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Korean J Women Health Nurs ( 여성건강간호학회지 ) Vol. 22. 4, 275-286, December 2016 pissn 2287-1640 eissn 2093-7695 http://dx.doi.org/10.4069/kjwhn.2016.22.4.275 중년이후여성에서삶의질저하에영향을미치는요인 : 폐경형태와대사증후군위험요인을중심으로 김지순 1 안숙희 2 충남대학교대학원간호학과 1, 충남대학교간호대학 2 Impact of Menopausal Status, Metabolic Syndrome and its Risk Factors on Impaired Quality of Life above Middle-aged Women Kim, Jisoon 1 Ahn, Sukhee 2 1 College of Nursing, Graduate School, Chungnam National University, Daejeon 2 College of Nursing, Chungnam National University, Daejeon, Korea Purpose: This study explored influencing factors on quality of life (QoL) above middle-aged women in relation to demographic factors, health-related factors, menopausal status, metabolic syndrome (MS) and its risk factors. Methods: This study was secondary data analysis from the Sixth Korea National Health and Nutrition Examination Survey 2013~2015 that utilized a complex, multi-stage probability sample design. Study sample of 2,310 was inclusive of (28.8%) of women who were over 40. To evaluate the factors that would influence an impaired quality of life, x 2 test, GLM, and logistic regression analysis were done. Results: Level of quality of life was lower in women with late post-menopause(over 10 years since menopause) than women with pre-menopause. Factors influencing impaired QoL were as follows: graduated middle school and elementary school or less (OR=2.43, 4.42, respectively, p<.05), no job (OR=1.92, p), stress (OR=1.92, p=.001), depression (OR=1.93, p=.001), insufficient sleep (OR=1.64, p=.003), late post-menopause (OR=2.61, p=.044) and over 85cm of waist circumference (OR=1.76, p=.01). Conclusion: These results suggest that late post-menopause may be an independent factor influencing an impaired QoL. To promote post-menopausal womens health, a nursing strategy is required to teach women how to manage levels of stress, depression, insufficient sleep, and abdominal obesity through health education, nutritional counselling, and physical activity program. Key Words: Menopause, Metabolic syndrome X, Quality of life, Depression, Sleep 서론 1. 