(손정민).fm

대한지역사회영양학회지 21(3): 284~292, 2016 http://dx.doi.org/10.5720/kjcn.2016.21.3.284 ISSN 1226-0983 (print) / 2287-1624 (on-line) RESEARCH ARTICLE 폐경비만여성의골밀도와골대사지표및식사의질상관성조사 정연아 1)2) 김미성 2) 신새론 3) 한아름 3) 서검석 4) 손정민 2) 1) 원광대학교병원영양팀, 2) 원광대학교식품영양학과, 3) 원광대학교병원가정의학과, 4) 원광대학교의과대학내과학교실, 소화기질환연구소 Relationship between Bone Mineral Density and Bone Metabolic Biochemical Markers and Diet Quality Index-International(DQI-I) in Postmenopausal Obese Women Yeonah Jeong 1)2), Misung Kim 2), Saeron Shin 3), Ahreum Han 3), Geomsuk Seo 4), Cheongmin Sohn 2) 1) Department of Nutrition Services, Wonkwnag University Hospital, Iksan, Korea 2) Department of Food and Nutrition, Wonkwang University, Iksan, Korea 3) Department of Family Medicine, Wonkwang University Hospital, Iksan, Korea 4) Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, Iksan, Korea Corresponding author Cheongmin Sohn Department of Food and Nutrition, Wonkwang University, 460 Iksandae-ro, Iksan, Jeonbuk 54538, Korea Tel: (063) 850-6656 Fax: (063) 850-7301 E-mail: ccha@wku.ac.kr ORCID: 0000-0003-0529-7037 Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (project no.: NRF- 2012R1A1A3012499). Received: June 13, 2016 Revised: June 22, 2016 Accepted: June 22, 2016 ABSTRACT Objectives: This study compared the differences of postmenopausal women's bone mineral density in relation to the degree of obesity, metabolism index and dietary factors that affect bone mineral density. Methods: The subjects included in the study are 39 postmenopausal women of normal weight with body mass index less than 25 kg/m 2 and 32 postmenopausal who are obese. Anthropometry and biochemical analysis were performed and nutrient intakes and DQI-I were assessed. Results: Normal weight women were 56.03 ± 3.76 years old and obese women were 58.09 ± 5.13 years old and there was no significant difference in age between the two groups. The T-score of bone mineral density was 0.03 ± 1.06 in normal weight women and -0.60 ± 1.47 in obese women and this was significantly different between the two groups (p<0.05). Blood Leptin concentration was significantly lower in normal weight women (6.09 ± 3.37 ng/ml) compared to obese women in (9.01 ± 4.99 ng/ml) (p<0.05). The total score of diet quality index-international was 70.41±9.34 in normal weight women and 64.93 ± 7.82 in obese women (p<0.05). T-score of bone mineral density showed negative correlations with percentage of body fat (r = -0.233, p=0.05), BMI (r = -0.197, p=0.017), triglyceride (r = -0.281, p=0.020) and leptin (r = -0.308, p=0.011). The results of multiple regression analysis performed as the method of entry showed that with 22.0% of explanation power, percentage of body fat (β = -0.048, p<0.05), triglyceride (β=-0.005, p<0.05) and HDL-cholesterol (β=0.034, p<0.01), moderation of DQI-I (β=-0.231, p<0.05) affected