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SMN SURGICAL METABOLISM AND NUTRITION Vol. 6, No. 2, December, 2015 pissn 2233-5765, eissn 2465-8383 http://dx.doi.org/10.18858/smn.2015.6.2.23 REVIEW ARTICLE 한국인의설탕섭취와비만과의연관성에대한체계적문헌고찰 최재경 1 ㆍ안아름 1 ㆍ박경식 2,4 ㆍ조재훈 3 ㆍ양은열 2 ㆍ조영빈 2 ㆍ권종률 2 ㆍ오재도 2 ㆍ윤익진 2 윤원정 2 ㆍ송은영 4 건국대학교의학전문대학원 1 가정의학교실, 2 외과학교실, 3 이비인후 - 두경부외과학교실, 4 건국대학교병원유방갑상선암센터 Systematic Review of the Evidence for an Association between Korean Sugar Intake and Risk of Obesity Jaekyung Choi, M.D., Ph.D. 1, Ah-Leum Ahn, M.D. 1, Kyoung Sik Park, M.D., Ph.D. 2,4, Jae Hoon Cho, M.D., Ph.D. 3, Eunyoel Yang 2, Young Bin Cho 2, Jong Ryul Kwon 2, Jaedo Oh, M.D. 2, Ik Jin Yun, M.D., Ph.D. 2, Wonjung Yun 2, Eun Yeong Song 4 Departments of 1 Family Medicine, 2 Surgery, 3 Otorhinolaryngology-Head & Neck, Konkuk University School of Medicine, 4 Breast and Thyroid Cancer Center, Konkuk University Medical Center, Seoul, Korea Background: The purpose of this study is to collect research data on sugar intake and obesity of Koreans and through systematic review, present our views on the topic. Materials and Methods: An analysis of previously reported research studies was conducted through systematic review and data were collected from databases in Korea and other countries. Out of 1,316 studies collected, 7 were chosen for the purpose of this research study. Result: According to a study including female Korean high school students and college students in Seoul as the subjects, those who were overweight had slightly lower sugar intake than those who were normal weight. Another study conducted on a large group of females showed that there was no substantial difference in the level of sugar intake between the Obese Group and the Normal Weight Group. In the group of Korean adults with a high level of carb consumption, the cross ratio of the overall sugar intake and obesity showed a tendency to increase, but no significant differences were observed. Intake of sugar-sweetened drinks by children and teenagers (age 7 to 12) in Korea resulted in an increase in the odds ratio of obesity. Conclusion: This study does not show that the amount of sugar intake and obesity does not show a direct correlation among Koreans. A more developed and thorough study that considers not only the amount of sugar intake, but also other factors such as physical activity or exercise, should be devised. (Surg Metab Nutr 2015;6:23-27) Key Words: Korean, Sugar intake, Obesity 서론 경제성장에따른소득수준의증가에따른식생활환경변화, 노동환경의변화로인한신체활동량감소등으로국내의 Received December 9, 2015. Accepted December 22, 2015. Correspondence to: Kyoung Sik Park, Department of Surgery, Konkuk University School of Medicine, Neungdong-ro 120-1, Gwangjin-gu, Seoul 05030, Korea Tel: +82-2-2030-7697, Fax: +82-2-2030-8270 E-mail: ks2002p@hanmail.net 비만인구는빠르게증가하는추세이다. 