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Korean J Fam Pract. 2014;4:284-292 한국성인에서흡연과대사증후군의연관성연구 : 국민건강영양조사자료를이용하여 Original Article 강지훈, 송윤미 *, 김효은, 박용순 1, 이종현 성균관대학교의과대학삼성서울병원가정의학과, 1 한림대학교의과대학성심병원가정의학과 Relationship between Smoking and Metabolic Syndrome in Korean Adults: Korean National Health and Nutrition Examination Survey Ji-Hun Kang, Yun-Mi Song*, Hyo-Eun Kim, Yong-Soon Park 1, Jong-Hyun Lee Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; 1 Department of Family Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea Background: This study aimed to evaluate an association between smoking and metabolic syndrome (MetS) in Korean population. Methods: Study subjects were 18,818 participants ( 19 years) from the Korean National Health and Nutrition Examination Surveys between 2007 and 2010. Smoking status was assessed using self-administered questionnaire and components of MetS were measured. Presence of Mets was ascertained according to revised National Cholesterol Education Program/Adult Treatment Panel III criteria. Logistic regression analysis was done to evaluate an association between smoking status and MetS with an adjustment for age, education, physical activity, alcohol intake, total fat intake, total fiber intake, and body mass index. Results: Compared with never-, Mets was more prevalent among both current s (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.20 to 1.95) and past s (OR, 1.31; 95% CI, 1.04 to 1.65) for men, while the prevalence of MetS was higher among only current s (OR, 1.72; 95% CI, 1.23 to 2.42) for women. For components of MetS, male current s had an increased risk for abdominal obesity (OR, 1.65; 95% CI, 1.23 to 2.22), high triglyceride (OR, 1.87; 95% CI, 1.56 to 2.25), and low high density lipoprotein cholesterol (OR, 1.36; 95% CI, 1.12 to 1.66) and a decreased risk for high blood pressure (OR, 0.81; 95% CI, 0.67 to 0.97) compared with never-s. Female current s showed increased risk for abdominal obesity (OR, 1.60; 95% CI, 1.13 to 2.26), high triglyceride (OR, 1.96; 95% CI, 1.48 to 2.58), and low high density lipoprotein cholesterol (OR, 1.39; 95% CI, 1.05 to 1.84). Conclusion: Smoking was associated with increased risk for Mets and most metabolic components in Korean adults. Keywords: Smoking; Metabolic Syndrome X; Koreans Received: August 22, 2013, Accepted: July 21, 2014 *Corresponding Author: Yun-Mi Song Tel: 02-3410-2442, Fax: 02-3410-0388 E-mail: yunmi.song@samsung.com Korean Journal of Family Practice Copyright 2014 by The Korean Academy of Family Medicine 서론 대사증후군은인슐린저항성을매개하여복부비만, 이상지질혈증 (dyslipidemia), 높은혈압, 공복포도당장애가한개인에서동시에발생하는질환으로 1) 심혈관질환, 2형당뇨병은물론암발생위험을증가시킨다. 2-5) 대사증후군발생위험을높이는요인으로는유전요인, 낮은교육수준, 적은신체활동, 284 Vol. 4, No. 4 Dec 2014 Korean J Fam Pract