T-score significantly. Conclusions: The results of the study showed that obese women have less bone density than those with normal weight women. In addition, the factor analysis result that affect bone mineral density showed that intake of fat is a very important factor. Therefore, postmenopausal women need to maintain normal weight and manage blood lipid levels within normal range. They also need to take various sources of protein and reduce consumption of empty calorie foods that have high calories, fat, cholesterol and sodium. Korean J Community Nutr 21(3): 284~292, 2016 KEY WORDS bone mineral density, bone metabolic markers, diet quality index-international, postmenopausal, obesity 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. 284

정연아 김미성 신새론 한아름 서검석 손정민 285 서 최근우리나라는생활수준및환경의변화와생활습관의서구화등으로인하여비만및만성질환의유병률이증가되고있다 [1]. 2014 년도국민건강영양조사의결과체질량지수 25 kg/m 2 을기준으로한중년여성의비만유병률은 50 대 29.3%, 60대 36.6%, 70대이상 37.3% 로나이가증가됨에따라서유병률이증가되었으며, 비만과관련된만성질환인고혈압, 고콜레스테롤혈증, 당뇨병등의유병률도연령의증가와함께증가되는것으로보고되고있어 [2,3], 비만과관련된만성질환의적극적인관리가요구되고있다. 비만인에서증가하는지방세포는이전까지는에너지원을축적하고대사를담당하는세포로인식되어왔으나내분비기관으로써의새로운역할에관심이모아지고있다. 간엽줄기세포로부터공통으로기원하는지방세포와조골세포는지방세포에서분비되는 adipocytokine 인렙틴과아디포넥틴에의해서로대사과정에연관되어있는것으로보고되고있다 [4,5]. 폐경후여성에있어에스트로겐감소로인하여조골세포와파골세포에영향을미쳐골교체율이빨라지고, 골흡수가골형성보다높아골손실이유발되고 [6], 2010년국민건강영양조사자료분석결과에서는우리나라 50대이상여성의골다공증유병률은 34.9%, 65세이상여성에서는 57.6% 로나타났다 [7]. 호르몬변화로인한체지방증가는골다공증의발생위험도를높이는요인으로보고되고있다 [8]. 비만과골밀도관련연구에서전통적으로비만인에서골밀도가높고오히려체중과골밀도가유의한양의상관성을나타내는것으로알려져있으나, 오히려최근연구에서는비만도가높을수록골다공증위험도가높아지고골밀도가감소된다는결과가보고되고있다. 폐경여성을대상으로한단면연구에서는골밀도와체중, 체질량지수가양의상관관계가있다고보고하였으나 [9-11], Global Longitudinal study of Osteoporosis in Women(GLOW) 의폐경여성의비만과관련하여메타분석한연구에서는비만은골절을예방하는인자가아니며, 발목과위쪽다리 (upper leg) 의골절이증가되는것으로상반된연구결과들이보고되었다 [12]. 따라서비만과골다공증과의심층연구가요구되어지는시점이다. 골대사에는성별, 영양상태, 신체활동, 내분비상태및흡연, 음주등다양한요인이관계된다. 특히영양상태와같이수정가능한요인은골량최적화를위한중요한중재요인으로작용한다. 최근식습관과질병과의관련성에대한연구에 론 서는단일영양소나몇가지의식품으로는질병및건강위험요인을설명함에제한점이있어 [13], 전체적인식사의균형이나식사의질을평가하는연구들이보고되고있다. 식사의질을평가하는 Diet Quality Index-International(DQI- I) 는영양소및식품섭취측면에서의식사의질평가이외에식사의다양성, 적정성, 절제성및균형성으로식사의질을평가하는것으로, 폐경후여성은갱년기증상의심화와삶의질저하가식사의질의저하를초래한다고알려져있어전반적인식사의질연구가필요할것으로생각된다 [14]. 따라서본연구에서는폐경여성을대상으로비만도에따른골밀도와식사의질과의관계를분석하여향후폐경이후의건강한골관련질환의예방을위한식생활교육의기초자료를제안하고자한다. 연구대상및방법 1. 조사대상및기간 전라북도소재대학병원건강증진센터에서 2013년 5월부터 12월까지건강검진을위하여병원을내원한수진자중본연구에동의한대상으로조사를실시하였다. 폐경기여성의정의는마지막월경이있은후 1년이상월경이없는자로하였으며, 설문내용및검사결과가부정확한경우를제외한폐경정상군 39명, 폐경비만군 32명총 71명을대상으로단면연구를실시하였다. 본연구는원광대학교병원임상시험심의위원회 (Institutional Review Board; IRB) 승인을받아시행하였다. 2. 신체계측, 골밀도측정 대상자의체중, 체지방률, 근육량등의신체구성성분은자동신체계측기 (Inbody Co., Korea) 을이용하여측정하였으며, 체질량지수 (Body Mass Index; BMI) 는체중 (kg)/ 신장 (m 2 ) 의공식을이용하여계산하였다. 복부둘레는줄자를이용하여장골능과늑골의하한선의중간부위를 0.1 cm 까지측정하였다. 연구대상자들의골밀도측정은골조직을통과하는초음파의감소속도를이용하여정량적초음파법으로측정하는자동골밀도측정장비 Osteo pro smart(bm Tech world wide Co., Korea) 를사용하였다. 3. 생화학적검사및골대사지표 혈액검사는대상자에게 12시간이상공복상태를유지시킨상태에서채혈하였으며, 정맥혈을취하여 3,000 rpm으로 15분간원심분리하여혈청을분리한후자동생화학분석