연구의필요성 건강관련삶의질은다양한신체적 정신적 사회적변화를 경험하는개인의주관적건강상태에대한만족도로, 생애주기에따라다양한인구학적특성과건강관련특성에의해영향을받는다 [1]. 우리나라여성의폐경연령은 48~52세로서, 2013년평균기대수명 85.1세를기준으로볼때대부분의여성은삶의 1/3 이상을폐경상태로살아가게된다 [2]. 폐경기여성은폐경 주요어 : 폐경기, 대사증후군, 삶의질, 우울, 수면 Corresponding author: Ahn, Sukhee College of Nursing, Chungnam National University, 266 Munwharo, Jung-gu, Daejeon 35015, Korea. Tel: +82-42-580-8324, Fax: +82-42-580-8309, E-mail: sukheeahn@cnu.ac.kr - 본연구는충남대학교자체연구비의지원을받았음. - This study was supported by Chungnam National University Research Fund. Received: Sep 30, 2016 / Revised: Oct 25, 2016 / Accepted: v 2, 2016 This is an open access article distributed under the terms of the Creative Commons Attribution n-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. c 2016 Korean Society of Women Health Nursing http://www.women-health-nursing.or.kr

김지순 안숙희 기로의이행을경험하면서임신으로부터해방감과더불어안면홍조와같은폐경증상, 수면장애, 스트레스, 우울감을경험하고 [3,4] 이런신체심리적변화가삶의질에부정적인영향을미친다 [5,6]. 실제로폐경기여성은폐경전월경을하는여성대비폐경을경험하면서삶의질이낮은편이고 [5] 자연폐경연령이높을수록삶의질점수는높다 [7]. 또한중년이후여성의삶의질에는인구학적요인 ( 고령, 낮은교육수준, 무배우자등 ), 신체건강요인 ( 비만, 운동비참여, 오랜폐경기간, 대사증후군등 ), 정신건강요인 ( 스트레스나우울감, 과소및과다수면등 ) 이보고 [7-9] 되어왔다. 폐경후여성은폐경기간이경과하면서중장기건강문제로대사증후군을포함한심혈관계질환이발생할위험에처한다. 그이유는폐경이후에에스트로겐호르몬의혈관보호효과감소, 혈중지질대사의변화, 복부로의지방축적으로인한내장비만, 인슐린저항성발현등생리적기전에따른다 [10]. 대사증후군이란심혈관계질환의발생과관련한여러위험인자들의조합으로이루어진질환으로, 진단기준은혈압, 고밀도지단백콜레스테롤 ( 이하 HDL-C), 중성지방, 혈당및허리둘레에대한위험요인중세개이상을갖고있을때이다 [10,11]. 실제로여성의대사증후군발생률은폐경전 13% 에서폐경후 42% 로 4.88배높으며, 40세기준연령이 10세증가시각각 4.16배, 9.52배로증가한연구 [12] 를볼때, 연령증가와폐경의효과가대사증후군이환율에영향을미친다. 대상자의일반적특성을통제한후에도폐경후여성은폐경전여성에비해또한동일연령대비남성보다여성의대사증후군발생률이높아폐경이독립적인영향요인으로나타났다 [13,14]. 또한폐경기에흔히발생하는우울이나스트레스, 과소및과다수면이신체활동의감소를유발하여대사증후군및위험요인의발생률을높인다 [15-17]. 대사증후군과삶의질과의연관성은성별과폐경유무에따라차이가있다. 여성의경우대사증후군자체가삶의질 [18] 에부정적인영향을미친반면, 남성에서는그관련성이나타나지않았다. 반면폐경상태를고려할때에는대사증후군을갖고있는폐경전여성의경우삶의질이나쁜것으로나타난반면, 폐경후여성에서는대사증후군과삶의질간에상관이없어차이를보이고있다 [18,19]. 그러나폐경이후여성의지방침착이복부로이동하여복부둘레가증가하는생리적변화를고려한연구에서는, 65~74세노인여성의복부둘레가클수록삶의질은낮고, 다양한만성질환을통제한후에도복부둘레가클수록삶의질하위영역인운동능력이저하되는것으로나타났다 [20]. 이는중년이후여성의삶의질을평가할때여성의건강관련 특성과더불어폐경기간을고려하고대사증후군유무뿐아니라위험요인의유형까지통합적으로고려할필요가있음을의미한다. 