소아과학교실 Nutrition Knowledge, Dietary Attitude, and Dietary Behavior among Children and Adolescents with Type 1 Diabetes Na-Yeon Noh, So-Young Nam, Hee-Suk Kang 1), Ji-Eun Lee 2), Soo-Kyung Lee Department of Food and Nutrition, Inha University, Incheon, Korea 1) Department of Pediatrics, Inha University Hospital, Incheon, Korea 2) Department of Pediatrics, School of Medicine, Inha University, Incheon, Korea, Abstract Type 1 diabetes is on the rise worldwide. Although nutrition education for patients with diabetes has become a routine practice, specifics and impacts of such educations need to be more researched. This study examined the status of nutrition knowledge, dietary attitude, and dietary behavior among children and adolescents with type 1 diabetes (9-19 year-old) and explored factors influencing dietary behaviors related to diabetes by applying the Theory of Planned Behavior. Face-toface interviews, using a pre-tested structured questionnaire, were conducted with 32 participants (11 boys and 21 girls) with type 1 diabetes followed by a diabetes clinic in a university hospital. This study found that the level of nutrition knowledge related to diabetes was generally low at 4 points out of a possible 10, however, the dietary attitude related to diabetes was found to be generally good at 26 points out of a possible 30. Participants were motivated to follow medical staff recommendations the most; however, their family was also important. Perceived behavioral control was low especially for eating-out and portion control. The dietary behavior related to blood glucose control showed low at 13 points out of a possible 20. Regression analysis showed that perceived behavioral control (p < 0.001) was significantly related to the dietary behavior related to blood glucose control. This rare study with children and adolescents with type 1 diabetes showed that nutrition education should include a component to improve perceived behavioral control through high-risk situation management. (Korean J Community Nutr 18(2) : 101~111, 2013) KEY WORDS : Type 1 diabetes children adolescent Theory of Planned Behavior 서 전세계적으로소아기와청소년기에주로발생하는제 1형 접수일 : 2013 년 1 월 03 일접수수정일 : 2013 년 3 월 15 일수정채택일 : 2013 년 4 월 01 일채택 *This study was conducted with Inha University grant for SK Lee. Corresponding author: Soo-Kyung Lee, Department of Food and Nutrition, Inha University, 100 Inharo, Namgu, Incheon 402-751, Korea Tel: (032) 860-8121, Fax: (032) 860-8120 E-mail: skleenutrition@inha.ac.kr 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. 론 당뇨병 (IDDM, type 1 diabetes) 이증가하고있다 (Silink 2002; Knip 2012). 미국의경우 2002년부터 2005년까지 15,600 명의청소년이새롭게제 1형당뇨병을진단받았고, 10세이상 19세미만의소아청소년에서의제 1형당뇨병발생률은 10만명당 18.6명으로나타났다 (NIDDK 2011). 한국의경우 15세미만의소아청소년에서제 1형당뇨병발생률은 1985 년부터 1986 년에는 10만명당 0.6명 (Karvonen 등 1993) 이었으나 1995년부터 2000년에는 10만명당평균 1.36명으로 (Shin 2008) 증가추세를보였다. 국민건강보험공단자료에서도제 1형당뇨병을포함한당뇨병으로등록된 5세이상 -19세이하의진료인원은 2007 년에는 760 명, 2011 년에는 829 명으로증가하였다 (National Health Insurance Corporation 2012). 그러므로한국에서도제 1형당뇨병유병률이증가하고있는것으로볼수있겠다. 101