286 폐경비만여성의골밀도, 골대사지표, 식사의질 기 (Mindray medical INC., China) 을이용하여혈당, 중성지질, 총콜레스테롤, HDL-cholesterol, 칼슘을분석하였다. LDL-cholesterol은 Frieldewald 공식 [total cholesterol(mg/dl)-(hdl-cholesterol(mg/dl))- TG(mg/dL)/5] 으로산출하였다 (Frielde wald 등 1972). C-terminal telopeptides of Type l collagen(immunodiagnostic systems Ltd., Denmark), 오스테오칼신 (Cusabio biotech Co., China), osteoprotegerin (Biovendor, Czech Republic) 은전용 kit를이용하여 ELISA reader(molecular devices, USA) 로분석하였다. 부갑상선호르몬, 렙틴, 아디포넥틴은분석전문기관에의뢰하여분석하였다. 4. 식사조사및식사의질분석식사조사는 24시간회상법을이용하여훈련된조사원이일대일면담을통하여실시하였으며, 식품섭취량의정확한측정을위하여음식모형을이용하여목측량을추정하였다. 식이섭취량과영양소분석은영양평가프로그램인 Computer Aided Nutritional Analysis Program 4.0 을이용하였다. 식사의질평가는 Diet Quality Index-International (DQI-I) 를사용하였으며, 식사의질지수는적정성 (adequacy, 40점 ), 절제성 (moderation, 30점 ), 다양성 (variety, 20점 ), 균형성 (overall balance, 10점 ) 의총 4가지항목으로구성되며, 총점은 4개의항목을합하여 0-100점으로평가하였다. 본연구의자료는 2013년조사된자료이나, DQI-I의평가도구의기준은 2015년새로이개정된한국인영양소섭취기준의 50세이상성인여성자료와한국지질 동맥경화학회의이상지질혈증치료지침에준하여설정하였다. 5. 통계처리본연구를통한모든자료처리는 SPSS(Statistical Package for Social Science) 21.0 을이용하여분석하였다. 수집된자료는평균 ± 표준편차로표시하였다. 체질량지수를기준으로정상군과비만군의차이분석은 t-test로검정하였다. 골밀도와생화학지표및식사의질과의상관성은 pearson's correlation coefficients로분석하였다. 골밀도에미치는변인의영향력을알아보기위해나이, 체중, 신장, 식이보충제복용여부, 호르몬제복용여부를보정한후부분상관계수를구하였다. 골밀도에대한영향력을파악하기위해다중회귀분석 (Multiple regression analy sis) 을실시하였으며, 모든통계적유의수준은 p<0.05 를기준으로하였다. 결 1. 조사대상자의신체계측치 본연구대상자의신체계측결과는 Table 1과같다. 대상자의나이는정상군 56.03세, 비만군 58.09세로유의한차이가없었다. 체질량지수는정상군 22.31 kg/m 2, 비만군 26.46 kg/m 2 이며, 허리엉덩이둘레비 (Waist-hip ratio) 는각각 0.86, 0.91로정상군보다비만군에서유의적으로높았다 (p<0.05). 체구성성분은체지방률, 체지방량에서모두비만군에서높게나타났다 (p<0.05). 2. 조사대상자의생화학지표 일반혈액검사지표와골대사지표의결과는 Table 2와같다. 일반혈액검사결과 HDL- 콜레스테롤은정상군 56.38 ±12.56 mg/dl, 비만군 54.65±13.61 mg/dl(p<0.05) 로조사되었으며, 혈당과부갑상선호르몬은비만군에서높은경향이나타났으나통계적인유의성은나타나지않았다. 렙틴은정상군 6.09±3.37 ng/ml, 비만군 9.01±4.99 ng/ml(p<0.05) 로조사되었다. 골형성표지자인오스테오칼신은정상군 15.33±8.00 ng/ml, 비만군 10.97±4.58 ng/ml(p<0.05), 골흡수표지자인 C-terminal telopeptides of Type l collagen(ctx) 는정상군 0.36±0.19 ng/ml, 비만군 0.53±0.35 ng/ml(p<0.05) 로조사되었다. Osteoprotegerin(OPG) 은정상군 2.95±2.39 pmol/l, 비만군 7.71±2.79 pmol/l(p<0.05) 로비만군에서높게나타났다. Table 1. Comparison of anthropometric measurements Anthropometric Normal (n=39) Obese (n=32) t Age (years) 56.03 ± 3.76 1) 58.09 ± 5.13 6 1.956 Height (cm) 157.74 ± 5.82 155.40 ± 5.81 6 1.684 Weight (kg) 55.65 ± 6.04 64.22 ± 6.25 6 5.855* Waist circumference (cm) 74.41 ± 5.23 81.78 ± 6.06 6 5.494* Body mass index (kg/m 2 ) 22.31 ± 1.58 26.46 ± 1.04 13.206* Body fat (%) 28.35 ± 4.01 35.55 ± 6.41 6 5.775* Fat mass (kg) 15.87 ± 3.31 22.31 ± 3.73 6 7.693* Lean body mass (kg) 39.78 ± 4.02 41.76 ± 3.91 6 2.092* Waist-hip ratio 0.86 ± 0.03 0.91 ± 0.04 6 5.038* *: p < 0.05 Significantly different between postmenopausal normal women and obese women by Student t-test 과