국민건강영양조사에따르면신체질량지수 (Body mass index, BMI) 가 25 이상인성인의비만유병율은 2007년 31.7% 로 1998년 26.0%, 2001년 29.2%, 2005년 31.3% 에서꾸준히증가하고있다. 또한, 아동과청소년비만율은 1998년약 5.8% 였지만 2007년에는 12.9% 로급격하게증가하였다.[1-4] 비만은고혈압, 심혈관질환, 당뇨병등의만성질환을증가시키며,[5] 이는심혈관질환의유발및심혈관질환을포함한모든사망률을증가시키는것으로알 Copyrights c The Korean Society of Surgical Metabolism and Nutrition

24 Surgical Metabolism and Nutrition Vol. 6, No. 2, 2015 려져있다.[6,7] 비만의증가에따른국가의부담비용도증가하고있다. 2008년국민건강보험공단에따르면우리나라국민의비만관련사회ㆍ경제적비용은직접비용 1조 771억원, 간접비용 7152억원으로총 1조 7923억원으로추정되고있다.[8] 비만은매우복잡한문제로단순하게식품의어떤단일성분이비만발생의원인이되지는않는다. 최근까지도비만의원인을분석하는데있어연구적관점은변화되고있으며, 관련연구가활발하게진행되고있다. 이러한비만의원인으로최근설탕섭취량이관심을받고있다. 설탕은포도당으로분해되며, 포도당은뇌에공급하는유일한에너지원이되고있다. 이러한포도당은신진대사에필수요소이며, 집중력향상과신체활동에필요한에너지를제공하고있다.[9] 미국질병관리센터 (CDC) 의미국국민건강영양조사 (NHANES) 자료에따르면총당류가운데첨가당 (Added Sugars) 의섭취현황은미국식사지침자문위원회 (DGAC) 의첨가당섭취권장량을초과한상태이다. 또한, 세계보건기구 (WHO) 의가공식품을통한당류섭취권고기준인전체칼로리의 10% 를초과하여섭취하고있다.[10] 이에반해 2010년부터 2012년까지총 3년간실시한국민건강영양조사자료를분석한결과우리국민의총당류섭취량은 1일열량의 13.4% 를차지, 모든연령대에서 20% 미만을유지하고있으며, 2010년대비 2012년총당류섭취량은 1.3 g이줄어든 65.3 g이다. 이는한국영양학회에서발표한 1일당류섭취권고기준인 50 100 g에포함되는수치이다.[11] 최근과량의설탕섭취시비만의유발요인이될수있다는해외문헌이보고되면서설탕이비만의주요원인으로대두되고있으며설탕섭취가건강에좋지않은영향을줄것이라는의견은지속적으로제기되고있는부분이다.[12,13] 이는비만뿐아니라충치, 심혈관계질환, 통풍, 지방간및일부암종에이르기까지다양한질환들이다량의설탕섭취와연결될수도있다는것이다.[12-15] 그러나연구설계의부적절함과식이섭취상태의측정법의차이및불일치하는문헌및자료들로인해서이러한쟁점에대한결론이나지않고있다. 해외문헌고찰결과가당음료의섭취가비만과관련성이있다는다수의주장이있으나 [16-21], 모든연구에서유의한수준의관련성을보이지는못하고있으며, 메타분석에서도통계적인유의성을보여주지못하고있다.[16,20] 또한비만은설탕에의한것이아니라, 생활태도, 운동부족, 과다영양섭취등복합적인영향으로인해발생한다는전문가들의의견도제기되고있다. 따라서한국인을대상으로한연구중에설탕과비만과관련된문헌을체계적으로고찰하고분석하여한국인의설탕섭취와비만과의연관성을분석하고자한다. 연구방법 1. 국내설탕과비만관련체계적문헌고찰 연구대상은한국인을대상으로한연구중에설탕과비만과관련된모든문헌을체계적문헌고찰순서및방법에따라분석하였다. 전자데이터베이스를통한검색은 2015년 2월 6 일에시행되었다. 국내는 KoreaMed와국가과학기술정보센터 (NDSL), 한국의학논문데이터베이스 (Kembase) 및한국학술정보 (KISS) 을, 국외는 Pubmed, Embase및 Cochrane Library를이용하였다. 학술지검색범위는해당사이트에서검색가능한기간부터 2015년 2월 6일검색당일까지홈페이지에게시된전체문헌을대상으로하였다. 문헌선택과정은 2명의연구자에의해수행되었다. 의견의불일치가있는경우는논의과정을거쳐결정하였으며, 합의되지않는경우는제 3자개입의원칙을정하였으나연구자간이견없이진행되었다. 영문과한글문헌검색에검색용어의구별이있어각각방법론을자세히기술하였고, 자세한문헌선택과정은흐름도로제시하였다 (Fig. 1). 1) 영문문헌검색영문문헌수집은 3종류의국외학술논문데이터베이스 Fig. 1. Study selection to evaluate the association between sugar intakes and obesity.