강지훈외 : 흡연과대사증후군 서구식식생활패턴등이거론되었다. 6-8) 그중흡연은그자체로심혈관질환과 2형당뇨병의독립적인위험요인으로알려져있으나, 9-11) 인슐린저항성과대사증후군의위험을증가시키는지에대해서는일관된연구결과가보고되지는않았다. 몇몇단면연구에서흡연은대사증후군과유의한연관성을보였고 12-14) 흡연군에서대사증후군의구성요소인복부비만, 높은혈압, 공복포도당장애, 및이상지질혈증의유병률이비흡연군에비해더높았다. 13) 또한 1989년에수행된한메타연구는흡연이중성지방을높이고고밀도지질단백 (high density lipoprotein, HDL) 콜레스테롤을감소시킨다는결과를보고하여흡연이인슐린저항및대사증후군과연관성이있음을시사하였다. 15) 그러나다른연구에서는흡연은이상지질혈증발생위험을높이지만인슐린저항성의다른지표인복부비만, 공복포도당장애및높은혈압위험은증가시키지않고인슐린저항성의지표로사용되는 homeostatic model assessment for insulin resistance이흡연군에서비흡연군에비해유의하게낮음을보여주었다. 16) 이외에네덜란드젊은성인을대상으로시행한한코호트연구에서도흡연양을감량하면복부비만도와혈압치가증가함을관찰하였다. 17) 한편한국인에서수행된연구들은대부분흡연이대사증후군위험도증가와연관성이있음을보고하였다. 13,18) Oh 등 13) 은하루 30개피이상의흡연을하는성인에서비흡연자와비교해서대사증후군의유병률이 1.7배이상높음을관찰하였다. Hong 등 18) 은남성흡연자의비흡연자에대한대사증후군유병비를 2.37로보고하였다. 그러나 Oh 등 13) 의연구는 1998년국민건강영양조사자료를이용하여연구대상자의대표성면에서는강점이있는연구였지만흡연과대사증후군의연관성이성별로어떻게다른가는평가하지못했다. Hong 등 18) 의연구는성인남성만을대상으로한연구이며한건강검진기관의수진자를대상으로한연구로연구결과의일반화가어려울수있으며, 여성에서의흡연과대사증후군간의연관성은평가되지못했다는제한점이있다. 따라서본연구자들은최근인 2007 2010년에조사된국민건강영양조사자료를이용하여여성과남성각각에서흡연과대사증후군의연관성을평가하였다. 또한흡연과대사증후군의각요소의연관성도평가하였다. 방법 1. 연구대상자선정과연구변수측정본연구대상자는 2007 2010년에수행된국민건강영양조사 19) 4기의 3개년자료와 5기인 2010년조사참여에동의한 19 세이상성인 25,146명중분석에필요한변수자료가불충분한 6,328명이제외된 18,818명이었다. 제외된 6,328명에는흡연설문에미응답자 1,642명과허리둘레, 혈압, 교육수준, 신체활동, 지방섭취, 조섬유섭취그리고체질량지수 (body mass index) 에대한정보가없거나 8시간이상공복상태에서측정한혈당, HDL 콜레스테롤, 중성지방에대한자료가없는 4,686 명이포함되었다. 건강설문의사회인구학적변수중성별, 나이는자기기입식설문지를통해조사하였으며 19세이상을성인으로구분하였다. 교육수준은구두질문을통한면접조사를통해고등학교졸업이상과미만으로구분하였다. 건강관련행태로는흡연, 음주, 신체활동을자기기입식설문조사하였다. 흡연행태에다른분류는현재흡연하지않으면서평생흡연량이 100개피이하인경우비흡연자, 현재흡연하지않으면서평생흡연량이 100개피이상인경우과거흡연자, 현재흡연중이며평생흡연량이 100개피이상인경우는현재흡연자로분류하였다. 음주행태는한번의술자리에서남자소주 7잔이상 ( 알코올 60 g), 여자 5잔 ( 알코올 40 g) 이상마시는것을고위험음주로정의하였는데, 본연구에서는연구대상자를고위험음주빈도가일주일에 1회이상인군과미만인군으로구분하였다. 20) 규칙적신체활동은중등도이상의신체활동또는격렬한신체활동을 1회 20분이상일주일에 3 일이상실천하는경우로정의하였다. 1일지방섭취량 (g) 과조섬유섭취량 (g) 은 24시간회상조사를통해서각개인이하루동안섭취한모든음식및식품으로부터 1일영양소섭취량의합을산출하였다. 21) 신체계측은가벼운옷을입고신발을벗은상태에서훈련된검사자가키 (kg) 와체중 (m) 을측정하였고, 체중을키의제곱으로나누어체질량지수 (kg/m 2 ) 를계산하였다. 허리둘레는측정자가대상자의측면에서최하위늑골하부와골반장골능과의중간부위에서피부를누르지않도록줄자를사용하여정상호기상태에서소수점한자리까지측정하였다. 혈압은 15분이상휴식을취한상태에서잘훈련된검사자에의해 5분간격으로 3회측정하였고두번째와세번째측정된혈압의평균을사용하였다. 혈액검사는 8시간금식을한참여자의혈당, HDL 콜레스테롤, 중성지방치를측정하였다. 22) 본연구는성균관대학교의과대학삼성서울병원기관윤리심사위원회의승인을받았다 (IRB file No. SMC 2013-04-083). 2. 대사증후군의정의대사증후군은 National Cholesterol Education Program/Adult Treatment Panel III 정의에따라복부비만, 공복포도당장애, 고 가정의학 Vol. 4, No. 4 Dec 2014 285

Ji-Hun Kang, et al: Smoking and Metabolic Syndrome 중성지방혈증, 저HDL 콜레스테롤혈증, 높은혈압다섯가지구성요소중 3가지이상을만족하는경우로정의하였다. 1) 복부비만은허리둘레로평가하며남자 90 cm 이상, 여자 85 cm 이상이면 23) 복부비만이있다고판단하였다. 공복포도당장애는공복혈당 100 mg/dl 이상이거나경구혈당강하제또는인슐린을사용하는경우로정의하였다. 고중성지방혈증은중성지방치가 150 mg/dl 이상이거나지질강하제약물치료를하는경우로정의하였다. 저HDL 콜레스테롤은남자 40 mg/dl 미만, 여자 50 mg/dl 미만이거나지질강하제약물치료를하는경우로정의하였다. 높은혈압은수축기혈압치가 130 mm Hg 이상이거나이완기혈압치가 85 mm Hg 이상이거나혈압약을복용하는경우로정의하였다. 3. 통계분석국민건강영양조사는복합표본설계로구성된자료이므로분산추정층, 층화변수및표본가중치를부여하여분석하였다. 