정연아 김미성 신새론 한아름 서검석 손정민 287 Table 2. Comparison of biochemical indices of subjects Biochemical Normal (n=39) Obese (n=32) t Glucose (mg/dl) 89.46 ± 10.35 1) 94.18 ± 13.60 0.032 Triglyceride (mg/dl) 113.53 ± 61.84 118.40 ± 61.05 0.332 Total cholesterol (mg/dl) 212.94 ± 35.11 210.71 ± 35.34 0.265 HDL-cholesterol (mg/dl) 56.38 ± 12.56 54.65 ± 13.61 0.555* LDL-cholesterol (mg/dl) 133.85 ± 32.14 132.38 ± 33.44 0.412 Parathyroid hormon (pg/ml) 29.43 ± 68.60 31.74 ± 68.29 1.144 Adiponectin (μg/ml) 11.47 ± 67.29 11.03 ± 64.32 0.304 Leptin (ng/ml) 6.09 ± 63.37 9.01 ± 64.99 2.919* Calcium (mg/dl) 9.47 ± 60.37 9.51 ± 60.41 0.434 Osteocalcin (ng/ml) 15.33 ± 68.00 10.97 ± 64.586 2.735* CTx (ng/ml) 2) 0.36 ± 60.19 0.53 ± 60.35 2.451* Osteoprotegerin (pmol/l) 2.95 ± 62.39 7.71 ± 62.79 7.711* 2) CTx: C-terminal telopeptides of Type l collagen *: p < 0.05 Significantly different between postmenopausal normal women and obese women by Student t-test Table 3. Comparison of bone mineral density of subjects Variable Normal (n=39) Obese (n=32) t T-score 0.03 ± 1.06 1) 0.60 ± 1.47 2.116* Z-score 1.69 ± 1.03 1.23 ± 1.52 1.514 Osteoporosis index 50.04 ± 4.69 46.63 ± 7.38 2.360* Speed of sound 1,363.36 ± 9.33 1,357.60 ± 9.83 2.523* *: p < 0.05 Significantly different between postmenopausal normal women and obese women by Student t-test 2. 조사대상자의골밀도대상자의골밀도측정결과는 Table 3에제시하였다. T- score는정상군에서 0.03±1.06, 비만군에서 -0.60±1.47 으로정상군에서높게나타났다 (p<0.05). Osteoporosis Index(OI) 는정상군 50.04±4.69, 비만군 46.63±7.38 (p<0.05), 골을통과하는초음파속도인 Speed of Sounds (SOS) 는정상군 1363.36±9.33, 비만군 1357.60±9.83 으로정상군보다비만군에서유의적으로낮았다 (p<0.05). 3. 조사대상자의영양소섭취상태와식사의질대상자의영양소섭취량을 1,000 kcal 대비하여분석한결과는 Table 4와같다. 총영양소섭취량은정상군과비만군간의유의한차이를보이지않았으나, 니아신 (p<0.05) 에서유의한차이를보였다. 대상자의식사의질평가인 DQI-I 분석결과는 Table 5 와같다. 다양성항목에서정상군은 15.35±3.32점, 비만군은 13.78±3.36 점으로조사되었으며 (p<0.05), 다양성의요소중단백질식품의급원별섭취정도의항목에서는정상군이 3.28±1.73점으로비만군의 2.43±1.83점보다점수가높았다 (p<0.05). 절제성의총점수는정상군은 22.69± 4.00점, 비만군은 20.62±4.55 점으로조사되었으며 (p< 0.05), DQI-I 총합계점수는정상군 70.41±9.34점, 비만군 64.93±7.82 점으로정상군에서유의적으로높게나타났다 (p<0.01). 4. 골밀도와신체계측및생화학지표와의상관관계골밀도 (T-score) 와신체계측및생화학검사와상관성 Table 4. Nutrient intakes compared to 1,000 kcal energy intake Variable Normal (n=39) Obese (n=32) t Carbohydrate (g) 128.38 ± 15,73.16 1) 150.70 ± 15,80.44 1.223 Protein (g) 28.45 ± 15,12.77 34.58 ± 15,27.32 1.245 Fat (g) 16.28 ± 155,8.78 15.96 ± 155,9.74 0.149 Fiber (g) 12.84 ± 155,7.13 14.30 ± 155,7.64 0.830 Calcium (mg) 260.08 ± 1,154.10 414.95 ± 1,802.84 1.080 Na (mg) 2,082.44 ± 1,575.38 2,472.17 ± 1,398.08 1.091 Vitamin A (ugrae) 516.10 ± 1,370.62 699.91 ± 1,563.53 1.649 Vitamin B 1 (mg) 0.85 ± 155,2.75 0.77 ± 155,1.55 1.707 Niacin (mgne) 8.62 ± 155,1.02 8.98 ± 155,1.11 0.821* Vitamin C (mg) 93.60 ± 1,225.81 93.08 ± 1,204.45 0.685 Vitamin D (ug) 1.39 ± 155,2.18 2.16 ± 155,4.35 0.964 Vitamin E (mg) 6.41 ± 155,3.48 6.91 ± 155,3.22 0.628 Vitamin K (ug) 122.21 ± 1,106.57 171.26 ± 1,159.73 1.545 *: p < 0.05 Significantly different between postmenopausal normal women and obese women by Student t-test