102 제 1 형당뇨병소아청소년 제 1형당뇨병은췌장베타세포파괴에의한인슐린결핍으로발생하는인슐린의존성 (Insulin-Dependent Diabetes Mellitus) 의만성질환으로인슐린절대부족으로인하여높아진혈당에대한조절과관리를위한치료가필요하다. 적절한혈당관리를통해합병증의발생을지연시키기위하여인슐린주사, 식사요법, 운동요법이조화를이루어야한다. 성장기에는혈당관리와더불어정상적으로성장하고발달할수있도록적절한에너지와영양소를공급해야하기때문에더욱어려움이있다고하겠다 (Silverstein 등 2005). 당뇨병의식사요법은환자가스스로식생활을조절하고관리할수있도록하는것을원칙으로한다 (Lee 2011). 당뇨환자에게실시하는영양교육은개별화된식사계획을토대로당뇨관련영양지식의수준은높이고, 식태도는개선시켜바람직한식행동으로옮기도록하는것이다 (Park 등 2006). 이러한영양교육의효과는주로제 2형당뇨병환자를대상으로한연구가보고되고있고 (Chung 등 2000; Lee 등 2003; Kang 등 2009), 제 1형당뇨병소아청소년환자를대상으로한연구는매우드문형편이다 (Kim & Kim 2000; Kang 등 2010). 특히제 1형당뇨병소아청소년의영양지식, 식태도, 식행동에관해서는연구된바가거의없다. 당뇨관련식행동에영향을미치는요인에대한선행연구는제 1형당뇨병환자를대상으로한연구는없었고, 제 2 형당뇨병환자를대상으로한선행연구 (Park & Kim 1994; Chun 등 1999; Kim & Park 2003; Silverstein 등 2005) 에서는성별, 연령, 학력은물론사회적지지, 주관적규범, 자아효능감과같은사회심리적요인에따라서도당뇨병의식사요법을실천하는데영향을미친다고보고하고있다. 즉, 식행동은영양지식뿐만아니라다양한요인에의해영향받기때문에당뇨병의식사요법을실천하는데영향을미치는요인을건강행동이론에근거하여이해하는것이필요하다. Lee & Park(2010) 은계획된행동이론을이용하여당뇨병환자의식행동을이해하고자시도하였다. Ajzen (1991) 의계획적행동이론 (Theory of planned behavior) 은행동에대한태도 (Attitude toward the behavior), 주관적규범 (Subjective norms), 인지된행동통제력 (Perceived behavioral control) 과같은세가지요인에의해행동을실천하려는의도 (Intention) 가형성되며, 이러한의도와인지된행동통제력이함께작동하여행동 (Behavior) 이나타난다고주장한다. 이연구는제 1형당뇨병소아청소년의영양지식, 식태도, 식행동에대하여알아보았고, 계획적행동이론을적용함으로써당뇨관련식행동에영향을미치는요인을파악하였다. 이연구결과는영양교육프로그램의효과를높이도록계획 하고실행하는데유용한자료로활용될수있을것이다. 연구대상및방법 1. 연구대상및기간 본연구는 2012년 5월부터 10월까지인천에소재한대학병원의소아당뇨병내분비센터에내원하고있는만 9~19 세의제 1형당뇨병환자 32명을대상으로하였다. 당뇨내분비센터외래대기실에서 1 : 1 면담방식으로설문조사를진행하였다. 이연구는인하대병원임상시험심사위원회의승인을받았다 ( 승인번호 12-0738). 2. 조사도구작성및조사내용 본연구의설문지는대상자의일반적특성, 당뇨관련영양지식, 계획적행동이론관련문항, 혈당조절관련식행동, 식사의질조사등으로구성하였고, 신체계측적특성과임상학적특성은의무기록을후향적으로조사하여이용하였다. 설문지작성후에예비조사를실시하여수정하고보완하였다. 1) 일반적특성조사 조사대상자의성별, 연령, 영양교육받은경험유무, 교육수준, 부모님의학력, 부모님의직장유무, 가족형태를조사하였다. 2) 신체계측적특성조사 병원에서측정된조사대상자의신장과체중을이용하여체질량지수 [Body mass index, BMI = 체중 (kg)/ 신장 (m) 5 ] 를계산하였고, 체중상태는대상자의연령에따라판정기준을다르게적용하였다. 우선만 18세이하대상자 27명은질병관리본부와대한소아과학회에서제공하는 2007년소아청소년표준성장도표 (KCDC & KPS 2007) 를이용하였다. 각성별과연령에해당하는체질량지수백분위수를이용하여 5백분위수미만은저체중, 5백분위수이상에서 85백분위수미만은정상체중, 85백분위수이상에서 95백분위수미만은과체중, 95백분위수이상또는체질량지수 25 이상은비만으로분류하였다. 만 19세이상에해당하는대상자 5명은체질량지수에따라 BMI 18.5 kg/m 5 이하를저체중, BMI 18.5-22.9 kg/m 5 를정상, BMI 23.0-24.9 kg/m 5 를과체중, BMI 25.0 kg/m 5 이상을비만으로분류하였다. 또한성별과연령을고려한성장발육상태를평가하기위하여연령별신장 z-score(haz: Height for Age z- score), 연령별체중 z-score(waz: Weight for Age z-score), 연령별체질량지수 z-score(baz: Body

노나연 남소영 강희숙 이지은 이수경 103 Mass Index for Age z-score) 를구하였다. 3) 임상학적특성조사당화혈색소 [HbAlc(%)], 당뇨병유병기간, 당뇨병합병증발생여부를조사하였다. 당화혈색소는연령대에따라 6~12세는 8.0% 미만, 13~19세는 7.5% 미만, 19세이상은 7.0% 미만을기준으로이에해당하는군은정상군으로그이상일경우는비정상군으로분류하였다 (American Diabetes Association 2012). 4) 에너지및영양소섭취상태조사 24시간회상법을이용하여 1일에너지와탄수화물, 단백질, 지방, 비타민 A, 티아민, 리보플라빈, 니아신, 비타민 C, 칼슘, 철의섭취량을조사하였다. 24시간회상법은식품모형과사진자료를보조도구로활용하여진행하였으며, 조사된섭취량은 CAN-Pro 4.0 전문가용프로그램 (Computer Aided Nutritional Analysis Program, The Korean Nutrition Society, Korea) 을이용하여영양소섭취량으로전환하였다. 탄수화물, 단백질, 지방으로부터의에너지비율도계산하였다. 5) 당뇨관련영양지식조사당뇨관련영양지식은기존의연구와관련된문헌을참고하여구성하였다 (Shim 등 2006). 총 10문항중 자신의 1 일처방열량, 자신의 1일처방열량에맞는곡류군교환단위수, 자신의 1일처방열량에맞는과일군교환단위수 에대한 3문항은정답을맞추면 잘알고있음, 응답을하였으나정답을맞추지못하였으면 잘못알고있음, 잘모르겠다고응답하였으면 모르고있음, 병원에서처방받지않았으면 처방받지않았음 으로분류하였다. 또한 밥 1/3공기대신바꿔먹을수있는크래커의개수 에대한문항은정답을맞추면 잘알고있음, 응답을하였으나정답을맞추지못하였으면 잘못알고있음 으로분류하였고이문항을제외한 6문항은정답을맞추면 잘알고있음, 응답을하였으나정답을맞추지못하였으면 잘못알고있음, 잘모르겠다고응답하였으면 모르고있음 으로분류하였다. 총점은 10점을만점으로 잘알고있음 에응답하였으면 1점을부여하고그외의경우는 0점을부여하여점수가높을수록영양지식이높은것으로평가하였다. 