흡연군별로연령차이가현저하여연구대상자의특성중연속변수로측정된특성 ( 허리둘레, 체질량지수, 혈압, 중성지방, HDL 콜레스테롤, 1일지방섭취량 1일조섬유섭취량 ) 은공분산분석을이용하여연령을고려한비교를했고, 범주변수로측정된특성 ( 교육수준, 신체활동및고위험음주빈도 ) 은연령표준화를시행한후에카이제곱검정으로비교하였다. 연구대상자의대사적특성은연령을보정하거나표준화하여비교하였다. 흡연상태와대사증후군간의연관성은다변량로지스틱회귀분석을사용하여평가하였다. 세개의분석모형을이용하여본연구에서측정된공변수들을단계적으로분석에투입하여공변수들이흡연과대사증후군의연관성에미치는영향을평가하였다. 분석모형 1에서는연령을보정하고, 분석모형 2에서는교육수준, 고위험음주여부, 신체활동, 1일지방및조섬유섭취량을보정하였다. 분석모형 3에서는추가로체질량지수를보정하였다. 분석에투입한공변수는본연구대상자에서흡연상태와연관이있었거나기존연구에서대사증후군과연관성이있다고보고된변수를기준으로선정하였다. 6,8) 흡연과대사증후군구성요소의연관성은연령, 교육수준, 고위험음주여부, 신체활동, 1일지방및조섬유섭취량, 체질량지수를공변수로보정한다변량로지스틱회귀분석을이용하여평가하였다. 모든분석은통계학적유의수준을 P값 <0.05 으로설정하여양방향검정을하였으며, IBM SPSS ver. 21.0 (IBM Co., Armonk, NY, USA) 을이용하여분석하였다. 결과 본연구대상자들의대사증후군유병률은 26.6% (n=5,004) 으로남성에서는 28.7% (n=2,170), 여성에서는 25.1% (n=2,834) 이었다. Table 1은연구대상자의성별에따라흡연행태와연령및대사적특성을비교평가한결과를보여준다. 남성에서는과거흡연자의연령이 49.4세로가장높았고, 여성에서는비흡연자의연령이 45.5세로가장높았다. 허리둘레와체질량지수평균은남성과여성모두과거흡연자에서가장높았다. 교육수준은고졸이상학력자의비율이남녀모두비흡연군에서가장높았다. 주 1회이상고위험음주를하는비율은남녀모두현흡연군에서가장높았고규칙적신체활동자는남성과여성모두각군간에차이가없었다. 수축기혈압은각군간에유의한차이가없었고이완기혈압은남성에서만과거흡연자가유의하게높았다. HDL 콜레스테롤은남성에서현재흡연군에서과거흡연군및비흡연군에비해낮게나타났다. 중성지방은남성과여성모두비흡연자가가장낮았고현재흡연자에서가장높았다. 1일지방섭취량과조섬유섭취량은각군간에차이가없었다. Table 2는남녀별흡연과대사증후군간의연관성평가결과를보여준다. 남성의경우연령만을보정한분석모형 1에서비흡연군에비해현재흡연군과 (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.18 1.77) 과거흡연군 (OR, 1.42; 95% CI, 1.17 1.72) 의대사증후군위험이유의하게높았다. 분석모형 2에서는교차비가약간감소했지만흡연과대사증후군간의연관성이유의하게유지되었다. 체질량지수를추가로더보정한분석모형 3에서는현재흡연자에서대사증후군의교차비가더증가하였다 (OR, 1.53; 95% CI, 1.20 1.95). 여성에서는분석모형 1과 2에서는흡연과대사증후군간의유의한연관성이관찰되지않았으나체질량지수를추가로보정한분석모형 3에서는비흡연자에비해현재흡연자의대사증후군위험이 1.72 (95% CI, 1.23 2.42) 배증가하였다. 하지만과거흡연자에서는비흡연자에비해유의한대사증후군위험증가는없었다. Table 3은본연구에서선정한공변수를모두보정한후의흡연과대사증후군구성요소간의연관성을평가한결과를보여준다. 남성의경우비흡연자에비해과거흡연자와현재흡연자는복부비만의위험이각각 1.45배 (95% CI, 1.08 1.96), 1.65배 (95% CI, 1.23 2.22) 높았다. 고중성지방혈증위험은과거흡연자와현재흡연자에서각각 1.46배 (95% CI, 1.21 1.78), 1.87배 (95% CI, 1.56 2.25) 높았다. 저HDL 콜레스테롤혈증위험은흡연자에서만 1.36배 (95% CI, 1.12 1.66) 높았다. 복부 286 Vol. 4, No. 4 Dec 2014 Korean J Fam Pract

강지훈외 : 흡연과대사증후군 Table 1. Age standardized characteristics* of study subjects according to self-reported smoking status, KNHANES between 2007 and 2010 Male Female Variable Never (n=1,655) Past (n=2,816) Current (n=3,079) P-value Never (n=10,264) Past (n=448) Current (n=556) P-value Age (y) 44.2±0.2 49.4±0.4 41.2±0.3 <0.01 45.5±0.2 42.6±1.0 42.1±0.9 <0.01 Waist circumference (cm) 83.3±0.3 84.7±0.2 84.2±0.2 0.02 78.0±0.2 79.8±0.6 77.1±0.5 0.02 Body mass index (kg/m 2 ) 23.9±0.1 24.3±0.1 24.0±0.1 0.01 23.2±0.0 23.4±0.2 22.5±0.2 0.01 Abdominal obesity 24.3 (3.0) 27.9 (2.4) 25.9 (2.4) <0.01 26.5 (1.4) 30.0 (6.4) 25.9 (5.2) 0.06 Duration of education (>12 y) 70.8 (1.1) 70.0 (0.7) 64.9 (0.8) <0.01 57.0 (0.4) 52.2 (2.1) 47.3 (1.9) 0.23 High risk alcohol intake (>1/wk) 21.4 (1.2) 31.6 (1.1) 41.8 (0.9) <0.01 6.00 (0.3) 17.8 (2.4) 28.5 (2.1) <0.01 Physical