288 폐경비만여성의골밀도, 골대사지표, 식사의질 Table 5. Diet Quality Index-International (DQI-I) Variable Score ranges (points) Normal (n=39) Obese (n=32) t Variety 0 20 15.35 ± 3.32 1) 13.78 ± 3.36 1.977* Overall food group variety 0 15 12.07 ± 2.43 11.34 ± 2.82 1.175 Within-group variety for protein source 0 55 3.28 ± 1.73 2.43 ± 1.83 1.993* Adequacy 0 20 31.05 ± 6.41 29.62 ± 6.52 0.925 Vegetable group 0 55 3.82 ± 1.35 3.34 ± 1.45 1.429 Fruit group 0 55 2.87 ± 2.24 3.12 ± 2.25 0.471 Grain group 0 55 3.71 ± 1.41 3.75 ± 1.10 0.105 Fiber 0 55 4.38 ± 1.13 4.18 ± 1.22 0.700 Protein 0 55 4.84 ± 0.53 4.81 ± 0.59 0.250 Iron 0 55 4.79 ± 0.76 4.62 ± 0.94 0.838 Calcium 0 55 2.84 ± 1.32 2.37 ± 1.38 1.458 Vitamin C 0 55 3.76 ± 1.62 3.50 ± 1.62 0.693 Moderation 0 40 22.69 ± 4.00 20.62 ± 4.55 2.035* Total fat 0 56 5.38 ± 1.40 5.15 ± 1.74 0.611 Saturated fat 0 56 5.53 ± 1.40 5.34 ± 1.65 0.525 Cholesterol 0 5 6 5.53 ± 1.46 4.81 ± 2.37 1.509 Sodium 0 56 0.76 ± 1.78 0.46 ± 1.34 0.787 Empty calorie foods 0 56 5.53 ± 1.09 4.96 ± 1.63 1.684 Overall balance 0 10 1.48 ± 1.93 1.00 ± 1.75 1.100 Macronutrient ratio (carbohydrate : protein : fat) 0 56 0.71 ± 1.41 0.37 ± 1.07 1.163 Fatty acid ratio (PUFA : MUFA : SFA) 2) 0 54 0.71 ± 1.25 0.43 ± 0.98 1.056 Total DQI-I Score 100 70.41 ± 9.34 64.93 ± 7.82 2.685** 2) PUFA: Polyunsaturated Fatty Acid, MUFA: Monounsaturated Fatty Acid, SFA: Saturated Fatty Acid *: p < 0.05, **: p < 0.01 Significantly different between postmenopausal normal women and obese women by Student t-test 분석결과는 Table 6과같다. T-score 는체질량지수 (r= -0.197, p<0.05), 중성지방 (r=-0.281, p<0.05), 렙틴 (r=-0.308, p<0.05) 과는음의상관성이나타났으며, HDL-콜레스테롤 (r=0.347, p<0.01) 과는양의상관관계를나타내었다. 5. 골밀도와식사의질과의상관관계골밀도 (T-score) 와식사의질과의상관분석은 Table 7 과같다. 골밀도 (T-score) 와상관성이나타난식사의질항목으로는단백질급원별다양성 (r=0.277, p<0.05), 총균형성 (r=0.276, p<0.05), 지방산 (PUFA : MUFA : SFA) 의섭취비율 (r=0.258, p<0.05) 과는양의상관성이나타났으며, 총절제성 (r=-0.305, p<0.05) 과절제성의항목중총지방산 (r=-0.239, p<0.05) 과는음의상관성이나타났다. 6. 골밀도에영향을미치는요인분석골밀도에영향을미치는요인을찾기위해다중회귀분석을실시한결과는 Table 8과같다. 설명력은 22.0% 로체지방률 (β=-0.048, p<0.05), 중성지방 (β=-0.005, p<0.05), Table 6. Correlation of bone mineral density (T-score) with related anthropometric and biochemical index Variable r p % Body fat 0.233 0.050 Body mass index 0.197 0.017 Triglyceride 0.281 0.020 HDL-cholesterol 0.347 0.004 Leptin 0.308 0.011 Adiponectin 0.160 0.194 Table 7. Correlation of bone mineral density (T-score) with related Diet Quality Index-International Variable r p Within-group variety for protein source 0.277 0.019 Moderation 0.305 0.010 Total fat 0.239 0.045 Overall balance 0.276 0.020 Fatty acid ratio (PUFA : MUFA : SFA) 0.258 0.030 식사의질중총절제성항목은 (β=-0.231, p< 0.05) 음의상관성이나타났고, HDL- 콜레스테롤은 (β=0.034, p<0.01) 양의상관성이나타났다.