Jaekyung Choi, et al: Korean Sugar Intake and Obesity 25 (Medline, Cochrane, Embase) 들을이용하여문헌검색을하였다. 또한검색시발행연도는조건으로써제한하지않았으나 PubMed의경우 1966년부터 2015년 2월 6일까지, Embase의경우 1974년부터 2015년 2월 6일까지의문헌이검색되었다. 논문검색시주요영문검색어는데이터베이스에서의 sugar (Mesh term: carbohydrates, dietary sucrose, sweetening agents와 coupling sugar) 와 obesity (Mesh term: obesity, weight gain, overweight, metabolic syndrome X) 와 Korea 공통으로하여검색하였다. 2) 한글문헌검색한글문헌수집은 5종류의국내학술논문데이터베이스들 ( 한국의학논문데이터베이스 : KMbase, 한국학술정보 : KISS, 과학기술정보통합서비스 : NDSL, 그리고 KoreaMed) 을이용하여문헌검색을하였다. 한글검색시발행연도는조건으로써제한하지않았다. 논문검색시한글검색어는관련분야전문가의견을수렴하여설탕, 자당, 백설탕, 갈색설탕, 기타설탕과비만, 과체중, 대사증후군을공통으로하여검색하였다. 3) 문헌의선정및제외기준본문의내용중에서체중감소나약물, 운동등의교란변수가관여할경우배제하였다. 종합적으로영문과한글문헌검색결과를취합한결과를 PRISMA Flow diagram으로작성하였다. 4) 자료분석본연구에서선행연구의고찰및분석은체계적인문헌고찰 (Systemic Review) 을통해이루어졌으며, 이를위해정성적합성또는가능한경우정량적합성을수행하고자그결과를표와그림으로제시하고자하였다. 결과 1. 최종문헌의선정및분류 전체문헌검색결과영문및한글논문을포함하여 1361개의문헌이검색되었다. 이중에서중복검색논문을제외한 1347개의문헌중에서제목과초록내용을바탕으로하여 1322개를제외하였고, 설탕과체중의관련성에대한언급이있는문헌 25개를 1차선별하였다. 선별된 25개의문헌의전문을읽고분석한결과최종적으로 7개의문헌이선별되었고이논문들의주요내용및고찰을기술하고자하였다 (Fig. 1). 2. 체계적문헌고찰결과 1) 비만군과대조군간의당류섭취량차이비만군과대조군간의당류섭취량차이를기술한문헌은최종적으로 5개의문헌이검색되었다. Yeon과 Bae [22] 에따르면서울지역여대생의식사섭취상태및식사의질평가를과체중군과정상군의비교를중심으로하여분석하였을때정상군이과체중군보다당류섭취를유의하게많이섭취했다고보고하였다. 정상군의당류급원식품의경우초콜릿>설탕>시럽>엿등으로나타났으며, 과체중군의경우당류의급원식품이시럽>설탕>엿>초콜릿등의순으로나타났으나, 두군간유의한차이를보이지는않았다. 해당연구의대상자에서 1일열량섭취량은정상군과과체중군에서각각 1,622.6 kcal, 1,630.7 kcal로두군간유의한차이는보이지않았으며, 탄수화물, 단백질및지방의섭취에서도두군간유의한차이는보이지않았다. Hong과 Lee [23] 는서울일부지역여자고등학생의식품및영영소섭취상태를조사한결과정상체중군이과체중군보다유의하게높다고보고하였다. Bae [24] 가비교적많은성인여성을대상으로하여정상군 2841명, 비만군 724명을조사한결과, 설탕섭취량에서비만군과정상군간의유의한차이는없었다. Yu와 Lee [25] 또한일부여대생의설탕섭취와비만지표와의관련성을조사한결과총당류섭취량은체중, 체질량지수, 체지방률과유의한상관관계를보이지않았다. Lee 등 [26] 에따르면 2001년국민건강ㆍ영양조사결과에근거하여우리나라성인의체중상태에따른식생활특성을살펴보았을때, 비만남성에서총당류및육류섭취가정상체중군보다유의하게높았다. Table 1. Studies to evaluate the association between sugar intakes and obesity Year Author Control Obese Control age Obese age Control BMI Obese BMI Control sugar intake Obese sugar intake 2010 Yeon & Bae [22] 111 249 20.5±1.9 20.2±2.0 NS 18.4±1.3 21.8±2.7 <0.001 13.8±14.3 10.3±9.3 0.7322 2010 Hong & Lee [23] 110 49 High school High school NS 20.4±0.1 25.4±0.4 <0.05 12.7±0.9 9.7±1.0 <0.05 2012 Bae [24] 2841 724 34.97±0.24 37.23±0.43 <0.001 21.64±0.04 27.52±0.13 <0.001 7.08±0.25 7.27±0.47 <0.05 2004 Yu & Lee [25] 913 112 20.4±2.3 20.1±2.5 <0.05 20.3±1.2 24.9±2.0 <0.05 6.8±9.2 6.2±9.8 NS