6) 계획적행동이론관련문항조사계획적행동이론 (Ajzen 1991) 에따라당뇨관련식태도, 당뇨관련주관적규범, 당뇨관련인지된행동통제력, 당뇨관 련실천의도에대한문항을구성하여 (Kim & Shin 2003; Seo 등 2011) 5점척도를이용하여조사하였다. 당뇨관련식태도는총 6문항으로조사하였다 (Cronbach's α = 0.788). 총점은 30점만점으로점수가높을수록당뇨병의식사요법을실천하는것에대해긍정적인태도를나타내는것으로평가하였다. 당뇨관련주관적규범에해당하는부분을규범적신념과순응동기로조사하였다. 가족 ( 부모님, 형제, 자매, 할머니등보호자 ), 선생님 ( 의사, 간호사, 영양사등 ), 제 1형당뇨병을가진또래친구또는선배와같은주변사람들이당뇨병의식사요법을실천하는것을지지할것인지에대한규범적신념과주변사람들의의견을얼마나따를것인지에대한순응동기를총 6문항으로조사하였다. 당뇨관련주관적규범은규범적신념과순응동기를곱하여합한값으로점수가높을수록주변사람들의영향이큰것으로평가하였다 (Cronbach's α = 0.850). 당뇨관련인지된행동통제력은당뇨병의식사요법을실천하는데쉽거나저해하는여러요인, 상황에서행동수행을용이하게하는자신감이있을때통제가되는지에대해총 4문항으로조사하였다 (Cronbach's α = 0.704). 총점은 20점만점으로점수가높을수록인지된행동통제력이높은것으로평가하였다. 당뇨관련실천의도는 앞으로한달이내에당뇨식을잘실천할생각이있는지 에대해조사하였다. 7) 혈당조절관련식행동관련조사혈당조절과관련된식행동을조사하기위해총 4문항을 5 점척도를이용하여조사하였다. 총점은 20점을만점으로점수가높을수록혈당조절과관련된식행동이높은것으로평가하였다. 3. 통계분석본연구에서수집된자료는 IBM SPSS 20.0(SPSS Inc., IBM corp., NY, USA) 프로그램을이용하여분석하였다. 혈당조절에따라어떠한차이가있는지알아보기위하여객관적혈당지표인당화혈색소수준을기준으로나눈정상군과비정상군의차이를분석하였다. 두군간의유의한차이는많이나타나지않았으나, 제 1형당뇨소아청소년의자료구축을위하여분석결과를두군으로나누어제시하였다. 모든변수들은평균과표준편차또는빈도와백분율로표시하였다. 두군간의유의성을검정하기위하여평균차이는비모수통계방법인 Mann-Whitney U test를, 분포차이는

104 제 1 형당뇨병소아청소년 Fisher's exact test를이용하였다. 통계적유의성은 p < 0.05 를기준으로하였다. 또한당뇨관련식행동에대한실천의도와혈당조절관련식행동에영향력을미치는변수를알아보기위해다중회귀분석을실시하였다. 계획적행동이론에근거하여당뇨관련식행동에대한실천의도를알아보기위해독립변수로식태도, 주관적규범, 인지된행동통제력이이용되었다. 혈당조절관련식행동을알아보기위한독립변수는실천의도와인지된행동통제력이이용되었다. 결 1. 대상자의일반적특성 대상자의일반적특성은 Table 1과같다. 총 32명의대상자중남자는 34.4%, 여자는 65.6% 로여학생의분포가더 과 높았다. 대상자의평균연령은약 14세였고, 영양교육을받은적이있다고응답한대상자는 81.2%, 영양교육을받은적이없다고응답한대상자는 18.8% 이었다. 대상자중초등학생은 28.1%, 중학생은 40.6%, 고등학생은 18.8%, 대학재학이상은 12.5% 이었다. 부모의학력은고등학교까지졸업한아버지가 53.1%, 어머니가 62.5% 로가장높은분포를보였다. 또한 59.4% 의부모님이모두직업을가지고있었고, 가족구성은핵가족이 62.5% 로조사되었다. 당화혈색소수준이비정상군은정상군에비하여나이가많아 (p < 0.001) 상급학교에재학중이었으며 (p < 0.001) 영양교육을받아본적이있다고답한빈도가높았다 (p < 0.05). 2. 대상자의신체계측적, 임상적특성 Table 2에는대상자의신체계측적특성과임상적특성이 Table 1. General characteristics of the subjects Sex Male Female 11 (34.4) 2) 3 (37.5) 21 (65.6) 2) 5 (62.5) 8 (33.3) 16 (66.7) < 1.000 3) Age (year) 13.97 ± 3.00 4) 10.63 ± 1.19 15.08 ± 2.55 < 0.001 5) Educational status Elementary school Middle school High school College Nutrition education Yes No Father's education < High school High school College 6) Mother's education < High school High school College 6) Parent's employment Both employed Father employed Mother employed Both unemployed Family size Nuclear family Extended family 9 (28.1) 2) 13 (40.6) 2) 6 (18.8) 2) 4 (12.5) 2) 7 (87.5) 1 (12.5) 26 (81.2) 2) 4 (50.0) 6 (18.8) 2) 4 (50.0) 1 (53.1) 2) 17 (53.1) 2) 13 (40.6) 2) 1 (53.1) 2) 5 (15.6) 2) 20 (62.5) 2) 6 (18.8) 2) 1 (53.1) 2) 19 (59.4) 2) 11 (34.4) 2) 2) 2 (56.2) 2) 3 (37.5) 5 (62.5) 1 (12.5) 4 (50.0) 3 (37.5) 2 (25.0) 6 (75.0) 20 (62.5) 2) 3 (37.5) 12 (37.5) 2) 5 (62.5) 2) N (%) 3) Fisher's exact test 4) Mean ± SD 5) Mann-Whitney U test 6) Single-parent family 2 (58.3) 12 (50.0) 6 (25.0) 4 (16.7) 22 (91.7) 2 (58.3) 1 (54.2) 14 (58.3) 8 (33.3) 1 (54.2) 4 (16.7) 16 (66.7) 3 (12.5) 1 (54.2) 17 (70.8) 5 (20.8) 2 (58.3) 17 (70.8) 7 (29.2) <0.001 3) <0.05 3) < 0.578 3) < 0.566 3) <0.05 3) < 0.116 3)