정연아 김미성 신새론 한아름 서검석 손정민 289 Table 8. Multiple regression analysis on bone mineral density (Tscore) by anthropometric and biochemical index and Diet Quality Index-International Variable r 2 β coefficient p % Body fat 0.048 0.049 Triglyceride 0.005 0.039 0.220 DQI-I(Moderation) 0.231 0.040 HDL-cholesterol 0.034 0.003 Adjusted for age, weight, height, dietary supplement, hormonal replacement therapy 고 본연구는폐경후여성을대상으로 BMI 기준 25 kg/m 2 미만의정상군과 25 kg/m 2 이상의비만군으로나누어골밀도차이와골대사지표및식사의질과의관련성을알아보고자수행하였으며, 도출된연구결과는폐경후여성의골다공증및골관련질환예방을위한영양교육의기초자료를제시하고자한다. 골밀도에영향을미치는요인들은나이, 폐경, 호르몬, 체중, 체질량지수, 지방량, 근육량, 영양소및식이섭취상태등이관련요인으로보고되고있다. 그중폐경은에스트로겐의감소로골흡수가증가되고, 골형성기능이감소되어골질량이줄어든다. 또한, 폐경으로인하여체성분의변화로체내지방량이증가된다 [15-17]. 최근골관련연구에서는체내지방량의증가가골밀도에긍정적인영향과부정적인영향을주는상반된연구들이보고되고있다. 그중골밀도에긍정적인영향을주는연구로는베트남폐경여성을대상으로진행된단면연구로연령이증가됨에따라체지방률이증가되고, 지방량이증가할수록요추, 대퇴경부등의골밀도가증가되는것으로조사되었다 [18]. 일본폐경여성을대상으로진행된연구에서도총지방량은팔, 척추, 골반, 다리등의골밀도와양의상관성이나타났으며 [19], 폐경여성을대상으로진행한뉴질랜드의단면연구에서도지방량은골밀도와양의상관성이나타난것으로보고하였다 [20]. 반면중국폐경여성을대상으로시행된단면연구에서지방량이많을수록골미네랄함량 (bone mineral content) 이낮은것으로조사되었으며, 체지방률을 4군으로구분하여골다공증발생위험도분석결과체지방률이높을수록골다공증의발생위험도가높은것으로조사되었다 [21]. 국내의폐경전 후여성을대상으로분석한결과에서도나이가증가됨에따라골다공증발생위험도가증가하였고, 체질량지수를 4분위로나누어 4분위가가장높음으로나타낼때체질량지수가 1 kg/m 2 증가할수록요골 찰 (1.07 배 ), 경골 (1.09배 ) 의골다공증위험도가증가하며, 허리둘레 1 cm가증가할수록요골 (1.04 배 ), 경골 (1.05배 ) 의골다공증발생위험도가증가하는것으로나타났다 [22]. 또한, 국내 30-60대여성을대상으로골밀도와관련요인을분석한연구에서는골밀도와체질량지수가음의상관성이나타났다 [23]. 본연구에서는폐경비만여성의골밀도가낮게조사되었으며, 골밀도와체지방률, 체질량지수가음의상관성이나타나중국인을대상으로시행된연구와국내의여성을대상으로한연구의결과와일치하였다. 이러한현상의관련기전으로는지방세포와조골세포가모두공통적인간엽줄기세포로부터기원함에있어지방세포와조골세포가대사기전에서로연관되어있음을나타내고있다. 지방세포에서분비되는아디포카인중렙틴은그수용체가연골세포와조골세포에서발현되며, 렙틴의분비가결핍된 ob/ob 마우스와렙틴의수용체가결핍된 db/db 마우스에서골밀도가높게나타났으며, ob/ob 마우스와 wild-type 마우스의뇌실내에렙틴을투여하면골흡수가감소되어골량이소실되는것으로나타났다 [24]. OPG는파골세포를형성하는 receptor activator of nuclear factor κ-b ligand(rankl) 에길항하는유인수용체로골재형성에관여하는골표지자이다. 렙틴은 OPG의 mrna를증가시켜, RANKL과 receptor activator of NF-κB(RANK) 의결합을방해하여파골세포의분화와성숙을억제하는것으로보고되고있다 [25,26]. 본연구대상자의렙틴농도는정상군 6.09±3.37 ng/ml, 비만군 9.01±4.99 ng/ml로골밀도가낮은비만군에서렙틴의농도가높은것으로조사되어선행연구결과와일치하는결과로나타났다. 