activity 26.2 (1.2) 29.5 (1.1) 24.9 (0.9) 0.10 21.8 (0.5) 22.6 (2.7) 20.7 (2.0) 0.31 Systolic blood pressure (mm Hg) 118.1±0.4 118.4±0.4 117.6±0.3 0.12 113.3±0.2 113.5±0.7 112.9±0.7 1.00 Diastolic blood pressure (mm Hg) 77.0±0.3 78.1±0.3 77.3±0.2 0.03 72.8±0.1 71.1±0.5 72.3±0.5 0.20 High blood pressure 41.1 (3.1) 43.4 (2.6) 37.1 (2.5) <0.01 32.3 (1.1) 30.5 (5.5) 32.1 (4.9) 0.06 HDL cholesterol (mg/dl) 48.3±0.4 48.5±0.3 47.5±0.3 0.02 53.8±0.2 53.7±0.7 53.6±0.8 0.09 Low HDL cholesterol 31.1 (3.5) 31.7 (3.1) 33.8 (2.8) 0.02 47.7 (1.6) 43.2 (7.3) 48.2 (6.3) 0.12 Triglycerides (mg/dl) 127.7±2.5 154.0±3.7 166.6±2.6 <0.01 109.2±0.9 115.0±3.3 131.6±4.7 <0.01 High triglyceride 30.5±3.3 38.4±3.2 41.2±2.7 <0.01 24.6±1.3 23.5±5.7 35.4±6.0 <0.01 Fasting glucose (mg/dl) 97.6±0.6 98.3±0.5 97.6±0.5 0.60 94.8±0.2 94.7±1.0 93.3±0.7 0.11 Impaired fasting glucose 31.2±3.1 33.6±2.5 30.1±2.4 <0.01 22.7±1.2 24.0±6.4 23.5±5.0 0.22 Fasting insulin (uiu/ml) 10.0±0.2 10.3±0.1 9.7±0.1 0.23 10.0±0.1 10.8±0.3 9.6±0.2 0.03 Homeostasis model assessment of 2.5±0.1 2.6±0.1 2.4±0.0 0.16 2.4±0.0 2.6±0.1 2.3±0.1 0.02 insulin resistance Total fat intake (g/d) 46.9±1.1 49.9±0.9 47.9±0.7 0.15 31.8±0.3 35.1±1.8 35.1±1.9 0.18 Total fiber intake (g/d) 8.4±0.2 8.5±0.1 7.9±0.1 0.01 6.9±0.8 6.3±0.2 6.2±0.3 0.01 Values are presented as mean±se or % (SE). KNHANES: Korean National Health and Nutrition Examination Survey, HDL: high density lipoprotein. *Age standardization was done for all variables using all participants in the fourth and fifth KNHANES as a reference population. Obtained by analysis of covariance or chi-square test. Defined as a waist circumference in men 90 cm and in women 85 cm, serum triglycerides 150 mg/ dl or drug treatment for elevated triglycerides, serum HDL cholesterol <40 mg/dl in men and <50 mg/dl in women or drug treatment for low HDL cholesterol, blood pressure 130/85 mm Hg or drug treatment for elevated blood pressure, fasting plasma glucose 100 mg/dl or drug treatment for elevated blood glucose. Moderate amount (60 g/d for males, 40 g/d for female), more frequently than once a week. Moderate or high intensity physical activity for 20 minutes, 3 times/wk. Calculated by fasting glucose (mg/dl) fasting insulin (uu/ml)/405. 비만, 고중성지방혈증, 저HDL 콜레스테롤혈증위험은과거흡연자보다는현재흡연자에서더높은경향이있었다 (P for trend<0.01). 하지만높은혈압위험은비흡연자에비해현재흡연자에서유의하게낮았다 (OR, 0.81; 95% CI, 0.67 0.97) 여성은비흡연자에비해과거흡연자와현재흡연자는복부비만의위험이각각 1.78배 (95% CI, 1.15 2.76), 1.60배 (95% CI, 1.13 2.26) 높았다. 현재흡연자는고중성지방혈증과저HDL 콜레스테롤혈증의위험이비흡연자에비해각각 1.96배 (95% CI, 1.48 2.58), 1.39배 (95% CI, 1.05 1.84) 높았으나과거흡연자는유의한위험증가를보이지않았다. 고찰 한국인에서 2007 년에서 2010 년사이의국민건강영양조 가정의학 Vol. 4, No. 4 Dec 2014 287