노나연 남소영 강희숙 이지은 이수경 105 Table 2. Anthropometric and clinical characteristics of the subjects Anthropometric characteristics Height (cm) 156.09 ± 10.65 2) 147.65 ± 12.80 158.91 ± 58.36 < 0.05 3) Weight (kg) 550.88 ± 12.46 542.51 ± 15.70 553.67 ± 10.09 < 0.05 3) BMI (kg/m 2 ) 520.59 ± 53.28 518.92 ± 53.64 521.15 ± 53.03 < 0.05 3) Weight status Underweight Normal Overweight Obesity 4) 26 (81.2) 4) 2 (56.2) 4) 4 (12.5) 4) 0 (550.0) 7 (587.5) 0 (550.0) 1 (512.5) 19 (79.2) 2 (58.3) 3 (12.5) < 1.000 5) (N = 27) (N = 8) (N = 19) HAZ 550.39 ± 51.28 551.25 ± 51.13 550.02 ± 51.19 < 0.05 3) WAZ 550.27 ± 50.89 550.77 ± 50.91 550.06 ± 50.81 < 0.100 3) BAZ 550.11 ± 50.75 550.26 ± 50.86 550.05 ± 50.72 < 0.595 3) Clinical characteristics HbAlc (%) 558.91 ± 51.86 2) 556.80 ± 50.56 559.61 ± 51.58 < 0.001 3) Duration of diabetes (year) 554.69 ± 53.44 551.50 ± 52.27 555.42 ± 53.15 < 0.01 3) Complications of diabetes Yes No 7 (21.9) 3) 0 (550.0) 25 (78.1) 4) 8 (100.0) 2) Mean ± SD 3) Mann-Whitney U test 4) N (%) 5) Fisher's exact test HAZ: Height for Age z-score WAZ: Weight for Age z-score BAZ: Body Mass Index for Age z-score 7 (29.2) 17 (70.8) < 0.150 5) 제시되어있다. 대상자의 81.2% 가정상체중이었고, 과체중이거나비만인대상자는 18.7% 이었다. 연령별신장 z-score 는 0.39, 연령별체중 z-score는 0.27, 연령별체질량지수 z-score는 0.1이었다. 신장 (p < 0.05), 체중 (p < 0.05), 체질량지수 (p < 0.05) 는당화혈색소가정상인군이당화혈색소가비정상인군에비해유의적으로낮은것으로나타났다. 연령별신장 z-score(haz) 는당화혈색소가정상인군이당화혈색소가비정상인군에비해유의적으로높았다 (p < 0.05). 평균당화혈색소수준은 9% 이었고평균당뇨병유병기간은 5년이었다. 대상자의 21.9% 가당뇨병관련합병증을가지고있었다. 당화혈색소 (p < 0.001) 와당뇨병유병기간 (p < 0.01) 은당화혈색소가정상인군이당화혈색소가비정상인군에비해유의적으로낮은것으로나타났다. 3. 에너지와영양소섭취실태조사대상자의에너지, 영양소섭취량및다량영양소에서오는에너지의비율은 Table 3과같다. 대상자의 1일에너 지섭취량은 1,799kcal 였고, 탄수화물로부터 62%, 단백질로부터 16%, 지방으로부터 23% 를에너지로얻고있었다. 니아신의섭취량은당화혈색소가정상인군이당화혈색소가비정상인군에비해유의적으로낮은것으로나타났다 (p < 0.01). 4. 당뇨관련영양지식조사대상자의당뇨관련영양지식은 Table 4와같다. 자신의 1일처방열량 을잘알고있는대상자는 37.5% 이었고, 31.2% 는모르고있는것으로나타났다. 자신의 1일처방열량에맞는곡류군교환단위수, 자신의 1일처방열량에맞는과일군교환단위수 를모른다고답한대상자는각각 59.4%, 62.5% 로가장높은분포를보였다. 총문항의합계평균점수는총 10문항중 4문항을맞추어서전반적으로낮은영양지식을갖고있는것으로나타났다. 특히식품교환표와관련된영양지식은정답율이 9.4~43.8% 로낮았으며, 당뇨병의식사요법과외식요법에관한영양지식은정답율이 59~75% 로높은결과를보였다. 당뇨병의식사요법으로옳

106 제 1 형당뇨병소아청소년 Table 3. Average intake of energy and nutrients Energy (kcal) 1,798.70 ± 470.48 2) 1,775.73 ± 508.73 1,806.36 ± 468.33 0.896 3) Carbohydrate (g) 1,278.08 ± 82.15 1,278.83 ± 87.31 1,277.83 ± 82.32 0.931 Protein (g) 1,571.23 ± 22.11 1,572.23 ± 20.34 1,570.90 ± 23.08 0.862 Fat (g) 1,545.15 ± 15.76 1,542.54 ± 14.82 1,546.02 ± 16.27 0.602 Vitamin A (µg RE) 1,713.06 ± 378.61 1,656.01 ± 333.23 1,732.07 ± 397.36 0.728 Thiamin (mg) 1,551.09 ± 0.36 1,551.02 ± 0.21 1,551.11 ± 0.40 0.602 Riboflavin (mg) 1,551.15 ± 0.58 1,550.85 ± 0.19 1,551.25 ± 0.63 0.128 Niacin (mg) 1,513.07 ± 5.89 1,557.62 ± 3.80 1,514.89 ± 5.35 < 0.01 Vitamin C (mg) 77.89 ± 39.63 1,576.96 ± 31.13 1,578.20 ± 42.68 0.862 Calcium (mg) 1,579.58 ± 301.57 1,487.44 ± 264.98 1,610.29 ± 311.88 0.338 Fe (mg) 1,513.20 ± 5.45 1,513.26 ± 3.40 1,513.18 ± 5.94 1.000 Calories from carbohydrate (%) 1,561.55 ± 5.83 1,562.05 ± 5.17 1,561.39 ± 6.13 0.695 Calories from protein (%) 1,515.78 ± 2.40 1,516.35 ± 2.35 1,515.59 ± 2.44 0.514 Calories from fat (%) 1,522.67 ± 5.36 1,521.59 ± 4.66 1,523.02 ± 5.62 0.384 2) Mean ± SD, 3) Mann-Whitney U test Table 4. Nutrition knowledge related to diabetes Correct answer 12 (37.5) 