19세에서 50세성인여성을대상으로비만도에따라렙틴을분석한연구에서도정상군에비해비만군에서렙틴의농도가높게조사되었다 [27]. 본연구에서도 OPG가정상군 2.95± 2.39 pmol/l, 비만군 7.71±2.79 pmol/l로비만군에서높게나타났다. 이는앞서언급한렙틴과 OPG 관련선행연구의결과와같이렙틴이 OPG의생성을증가시켜비만군에서 OPG의농도가높게나타났으며, 이는골대사에영향을주어비만군에서골밀도가낮게나타난것으로사료된다. 생화학적골형성표지자인오스테오칼신은국내의성인여성을대상한 Yeo의연구에서는연령이증가할수록오스테오칼신의농도가증가되는것으로조사되었으며, 폐경기인 40대에서 50대사이에서오스테오칼신의농도가상승되는것으로나타났다 [28]. 중국폐경여성을대상으로시행된연구에서는복부비만을기준으로정상군에비해비만군의오스테오칼신의농도가낮게조사되었다 [29]. 또한한국폐경여성을대상으로대사증후군과비대사증후군을구분하여분

290 폐경비만여성의골밀도, 골대사지표, 식사의질 석한연구에서는폐경대사증후군에서오스테오칼신의농도가낮은것으로조사되었다 [30]. 복부비만과대사증후군기준으로폐경여성의오스테오칼신의농도를분석한선행연구결과는비만군에있어서오스테오칼신의농도가낮게나타난본연구결과와동일하게나타났다. 개인의영양상태를파악하기위해서는개인의영양소섭취의과잉과부족등의평가와함께전반적인식사의질의평가도필요하다. 본연구의식사의질평가결과비만군의식사의질이정상군에비해낮은것으로조사되었다. 중국인여성을대상으로식사의질 (DQI-I) 과골절발생위험도를분석한연구에서는식사의질의총점을 4분위로구분하여총식사의질의점수가높은 4군의고관절골절 (hip fractures) 의발생위험도가낮은것으로보고하였다 [31]. 본연구에서는 DQI-I 를이용하여정상군과비만군의식사의질을평가하여골밀도에영향을미치는요인이무엇인지분석한결과골밀도와식사의질의다양한단백질섭취, 균형성과지방산섭취가양의상관성이나타났으며, 절제성항목중총지방산, 절제성총합 ( 총지방산, 포화지방산, 콜레스테롤, 나트륨및 empty calorie foods 섭취 ) 은음의상관성이나타났다. 이에, 칼슘섭취뿐만아니라향후폐경여성의식사계획시동물성과식물성단백질을고려하며, 지방산섭취시그비율을맞추고, 과도한포화지방, 콜레스테롤, 나트륨등의섭취와첨가당의함량이높은 empty calorie foods 섭취를지양하는식이자료가필요한것으로사료된다. 본연구의골밀도에영향을미치는식사의요인과생화학적지표분석결과골밀도와혈중중성지방, 식사의질에서절제성 ( 지방관련항목 ) 이음의상관성을나타냈으며, HDL- 콜레스테롤이증가할수록골밀도가증가되는요인으로조사되었다. 본연구와유사한연구결과는일본폐경여성을대상으로한연구로요골과대퇴경부및요추의골밀도와 HDL- 콜레스테롤과양의상관성이나타났으며, 낮은중성지방농도는폐경여성의척추골절을예방하는요인으로제시된바있다 [32]. 한국인폐경여성을대상으로시행된연구에서도대퇴골전자부 (Trochanter) 골밀도와총콜레스테롤과 LDL- 콜레스테롤이음의상관관계를보인다고하였다 [33]. 내인성콜레스테롤이파골세포의형성과생존에관여하며 [34], 산화된지질은생체내에서조골세포의활성과골밀도형성을억제하는것으로추측하였다 [35]. 이는지질과콜레스테롤이골대사에관여하는것으로본연구의결과에서혈중지질과골밀도와의관련성이나타난것을설명할수있었다. 또한본연구에서골밀도는혈중지표이외의식사의질의평가의절제성항목중총지방산과절제성총합 ( 총지방산, 포화지방산, 콜레스테롤, 나트륨및 empty calorie foods 섭취 ) 과관련성이도출되었다. 이에향후폐경기여성의건강한골상태유지를위해서는골형성관련영양소의적절한섭취와더불어, 한국인영양소섭취기준에서제시하는적절한지방산의섭취비율유지와과다한지방의섭취를제한하는내용의식생활교육이이루어져야할것으로생각되어진다. 요약및결론 본연구에서는폐경후여성을대상으로골밀도와식사의질과의관련성을알아보고자하였다. 체질량지수에따라 25 kg/m 2 미만인정상군 39명과 25 kg/m 2 이상의비만군 32명, 총 71명을대상으로단면연구를시행하였다. 1. 대상자의평균나이는정상군 56.03±3.76세, 비만군 58.09±5.13세였으며유의한차이를보이지않았다. 