Ji-Hun Kang, et al: Smoking and Metabolic Syndrome Table 2. Association* between self-reported smoking status and metabolic syndrome Model Never (reference) Past Current P for trend All subjects Model 1 1 1.18 (1.02 1.37) 1.38 (1.19 1.59) <0.01 Model 2 1 1.13 (0.98 1.31) 1.25 (1.01 1.45) <0.01 Model 3 1 1.22 (1.03 1.44) 1.55 (1.31 1.85) <0.01 Male Model 1 1 1.42 (1.17 1.72) 1.45 (1.18 1.77) <0.01 Model 2 1 1.35 (1.12 1.64) 1.32 (1.08 1.63) 0.01 Model 3 1 1.31 (1.04 1.65) 1.53 (1.20 1.95) <0.01 Female Model 1 1 1.16 (0.77 1.73) 1.19 (0.86 1.65) 0.16 Model 2 1 1.14 (0.77 1.71) 1.12 (0.81 1.55) 0.34 Model 3 1 1.18 (0.78 1.76) 1.72 (1.23 2.42) 0.01 Values are presented as odds ratio (95% confidence interval). HDL: high density lipoprotein. *Estimated by logistic regression analysis. Metabolic syndrome is defined any three or more following criteria: abdominal obesity, defined as a waist circumference in men 90 cm and in women 85 cm, serum triglycerides 150 mg/dl or drug treatment for elevated triglycerides, serum HDL cholesterol <40 mg/dl in men and <50 mg/dl in women or drug treatment for low HDL cholesterol, blood pressure 130/85 mm Hg or drug treatment for elevated blood pressure, fasting plasma glucose 100 mg/dl or drug treatment for elevated blood glucose. In model 1, age was adjusted; in model 2, age, sex, education, alcohol intake, physical activity, total fat intake, and total fiber intake were adjusted; in model 3, age, education, alcohol intake, physical activity, total fat intake, total fiber intake, and body mass index were adjusted; sex was adjusted in the analysis for all subjects. Assessed by linear by linear association in which smoking status was put as a continuous variable. 사자료를이용하여흡연과대사증후군간의연관성을평가한결과한국남성과여성모두에서대사증후군의위험은비흡연군에비해과거흡연군이나현재흡연군에서유의하게높았고, 이연관성은현재흡연군에서더뚜렷하였다. 이는이전에시행된흡연과대사증후군간의양의연관성을보고한여러연구들에서관찰한결과와일치하는소견이다. 13,16,24) 본연구의결과는본저자들이파악한바에의하면한국인에서는최초로여성에서의흡연과대사증후군의연관성이남성과는다를수도있음을평가한연구로여성에서는남성과달리과거흡연군의대사증후군위험이비흡연군에비해유의하게높지는않았고현재흡연군에서만유의한위험증가가관찰되었다. 성별차이는대사증후군구성요소에대한분석에서도관찰되었는데남성현재흡연자는비흡연자에비해높은혈압위험이유의하게낮았지만여성에서는흡연과높은혈압간에는유의한연관성은관찰되지않았다. 또한남성에서는현재흡연자와과거흡연자모두에서고중성지방혈증위험이증가했지만여성에서는현재흡연자에서만유의한위험증가가관찰되었다. 그런데연관성의방향이남녀간에다 르지않았음을고려하면여성의흡연율이남성보다현저하게낮고따라서과거흡연자나현재흡연자숫자가적어분석의검정력이충분하지않았고이에유의한연관성의관찰이어려웠을수있다고생각된다. 기존연구에서흡연이중성지방치를높이고 HDL 콜레스테롤치를낮춘다는연구결과는흡연으로인한혈중지질치변화가흡연과대사증후군간의연관성성립에중요한역할을할것임을시사한바있다. 15) 본연구에서도남녀모두에서흡연은대사증후군의구성요소중고중성지방혈증, 저HDL 콜레스테롤혈증과유의한연관성이있는것으로관찰되어흡연-대사증후군의연관성경로에두요인이중요한역할을함을시사한다. 본연구에서는비록여성에서는통계적유의성은없었지만남녀모두과거흡연자에서대사증후군의위험이높은경향이있었다. Williamson 등 25) 은금연후에체중증가가발생하면서복부비만도가증가하고중성지방치가높아짐을보고하였는데아마도이런기전을통해과거흡연자에서대사증후군의위험이높아질것으로추정되지만본연구는단면적인 288 Vol. 4, No. 4 Dec 2014 Korean J Fam Pract