26 Surgical Metabolism and Nutrition Vol. 6, No. 2, 2015 다음은 7개의문헌중정상군과비만군의비교대조군연구들만별도로정리한표이다 (Table 1). 2) 당류섭취량에따른비만도양상분석 Chung [27] 은 2011년과 2002년도국민건강조사자료를이용하여한국성인의총당류섭취와대사증후군과의관계를분석한결과고탄수화물섭취군에서총당류섭취량과비만의교차비가증가하는경향을보이나유의한차이는없다고보고하였다. Lee 등 [28] 이 2008년부터 2011년까지국민건강조사자료를이용하여한국소아및청소년들에서가당음료섭취와관련된식이요인들과체중과의관계를분석한결과, 7 12세남자아이들에서가당음료를섭취하는경우비만의교차비가증가한다고보고하였다. 고찰 본연구에서는한국인의설탕섭취량과비만과의관련성을파악하고자하였다. 이중먼저 4개의논문의연구대상의특성을살펴보면, 주로정상군과비만군간의당류섭취량의차이를비교한것이다. Yu와 Lee [25] 의연구결과와더불어 Hong과 Lee [23] 의연구결과에서도과체중군이정상체중군에비해식품섭취량이다소낮은경향을보이는것으로조사되었는데이는과체중군이정상체중군에비해체중에대한관심이많았고체중감량을위해식이섭취량을제한하였기때문일것이라고언급하고있다. Yeon과 Bae [22] 의연구결과에서도비만여자대학생의경우설탕섭취량이정상체중인여대생에비해유의하게낮았고, 전체적인식습관양상에서도 3대열량영양소의섭취비율도부적절한것으로나타났다. 따라서적정체중유지를위해서는식사의질을포함한올바른식생활에대한교육과실천방안의제시가우선적으로필요하다고생각된다. Lee 등 [26] 의연구결과에따르면우리나라성인의체중상태에따른식생활특성을살펴보았을때, 비만남성에서총당류섭취뿐만아니라전체적인육류섭취가정상체중군보다유의하게높았는데이를통해서비만남성군에서는전체적인칼로리섭취량이높고이로인해총당류섭취량이증가한양상이라고생각된다. 다른한편으로당류섭취량에따른비만도의차이를살폈을때, 당류섭취량이증가함에따라서일부군에서비만도가증가하는것으로나타났다.[27,28] 하지만이러한결과만으로총당류섭취의증가와비만의직접적인관련성을보인다고할수는 없다. 미국사회에서는최근까지비만의원인에대한관점에변화를가지고있는데, 1970년대에는당과관련하여, 1980 1990 년대는지방과관련하여, 2000년대는과잉의에너지와관련하여언급되고있다. 즉더커진 1회식사분량과빈번한간식에의한총에너지섭취증가와기술발달에따른신체활동의감소가미국사회에서비만증가의원인으로규정되고있다.[29,30] 비만인과정상체중인과의열량섭취량에대한연구들을살펴보면, Kim 등 [31] 은 20대젊은남성의경우, 비만도에따른군간열량섭취량에유의적인차이가없었다고보고하였으며, Nam 등 [32] 도표준체중법에의한비만지수에따라분류된비만군과정상체중군간에열량및영양소섭취량에유의한차이를보이지않았다고보고하였다. 또한 Lee와 Lee [33] 는체질량지수에따른여대생의영양소섭취상태를분석한연구에서저체중군, 정상군, 과체중군간열량섭취량은유의한차이를보이지않았다고보고하였다. 그러나 Afolabi 등 [34] 은성인여성을대상으로한연구에서열량섭취는체질량지수와유의적인양의상관성을보였다고보고하였으며, Baecke 등 [35] 의연구에서는비만군의열량섭취량이비비만군에비해오히려적은것으로나타나비만인의열량섭취량에대해아직까지정확한결론을내리기는어렵다.[22] 또한 Heitmann 등 [36] 의연구등에따르면비만은생활태도, 운동부족, 영양섭취과다등다양한영향에의해복합적으로발생한다정의했으며, Szponar와 Rychlik [37] 는특정영양소의과잉, 결핍이없는균형된식사를할때심혈관계질환, 골다공증, 암등과같은만성질환의원인중의하나인비만을예방할수있다고발표했다. 결론적으로본연구는설탕과비만의관련성을보는단면적연구들에대한분석위주로그인과관계를명확히정의하는데는제한점이있다. 또한일부연구결과에있어비만군의당류섭취가오히려정상군의섭취량보다낮게나타나는등그인과관계가명확하지않다는사실을발견할수있다. 본연구에서는설탕섭취량과비만도와관련성에대한연구만수행하였으나앞으로좀더많은한국인을대상으로총설탕섭취량과더불어신체활동이나운동을포함한비만과관련된다른요인과의복합적인상관성을알아볼필요가있을것이다. 이외에도식생활의변화와더불어한국인의총설탕섭취량증가추세에따른다른질병과의관련성에대한연구들이다양하게이루어져야할것으로사료된다.

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