2) 3 (37.5) 9 (37.5) Wrong answer 9 (28.1) 3 (37.5) 6 (25.0) One s prescribed calorie per day Did not know 10 (31.2) 2 (25.0) 8 (33.3) No prescription provided 1 (53.1) 1 (54.2) Correct answer 3 (59.4) 1 (12.5) 2 (58.3) The appropriate number of exchange Wrong answer 9 (28.1) 2 (25.0) 7 (29.2) unit of starches for one s prescribed Did not know 19 (59.4) 5 (62.5) 14 (58.3) calorie per day No prescription provided 1 (53.1) 1 (54.2) The appropriate number of exchange unit of fruits for one s prescribed calorie per day The number of crackers that can replace one-third bowl of rice The foods with the most amount of carbohydrate The amount of fruits that cannot replace one exchange unit of banana The content of carbohydrate of the shown foods exchange What is not desirable eating-out behaviors? What is not appropriate for the diet therapy of diabetes? What is not right reason for diet therapy for diabetes? 0.910 3) 1.000 3) Correct answer 7 (21.9) 1 (12.5) 6 (25.0) Wrong answer 4 (12.5) 2 (25.0) 2 (58.3) Did not know 20 (62.5) 5 (62.5) 15 (62.5) 0.631 3) No prescription provided 1 (53.1) 1 (54.2) Correct answer 14 (43.8) 4 (50.0) 10 (41.7) Wrong answer 18 (56.2) 4 (50.0) 14 (58.3) 0.703 3) Correct answer 13 (40.6) 3 (37.5) 10 (41.7) Wrong answer 17 (53.1) 4 (50.0) 13 (54.2) 0.670 3) Did not know 2 (56.2) 1 (12.5) 1 (54.2) Correct answer 4 (12.5) 4 (16.7) Wrong answer 20 (62.5) 5 (62.5) 15 (62.5) 0.511 3) Did not know 8 (25.0) 3 (37.5) 5 (20.8) Correct answer 8 (25.0) 1 (12.5) 7 (29.2) Wrong answer 7 (21.9) 2 (25.0) 5 (20.8) 0.752 3) Did not know 17 (53.1) 5 (62.5) 12 (50.0) Correct answer 24 (75.0) 5 (62.5) 19 (79.2) Wrong answer 6 (18.8) 3 (37.5) 3 (12.5) 0.336 3) Did not know 2 (56.2) 2 (58.3) Correct answer 24 (75.0) 3 (37.5) 21 (87.5) Wrong answer 4 (12.5) 3 (37.5) 1 (54.2) <0.05 3) Did not know 4 (12.5) 2 (25.0) 2 (58.3) Correct answer 19 (59.4) 4 (50.0) 15 (62.5) Wrong answer 11 (34.4) 3 (37.5) 8 (33.3) 0.676 3) Did not know 2 (56.2) 1 (12.5) 1 (54.2) score 4.00 ± 1.92 4) 3.13 ± 1.46 4.29 ± 1.99 0.147 5) 2) N (%), 3) Fisher's exact test, 4) Mean ± SD, 5) Mann-Whitney U test

노나연 남소영 강희숙 이지은 이수경 107 지않은것 에따른문항의빈도에서당화혈색소가정상인군과당화혈색소가비정상인군간의유의적인차이가있었다 (p < 0.05). 5. 대상자의당뇨관련식태도조사대상자의당뇨관련식태도는 Table 5에정리한바와같다. 당뇨관련식태도에대한문항은 5점만점중모두 4점이상으로나타나대상자의식태도는전반적으로좋은것으 Table 5. Attitude toward diabetes-related dietary behaviors I think it is important to have a proper amount of meal at regular time for blood glucose control 54.75 ± 0.51 2) 54.63 ± 0.52 54.79 ± 0.51 0.263 3) I think it is important to eat the meal and snacks timed with insulin injection 54.25 ± 0.80 54.13 ± 1.13 54.29 ± 0.69 0.943 I think that I should calculate carbohydrate amount of foods using the nutrition labeling 54.00 ± 0.72 54.00 ± 0.93 54.00 ± 0.66 0.730 I think that if I eat salty, sweet, and fatty food too much, the complications will rapidly occur 54.34 ± 0.75 54.75 ± 0.46 54.21 ± 0.78 0.077 I think that practicing diabetic diets means eating healthy meals with the calorie and nutrients needed for growth 54.34 ± 0.70 54.50 ± 0.54 54.29 ± 0.75 0.566 I think that my blood glucose will be well controlled. if I practice the diet therapy for diabetes 54.53 ± 0.62 54.63 ± 0.52 54.50 ± 0.66 0.725 score 26.22 ± 2.88 26.63 ± 2.45 26.08 ± 3.05 0.759 2) Mean ± SD, Response categories used a 5-point Likert scale (High scores indicate strong agreement.). 