체구성성분은두그룹간에체지방률, 체지방량, 제지방량, 복부지방률이모두유의하게비만군에서높게나타났다 (p<0.05). 2. 렙틴은정상군은 6.09±3.37 ng/ml, 비만군은 9.01 ±4.99 ng/ml 이었다 (p<0.05). 오스테오칼신은정상군에서 15.33±8.00 ng/ml, 비만군에서 10.97±4.58 ng/ml 이며, Osteoprotegerin의평균농도는정상군 2.95± 2.39 pmol/l, 비만군 7.71±2.79 pmol/l로유의한차이를보였다 (p<0.05). 3. 골밀도측정결과 T-score는정상군에서 0.03±1.06 이고비만군에서 -0.60±1.47로조사되었다 (p<0.05). Osteoporosis index는정상군 50.04±4.69, 비만군 46.63±7.38, Speed of sound는각각 1,363.36±9.33, 1,357.60±9.83으로정상군보다비만군에서유의적으로낮게나타났다 (p<0.05). 4. 식사의질평가인 DQI-I 분석결과다양성항목에서정상군은 15.35±3.32점, 비만군은 13.78±3.36점으로조사되었으며, 다양성 (variety) 의요소중단백질식품의급원별섭취정도의항목에서는정상군이 3.28±1.73 점으로비만군의 2.43±1.83 점보다점수가높았다 (p<0.05). 절제성 (moderation) 의총점수는정상군은 22.69±4.00점, 비만군은 20.62±4.55 점으로조사되었으며 (p<0.05), DQI-I 총합계점수는정상군 70.41±9.34점, 비만군 64.93± 7.82점으로정상군에서유의적으로높게나타났다 (p<0.05). 5. 골밀도 (T-score) 와신체계측및생화학검사와의상관성분석결과 T-score 는체질량지수 (r=-0.197, p< 0.05), 중성지방 (r=-0.281, p<0.05), 렙틴 (r=-0.308, p<0.05) 과는음의상관성이나타났으며, HDL- 콜레스테롤 (r=0.347, p<0.01) 과는양의상관관계를나타내었다.

정연아 김미성 신새론 한아름 서검석 손정민 291 6. 골밀도 (T-score) 와단백질급원별다양성항목 (r=0.277, p<0.05), 총균형성항목 (r=0.276, p<0.05), 지방산 (PUFA : MUFA : SFA) 의섭취비율항목 (r=0.258, p<0.05) 과는양의상관성이나타났으며, 총절제성항목 (r=-0.305, p<0.05), 총지방항목 (r=-0.239, p<0.05) 과는음의상관성이나타났다. 7. 다중회귀분석을통하여골밀도 (T-score) 와의관련요인에대한영향력을파악한결과, 설명력은 22.0% 로체지방률 (β=-0.048, p<0.05), 중성지방 (β=-0.005, p<0.05), 총절제성항목 (β=-0.231, p<0.05) 은음의상관성이나타났고, HDL-콜레스테롤은 (β=0.034, p<0.01) 은양의상관성이나타났다. 따라서폐경이후여성의정상수준의골밀도유지및골다공증예방을한국인영양소섭취기준에부합되는지방산섭취와비만예방을위한체중조절이필요하며, 정상수준의혈중중성지방과 HDL- 콜레스테롤을유지할수있는혈중지질수준의바람직한관리를위한식사조절이필요할것으로사료된다. References 1. Baik IK, Shin C. Association of daily sleep duration with obesity, macronutrient intake, and physical activity. Korean J Community Nutr 2011; 16(3): 315-323. 2. Ministry of Health and Welfare and Korea Centers for Disease Control and Prevention. Korea Health Statistics 2014: Korea National Health and Nutrition Examination Survey [KNHANES VI-2] [internet]. 2015 [cited 2016 May 01]. 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