강지훈외 : 흡연과대사증후군 Table 3. Association* between self-reported smoking status and components of metabolic syndrome Metabolic component Never (reference) Past Current P for trend All subjects Abdominal obesity 1 1.52 (1.24 1.86) 1.66 (1.36 2.03) <0.01 Impaired fasting glucose 1 1.10 (0.94 1.28) 0.99 (0.86 1.15) 0.78 High triglyceride 1 1.26 (1.10 1.44) 1.80 (1.58 2.05) <0.01 Low HDL cholesterol 1 1.01 (0.88 1.16) 1.34 (1.17 1.54) <0.01 High blood pressure 1 0.90 (0.78 1.03) 0.82 (0.71 0.94) 0.01 Male Abdominal obesity 1 1.45 (1.08 1.96) 1.65 (1.23 2.22) <0.01 Impaired fasting glucose 1 1.13 (0.92 1.39) 1.02 (0.84 1.25) 0.90 High triglyceride 1 1.46 (1.21 1.78) 1.87 (1.56 2.25) <0.01 Low HDL cholesterol 1 1.07 (0.87 1.30) 1.36 (1.12 1.66) <0.01 High blood pressure 1 1.01 (0.84 1.21) 0.81 (0.67 0.97) <0.01 Female Abdominal obesity 1 1.78 (1.15 2.76) 1.60 (1.13 2.26) <0.01 Impaired fasting glucose 1 0.98 (0.65 1.32) 0.99 (0.71 1.38) 0.84 High triglyceride 1 0.95 (0.69 1.31) 1.96 (1.48 2.58) <0.01 Low HDL cholesterol 1 0.87 (0.67 1.14) 1.39 (1.05 1.84) 0.04 High blood pressure 1 0.86 (0.58 1.21) 0.98 (0.70 1.37) 0.65 Values are presented as odds ratio (95% confidence interval). HDL: high density lipoprotein. *Estimated by logistic regression analysis with an adjustment for age, education, alcohol intake, physical activity, total fat intake, total fiber intake, and body mass index. Sex was additionally adjusted in the analysis for all subjects. Abdominal obesity, defined as a waist circumference in men 90 cm and in women 85 cm, serum triglycerides 150 mg/dl or drug treatment for elevated triglycerides, serum HDL cholesterol <40 mg/dl in men and <50 mg/dl in women or drug treatment for low HDL cholesterol, blood pressure 130/85 mm Hg or drug treatment for elevated blood pressure, fasting plasma glucose 100 mg/dl or drug treatment for elevated blood glucose. Assessed by linear by linear association in which smoking status was put as a continuous variable. 연구여서이를확인할수는없었다. 본연구에서는대사증후군구성요소중남성과여성모두에서복부비만과흡연의연관성이가장높았는데이는이전의한국인에서수행된연구결과와일치하는결과이다. 13,18) 본연구와유사한국민건강영양조사참여대상에서수행된 Oh 등 13) 의연구에서는하루 40개피이상의흡연을하는군의복부비만위험이비흡연군에비해높은경향을보였지만 (OR, 1.54; 95% CI, 0.92 2.56) 통계적으로유의하지않았는데, 이는 Oh 등 13) 의연구에서는연구수행시기가달라연구대상자의복부비만유병률이본연구대상에서보다낮았기때문일가능성이있겠다. 한편이탈리아인을대상으로수행된 Masulli 등 16) 의연구에서는흡연이복부비만의위험을증가시키지않고, 인슐린저항성에영향을주지도않는다고보고하였다. 이와 같이연구간에관찰된결과가차이나는이유로는같은체질량지수에서도복부비만도가인종마다다름을고려할때 26) 흡연이복부비만도발생에미치는위험이인종마다다를수있음을생각해볼수있으나이를지지할만한연구결과는드물어이를확인하기위한추가연구가필요하다. 대사증후군발생의주요병인으로는복부비만, 인슐린저항성이중요한것으로알려져있다. 27,28) 동일한체질량하에서흡연은신체의지방분포를변화시켜복부비만도를높이고이로인해대사증후군위험을증가시키는것으로생각된다. 29,30) 이러한경향은여성에서더욱현저한데본연구에서흡연여성의체질량지수가비흡연여성에비해유의하게낮고허리둘레평균치도더낮음에도불구하고복부비만위험이흡연여성에서유의하게높음이관찰되었다. 또한체질량지수에 가정의학 Vol. 4, No. 4 Dec 2014 289