3) Mann-Whitney U test Table 6. Subjective norms toward diabetes-related dietary behaviors Normative Belief I think that I comply with opinions of my family (e.g. grandparents, parents, or sibling). 53.59 ± 50.95 2) 53.38 ± 51.30 53.67 ± 50.82 0.562 3) I think that I comply with opinions of my educators (e.g. doctors, nurses, or nutritionists). 53.81 ± 50.90 53.88 ± 51.13 53.79 ± 50.83 0.747 I think that I comply with opinions of my friends or seniors who have 53.34 ± 50.97 type 1 diabetes. 53.25 ± 51.28 53.38 ± 50.88 1.000 Motivation to Comply I think that if I do well regulating blood glucose through insulin injection, diet therapy, and exercise therapy, my family 54.72 ± 50.52 54.88 ± 50.35 54.67 ± 50.57 0.341 (e.g. grandparents, parents, or sibling) will like it. I think that if I do well regulating blood glucose through insulin injection, diet therapy, and exercise therapy, my educators 54.56 ± 50.67 54.75 ± 50.46 54.50 ± 50.72 0.436 (e.g. doctors, nurses, or nutritionists) will like it. I think that if I do well regulating blood glucose through insulin injection, diet therapy, and exercise therapy, my friends or seniors 54.03 ± 50.93 54.00 ± 50.93 54.04 ± 50.96 0.872 who have type 1 diabetes will like it. Subjective norms My family(e.g. grandparents, parents, or sibling) 17.03 ±5 5.10 4) 16.25 ± 55.82 17.29 ± 54.95 0.687 My educators (e.g. doctors, nurses, or nutritionists) 17.50 ± 55.27 18.50 ± 56.12 17.17 ± 55.06 0.564 My friends or seniors who has type 1 diabetes 13.81 ± 56.17 13.13 ± 56.90 14.04 ± 56.05 0.709 score 48.34 ± 14.56 47.88 ± 17.42 48.50 ± 13.90 0.913 2) Mean ± SD, Response categories used a 5-point Likert scale (High scores indicate strong agreement.). 3) Mann-Whitney U test, 4) Data multiplied Normative Belief by Motivation to Comply

108 제 1 형당뇨병소아청소년 로나타났다. 그러나 식품의영양성분표시를이용하여탄수화물계산을해야하는것 에대해서는평균 4점으로가장낮은식태도를보였으며, 반대로 혈당조절을위해알맞은양의식사를규칙적인시간에먹는것 에대해서는평균 4.75 점으로가장높은식태도를가지고있는것으로나타났다. 6. 당뇨관련주관적규범조사대상자의당뇨관련주관적규범은 Table 6과같다. 의사, 간호사, 영양사등선생님의의견에따라야한다는생각 (3.81 + 0.90) 이많았으나순응하고자하는동기는선생님 (4.56 + 0.67) 보다가족 (4.72 + 0.52) 이더높았다. 당뇨병의식사요법을실천하는것에있어서소아당뇨를가진또래친구또는선배의영향은가장낮았다. 7. 당뇨관련인지된행동통제력조사대상자의당뇨관련인지된행동통제력은 Table 7에나타내었다. 당뇨병의식사요법을실천하는데인슐린주사 (4.25 + 1.05), 저혈당예방 (4.25 + 0.98) 과관련된요인에서인지된행동통제력은높은것으로나타났다. 반면에외식 (3.50 + 0.95), 식생활자가관리 (3.75 + 0.92) 와같은상황에서인지된행동통제력은낮았다. 8. 당뇨관련실천의도와혈당조절관련식행동조사대상자의당뇨관련실천의도와혈당조절관련식행동은 Table 8과같다. 앞으로한달이내에당뇨식을실천할생각 에대해서는총 5점만점에서 4점으로대상자의당뇨관련실천의도가비교적높은편이었다. 그러나혈당조절관련식행동에관한 4문항에대한점수는총 20점만점에서 13점으로나타나대체적으로낮은경향을나타내었다. 특히 외식을할때식사량을조절한다 에대해서는평균 3.06점으로가장낮은수준을보였으며, 반대로 하루에식사를규칙적인시간에먹는다 에대해서는평균 3.78 점으로가장높은수준을보였다. Table 7. Perceived behavioral control toward diabetes-related dietary behaviors I can have a meal with insulin injection when it is mealtime, although I was playing with friends. 54.25 ± 1.05 2) 54.13 ± 1.46 54.29 ± 0.91 0.904 3) I can have a balanced meal (not junk food or fast food) myself if parents cannot prepare my meal. 53.75 ± 0.92 53.88 ± 0.99 53.71 ± 0.91 0.748 I can select a healthy food and have a proper amount of food when I eat out with family or friends. 53.50 ± 0.95 53.75 ± 0.89 53.42 ± 0.97 0.407 I can eat a snack for preventing hypoglycemia although it is difficult to practice. 54.25 ± 0.98 54.00 ± 1.60 54.33 ± 0.70 0.830 score 15.75 ± 2.84 15.75 ± 3.85 15.75 ± 2.52 0.827 2) Mean ± SD, Response categories used a 5-point Likert scale (High scores indicate strong agreement.). 3) Mann-Whitney U test Table 8. Behavioral intention and dietary behaviors related to blood glucose control Behavioral intention I intend to practice diabetic diets within one month. 54.00 ± 0.62 2) 54.25 ± 0.71 53.92 ± 0.58 0.189 3) Dietary behavior I follow the diet therapy for diabetes well. 53.09 ± 0.96 53.63 ± 1.06 52.92 ± 0.88 0.092 I have meals with the calorie needed for a day prescribed by the hospital. 53.25 ± 0.98 53.50 ± 0.93 53.17 ± 1.01 0.425 I have meals at regular time every day. 53.78 ± 1.01 53.88 ± 0.84 53.75 ± 1.07 0.874 I control the amount of meal when eating out. 53.06 ± 0.98 53.13 ± 1.36 53.04 ± 0.86 0.767 score 13.19 ± 2.44 14.13 ± 3.14 12.88 ± 2.15 0.289 2) Mean ± SD, Response categories used a 5-point Likert scale (High scores indicate strong agreement.). 3) Mann-Whitney U test

노나연 남소영 강희숙 이지은 이수경 109 Table 9. Multiple regressions on the Theory of Planned Behavior 1) B Dependent variable = Behavioral intenetion 2) Dietary attitude 0.474 0.061 Subjective norms 0.236 0.336 Perceived behavioral control 0.323 0.151 Dependent variable = Dietary behavior 3) Behavioral intention 0.216 0.118 Perceived behavioral control 0.549 < 0.001 1) Multiple logistic regression analysis adjusted for age and sex. 2) Standardized parameter estimate R 2 = 0.311, model F = 2.350, p = 0.069 3) Standardized parameter estimate R 2 = 0.553, model F = 8.356, p = 0.000 9. 계획적행동이론분석 조사대상자의당뇨관련실천의도와혈당조절관련식행동에영향을미치는요인이무엇인지알아보기위해연령과성별을보정한다중회귀분석을실시한결과는 Table 9와같다. 당뇨관련식태도, 주관적규범, 인지된행동통제력은당뇨관련실천의도와유의미한관련이없는것으로나타났다. 반면에인지된행동통제력 (p < 0.001) 은혈당조절관련식행동에유의하게관련되어있었다. 고 대학병원에서관리되고있는제1형당뇨병소아청소년을대상으로조사한결과신장, 체중, BMI의평균 z-score가 0보다약간높은수준이어서신체크기및비만정도는당뇨병을가지지않은또래소아청소년과비슷한수준임을알수있었다. 약 5년간의당뇨병유병률을가지고있었고 22% 가당뇨관련합병증을가지고있었다. 대다수 (81.2%) 가영양교육을받은경험이있다고답하였는데이는제1형당뇨병초기진단후대부분입원하여영양교육을포함한포괄적인치료를받기때문인것으로생각된다. 혈당조절관련식생활등이잘조절되고있는지를알려주는당화혈색소수준은평균 9% 정도였는데연령이높아지면서높아지는추이를보였다. 이는또래의제1형당뇨병소아청소년을대상으로한연구와비슷한수준이었다 (Kang 등 2010). 또한당화혈색소수준이비정상군에서영양교육경험율이높지만당화혈색소수준은제 2차성징과더불어연령등다른요인들이관련되어있지않나생각된다 (Choe 등 2000; Silverstein 등 2005). 대상자의에너지섭취비율은탄수화물 : 단백질 : 지방 =62% :16% :23% 였고에너지및영양소섭취수준은한국인영양섭취기준 (2010) 과비교하여대체로양호한수준이었다. 찰 제 1형당뇨병소아청소년들의당뇨관련영양지식은총 10점만점에서평균 4점으로전반적으로낮은영양지식을갖은것으로나타났다. 전체대상자의 32명중영양교육을받았다고응답한대상자가 26명으로대부분의대상자가영양교육을받았음에도불구하고, 영양지식의수준이높지않은것으로보인다. 이연구에서당뇨관련영양지식중특히식품교환표와관련된영양지식이낮은것은 Choe 등 (2000) 의연구에서도유사하게나타났다. 이는당뇨병의식사요법을위한영양교육시적절한섭취량과균형잡힌식사에대한교육자료로써식품교환표가활용되어야함에도불구하고 (Oh & Kim 2010) 일반인들이쉽게익히지못하는어려운부분임을시사한다고하겠다. 그러나당뇨의자가관리를하기위해서는필요한요소이므로반복적인교육을통하여익숙하게사용할수있도록하는것이중요하겠다. 당뇨관련식태도는 Lee 등 (2003) 의제 2형당뇨병환자를대상으로영양교육의효과를알아본연구결과와비슷하게전반적으로좋은것으로나타났다. 반면, 식품의영양성분표시를이용하여탄수화물계산을해야하는것 에대해서는상대적으로낮은식태도를보였다. 이연구대상자는인슐린주사를하루 4회이상으로치료받기때문에식사를계획할때혈당에가장많은영향을미치는영양소인탄수화물을고려하는것이필요하다. 따라서식품의영양성분표시에대한지식을높이고, 이에대한식태도를변화시킬수있도록영양교육에서더욱강조되어야할것이다. 