Ji-Hun Kang, et al: Smoking and Metabolic Syndrome 따라구분하여분석했을때과체중군내에서현재흡연자와과거흡연자에서유의하게높은복부비만비율을보여흡연이체중자체보다복부비만과연관되어대사증후군및구성요소에영향을준다는주장을뒷받침한다. 본연구에서공복포도당장애의위험은흡연상태에따라유의한차이가없었는데이는 Oh 등 13) 과 Hong 등 18) 의한국인에서수행된연구결과와일치한다. 하지만흡연이 2형당뇨병을증가시키는결과를보고한 Kowall 등 31) 의코호트연구와 Willi 등 11) 의메타분석결과와는일치하지않았다. 이를확인하기위해서는코호트연구나임상시험과같은좀더잘설계된연구가필요하겠다. 고중성지방혈증은남성에서는현재흡연자과거흡연자모두에서높은위험을보여이전의한국및외국에서의연구들과같은결과를보였고 13,16,18,24) Craig 등 15) 의메타연구와도일치하였다. 여성현재흡연자또한비흡연자에비해높은고중성지방혈증위험을보여흡연이남성과여성에서일관되게고중성지방혈증위험을높임을시사한다. 저HDL 콜레스테롤혈증은남녀모두현재흡연자에서비흡연자에비해높은위험을보여주어흡연자에서 HDL 콜레스테롤이낮다는이전의연구들과 13,15,16,18,24) 일치하는결과를나타냈다. 흡연은체내의지질대사를변화시키고본연구에서관찰한결과처럼고중성지방혈증및저HDL 콜레스테롤혈증의유병률을증가시키는것으로알려져있다. 흡연은체내의인슐린길항호르몬인카테콜아민, 코티졸, 성장호르몬증가와지방분해증가를유도하여유리중성지방수치증가를초래한다고한다. 32) 또한흡연으로인해증가된체내의니코틴이니코틴성수용체 (nicotinic receptor) 에작용하여지방분해를촉진시키고지방세포에서의아디포넥틴분비를감소시킨다. 33) 결과적으로증가된유리지방산이췌장베타세포에손상을주어공복포도당장애를일으키고감소된아디포넥틴이인슐린저항성을증가시키는것으로생각된다. 34) 기존에수행된연구중흡연과높은혈압간의연관성을확인하지못한연구도있었지만, 13,24) 본연구에서는남성은흡연자에서비흡연자에비해높은혈압위험이유의하게낮았으며이는 Green 등 35) 과 Mikkelsen 등 36) 의연구에서흡연자에서비흡자에비해낮은혈압을보인연구와일치하는결과였다. 혈압에미치는흡연의생물학적영향을평가한연구에서흡연은단기적으로는혈압을높이지만 37) 장기적으로는혈압을낮추는방향으로작용하는것으로보고되었고, 35) 이는흡연의대사산물인코티닌의혈관확장작용때문으로알려져있다. 38) 그러나일부연구에서코티닌이흡연자에서는혈압을낮추나비흡연자에서혈압을높인다는보고가있어흡연이 혈압에미치는영향은보다복잡한기전이작용하는것으로생각된다. 39) 본연구는몇가지제한점을가진다. 첫째, 단면연구설계로수행되어흡연과대사증후군및구성요소간의명확한시간적선후관계를파악할수없었다. 둘째, 자가보고한흡연으로흡연여부를판단함으로써측정정확도가낮을수있다. 하지만흡연자가비흡연자나과거흡연자로보고하는경향이높음을고려하면, 40) 이로인해서는연관성의과대평가보다는과소평가가발생했을가능성이더높아서본연구의결과에심각한비뚤림을초래하지는않았을것으로생각된다. 셋째, 본연구의공변수인 1일지방섭취량과조섬유섭취량을평가할때 24시간회상설문지를사용함으로써정확도가떨어져정보비뚤림 (information bias) 이발생했을수있겠다. 본연구의강점은남성과여성을구분하여흡연의대사증후군에대한영향을평가한한국의첫번째연구이고, 전국민에서확률표본추출방법에의해대표성있는연구대상자를선정한국민건강영양조사자료를사용하여분석을함으로써연구결과의일반화가가능하다는점이다. 결론적으로, 본연구에서남녀모두에서흡연은대사증후군과독립적인연관성이있었고이런결과는흡연이대사증후군의위험요인임을시사한다. 요약 연구배경 : 본연구의목적은한국성인에서흡연과대사증후군의연관성을평가하기위해수행되었다. 방법 : 2007년에서 2010년국민건강영양조사자료를바탕으로 19세이상의성인 18,818명을대상으로연구를수행하였다. 흡연상태는자기기입식설문지를통해조사하였으며대사증후군은 National Cholesterol Education Program/Adult Treatment Panel III 기준에따라정의하였다. 흡연상태와대사증후군간의연관성은다변량로지스틱회귀분석을사용하여평가하였고연령, 교육수준, 고위험음주여부, 신체활동, 1일지방및조섬유섭취량, 체질량지수를보정하였다. 결과 : 남성에서비흡연자와비교하여현재흡연자 (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.20 1.95) 와과거흡연자가 (OR, 1.31; 95% CI, 1.04 1.65) 대사증후군의위험이유의하게증가하였으며여성에서는현재흡연자에서대사증후군의위험이증가하였다 (OR, 1.72; 95% CI, 1.23 2.42). 대사증후군구성요소별로는남성현재흡연자는비흡연자에비해복부비만 (OR, 1.65; 95% CI, 1.23 2.22), 고중성지방혈증 290 Vol. 4, No. 4 Dec 2014 Korean J Fam Pract

강지훈외 : 흡연과대사증후군 (OR, 1.87; 95% CI, 1.56 2.25), 저 high density lipoprotein (HDL) 콜레스테롤혈증 (OR, 1.36; 95% CI, 1.12 1.66) 의위험이유의하게높았고높은혈압의위험은유의하게 (OR, 0.81; 95% CI, 0.67 0.97) 낮았다. 여성현재흡연자는비흡연자에비해복부비만 (OR, 1.60; 95% CI, 1.13 2.26), 고중성지방혈증 (OR, 1.96; 95% CI, 1.48 2.58), 저HDL 콜레스테롤혈증 (OR, 1.39; 95% CI, 1.05 1.84) 의위험이높았다. 결론 : 흡연은한국성인에서대사증후군및대사증후군구성요소의위험증가와연관성이있다. 중심단어 : 흡연 ; 대사증후군 ; 한국인 REFERENCES 1. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C; American Heart Association, et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004;109:433-8. 2. Hanson RL, Imperatore G, Bennett PH, Knowler WC. Components of the metabolic syndrome and incidence of type 2 diabetes. Diabetes 2002;51:3120-7. 3. Isomaa B, Almgren P, Tuomi T, Forsen B, Lahti K, Nissen M, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24:683-9. 4. Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002;288:2709-16. 5. Esposito K, Chiodini P, Colao A, Lenzi A, Giugliano D. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care 2012;35:2402-11. 6. Lee WY, Jung CH, Park JS, Rhee EJ, Kim SW. Effects of smoking, alcohol, exercise, education, and family history on the metabolic syndrome as defined by the ATP III. Diabetes Res Clin Pract 2005;67:70-7. 7. Groop L. Genetics of the metabolic syndrome. Br J Nutr 2000;83 Suppl 1:S39-48. 8. Lutsey PL, Steffen LM, Stevens J. Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Circulation 2008;117:754-61. 9. Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet 2011;378:1297-305. 10. Jee SH, Suh I, Kim IS, Appel LJ. Smoking and atherosclerotic cardiovascular disease in men with low levels of serum cholesterol: the Korea Medical Insurance Corporation Study. JAMA 1999;282:2149-55. 11. Willi C, Bodenmann P, Ghali WA, Faris PD, Cornuz J. Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis. JAMA 2007;298:2654-64. 12. Geslain-Biquez C, Vol S, Tichet J, Caradec A, D Hour A, Balkau B, et al. The metabolic syndrome in s. The D.E.S.I.R. study. Diabetes Metab 2003;29:226-34. 13. Oh SW, Yoon YS, Lee ES, Kim WK, Park C, Lee S, et al. Association between cigarette smoking and metabolic syndrome: the Korea National Health and Nutrition Examination Survey. Diabetes Care 2005;28:2064-6. 14. Nakashita Y, Nakamura M, Kitamura A, Kiyama M, Ishikawa Y, Mikami H. Relationships of cigarette smoking and alcohol consumption to metabolic syndrome in Japanese men. J Epidemiol 2010;20:391-7. 15. Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. BMJ 1989;298:784-8. 16. Masulli M, Riccardi G, Galasso R, Vaccaro O. Relationship between smoking habits and the features of the metabolic syndrome in a non-diabetic population. Nutr Metab Cardiovasc Dis 2006;16:364-70. 17. Bernaards CM, Twisk JW, Snel J, van Mechelen W, Kemper HC. In a prospective study in young people, associations between changes in smoking behavior and risk factors for cardiovascular disease were complex. J Clin Epidemiol 2005;58:1165-71. 18. Hong AR, Lee KS, Lee SY, Yu JH. Association of current and past smoking with metabolic syndrome in men. J Prev Med Public Health 2009;42:160-4. 19. Korea Centers for Disease Control and Prevention. The Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV - 1, 2, 3) 2007-2009. Cheongju: Korea Center for Disease Control and Prevention; 2010. 20. Gaziano JM, Buring JE, Breslow JL, Goldhaber SZ, Rosner B, VanDenburgh M, et al. Moderate alcohol intake, increased levels of high-density lipoprotein and its subfractions, and decreased 가정의학 Vol. 4, No. 4 Dec 2014 291

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