당뇨관련주관적규범은선생님 ( 의사, 간호사, 영양사등 ) 의영향이가장큰것으로나타나 Choe 등 (2000) 의연구와유사하였다. 한편, 이연구에서는사회적지지에대해서조사하지않았지만, 당뇨병관리에있어서가족들로부터충분한지지를얻는것이중요하다고보고되고있다 (Park 2001). 이연구에서주관적규범으로선생님그다음으로가족의영향도높은것으로나타났고다수의연구가가족의도움이매우중요함 (Silverstein 등 2005; American Diabetes Association 2012) 을강변하고있기때문에제 1형당뇨병소아청소년을위한영양교육은대상자뿐만아니라가족에게도교육의효과가미칠수있도록고려되어야할것이다. 당뇨관련인지된행동통제력은특히외식, 식생활자가관리와같은상황에서자신감이부족한것으로나타났다. 따라서영양교육은제 1형당뇨병환자들에게올바른외식과식생활자가관리를잘실천할수있도록자신감을높여줄수있는방안이고려되어야할것이다. 제 1형당뇨병환자의당뇨관련식태도, 주관적규범, 인지된행동통제력은실천의도에영향을미치지않는것으로나타났다. 제 2형당뇨병환자의자가관리에대한행동을계

110 제 1 형당뇨병소아청소년 획적행동이론에적용한 Lee & Park(2010) 의연구에서인지된행동통제력은실천의도에영향을미치는요인이었지만, 이연구에서는영향을미치는요인으로나타나지않았다. 그리고 Park 등 (2000) 의당뇨환자를대상으로한연구에서주관적규범이실천의도에가장영향을미치는유의적변수이었지만, 이연구에서는영향을미치는요인으로나타나지않았다. 이같은결과는계획적행동이론에따른요인들의문항과문항수의차이로인한것일수도있고대상집단의특성으로부터기인한것으로생각할수있겠다. 혈당조절관련식행동에영향을미치는요인을분석한결과를살펴보면, 회귀모형에서인지된행동통제력이혈당조절관련식행동에유의미한영향력을미치는것으로나타났다. 당뇨병의식사요법을실천하고자하는실천의도가높아질때실제로식행동으로이어질가능성이있다고보고하고있으나 (Lee & Park 2010), 이연구에서실천의도는혈당조절관련식행동에유의한관련성을보이지않았다. 반면, 인지된행동통제력은혈당조절관련식행동에영향을주는변수였다. 그러므로영양교육도식이요법에관련된영양지식전달과더불어실생활에서어려운상황에대처해나갈수있는대안을제시하고연습할수있는기회를제공해야한다 (Holli 등 2003). 이연구는많이연구되지않은제 1형당뇨병소아청소년의영양지식, 식태도, 식행동에대하여알아본점과계획적행동이론을적용하여당뇨관련식행동에영향을미치는요인에대해파악하였다는것이장점이라고하겠다. 그러나대상자의연령대가아동기에서청소년기까지비교적넓으면서대상자의수가적기때문에연구된변수와연령과의관련을자세히알아보지못하였다. 이연구는작은규모이기에제 1 형당뇨병환자전체로확대, 적용하는데제한이있고, 제 1 형당뇨병환자를대상으로연구한결과이기때문에제 2형당뇨병환자에게적용할때는두당뇨병종류에따른차이를고려해야할것이다. 하지만, 제 1형당뇨병소아청소년에대한영양연구가필요함에도불구하고거의없는상황에서귀중한초기기초자료를제공하는연구라고하겠다. 요약및결론 이연구는제 1형당뇨병소아청소년의영양지식, 식태도, 식행동에대하여알아보았다. 그리고계획적행동이론을적용하여당뇨관련식행동에영향을미치는요인을파악하였다. 연구대상자의평균연령은 14세, 당화혈색소수준은평균 9%, 당뇨병유병기간은 5년이었다. 에너지섭취비율은탄수화물 : 단백질 : 지방 =62% :16% :23% 로나타났다. 당뇨관련영양지식은전반적으로낮은것으로나타났으며, 특히식품교환표와관련된영양지식이낮았다. 당뇨관련식태도는전반적으로좋은것으로나타났지만, 식품의영양성분표시를이용하여탄수화물계산을하는것 에대한식태도는가장낮았다. 당뇨관련주관적규범은선생님 ( 의사, 간호사, 영양사등 ) 의영향이가장큰것으로나타났고, 외식과같은상황에서인지된행동통제력은낮은것으로보였다. 혈당조절관련식행동은 하루에식사를규칙적인시간에먹는것 을제외하고는전반적으로낮은경향을나타내었다. 계획적행동이론요인은실천의도에유의미한영향력을미치지않았으며, 혈당조절관련식행동에영향을미치는요인은인지된행동통제력으로나타났다. 이연구결과, 제 1형당뇨병소아청소년의당뇨관련식행동을변화시키기위해서는다양한상황에서당뇨식을실천할수있는실질적인방법제시와훈련의기회를포함한다양한맞춤형영양교육이필요할것으로사료된다. 이연구는늘어나는제 1형당뇨소아청소년의건강과나아가삶의질을높이는데필요한기초자료를제공하며, 보다명확하고다양한자료를얻기위해서는큰규모의코호트연구가필요할것이다. 감사의글 본연구에참여해주신제 1형당뇨병소아청소년들께감사드립니다. 이연구에도움을주신손민교수님, 박동호교수님을비롯한모든분들께감사드립니다. 참고문헌 Ajzen I (1991): The theory of planned behavior. Organizational Behavior and Human Decision Processes 50: 179-211 American Diabetes Association (2012): Standards of medical care in diabetes. Diabetes Care 35(Suppl 1): S11-63 Choe SJ, Park HR, Park DY, Ahn HS (2000): A study on the sociopsychological factors influencing the dietary compliance of diabetics by using focus group interview. Korean J Community Nutr 5(1): 23-35 Chun JH, Jung SB, Sohn HS (1999): Self-care and related factors in patients with diabetes. J Korean Diabetes Assoc 23(2): 193-206 Chung SO, Song OK, Ko JM, Wi JH, Lee TH, Yum JH, Cho DK, Son JH, Nam HW, Yoo HJ, Lee YN, Kim SG, Moon HK, Kim ES (2000): The effects of teaching methods on the dietary compliance and hemoglobin a1c level in patients with diabetes mellitus. J Korean Diabetes Assoc 21: 560-573 Holli BB, Calabrese RJ, Maillet JO (2003): Communication and education skills for dietetics professionals. Lippincott Williams & Wilkins, Philadelphia

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