중년이후여성의삶의질에영향을미치는연구논문을고찰한결과, 대부분연구에서는소규모임의표본을이용하거나삶의질을폐경유무또는대사증후군유무에따라삶의질을평가하거나삶의질관련요인을단변량적접근을이용하여보고하였다. 즉삶의질에영향을미치는다양한요인을통합적으로평가하지않아관련요인의상대적중요성을해석하는데제한점이있고, 일부보고에서는그관련성에대해일관된결과를나타내지않고있다. 이에본연구는중년이후여성을대상으로폐경기간에따른삶의질수준을파악하고, 인구학적특성, 건강관련특성, 폐경기간과대사증후군유무및위험요인과삶의질간에관련성을검정하고, 또한삶의질저하에미치는관련요인을다변량분석법을통해상대적중요도를평가하고자한다. 이는건강한폐경기로의이행을도모할수있도록질병예방과건강증진을위한간호전략을수립하는데중요한기초자료로활용할수있을것이다. 2. 연구목적본연구는중년이후여성의삶의질에영향을미치는요인들을폐경기간과대사증후군을중심으로통합적으로탐색하기위함이며, 구체적인목적은다음과같다. 폐경기간에따른대상자의인구학적특성, 건강관련특성, 대사증후군유무및위험요인과의관련성을확인한다. 대상자의폐경기간, 대사증후군및위험요인에따른삶의질수준을파악한다. 대상자의삶의질저하에따른인구학적특성, 건강관련특성, 폐경기간, 대사증후군유무및위험요인과의관련성을확인한다. 대상자의삶의질저하에영향을미치는요인을통합적으로검정한다. 연구방법 1. 연구설계 본연구는중년이후여성의폐경기간과대사증후군및위험요인을중심으로삶의질수준을파악하고삶의질저하에폐경기간과대사증후군및위험요인이미치는영향을통합적으 276 Korean Journal of Women Health Nursing

중년이후여성에서삶의질저하에영향을미치는요인 : 폐경형태와대사증후군위험요인을중심으로 로탐색하기위해국민건강영양조사자료를이용하여상관성을분석한이차자료분석연구이다. 2. 연구자료와대상본연구자료는질병관리본부의제6기 (2013~2015) 국민건강영양조사중 1차년도인 2013년도자료를원자료로하여연구목적에따라자료를추출한 2차자료이다. 원자료의표본설계구성은추출틀로는 2010 인구주택총조사자료 ( 약 30만개조사구 ) 이고, 추출단위는연간 192개조사구를추출하는데 1차로표본조사구당 20가구를추출하고 2차로표본가구내만 1 세이상가구원 ( 약 1만명 ) 을추출하는방식으로, 층은시도, 동읍면, 주택유형을층화하고내재적층은성별, 연령, 주거면적, 가구주학력비율로층화한복합표본설계였다. 본연구의대상자는개별변수마다결측치가적용되면서대상자수가각기다르나복합표본설계자료분석시일부자료선택으로인한추정치의표준오차편향발생을고려하여전체 8019명중 40세이상여성인 2310명 (28.8%) 을관심집단으로하여자료분석을시행하였다. 3. 연구도구 1) 삶의질건강관련삶의질은 EQ-5D로측정하고그값에질가중치를적용한 EQ-5D index 값을이용하였다 [21]. EQ-5D는 Euro- Qol Group이건강관련삶의질을기술하기위해개발한도구로, 운동능력 ( 걷기 ), 자기관리 ( 목욕이나옷입기 ), 일상활동 ( 일, 공부, 가사일, 가족또는여가활동 ), 통증 / 불편, 불안 / 우울등하위 5개하위척도로구성된다. 해당질문에대해지장이없거나문제가없으면 1점, 다소지장이있거나문제가있으면 2점, 수행을할수없거나문제가매우심하면 3점으로측정한다. EQ-5D의신뢰도와수렴및판별타당도를확인하였다. 또한범주형변수에해당하는수준 (level) 에대하여계산한 Cohen s Kappa 값은일상활동영역에서 0.64로가장높은수준을보였고, 불안 / 우울영역이 0.32로가장낮은값을보였다. EQ-5D- 3L index 값은급내상관계수 (Intra-class Correlation Coefficient, ICC) 를이용하여신뢰도를평가한결과, ICC는 0.61로나타나상당히높은 (substantial) 수준의신뢰도를보였다 [21]. 본연구에서는삶의질저하에미치는영향요인을탐색하기위해선행연구 [3] 에근거하여 EQ-5D index 점수를 4등분하여최하위군인 25% 이하인집단은삶의질저하군으로, 나머지는 삶의질비저하군으로재분류하여코딩하였다. 2) 폐경기간폐경기간은대상자의월경유무와무월경사유, 폐경연령, 만나이 ( 연령 ) 자료를이용하여폐경전기와폐경후기로우선구분하였다. 폐경후기에서는폐경후심혈관계질환의위험도가폐경후 5~10년째부터증가하기때문에 [22] 폐경후기는폐경경과기간이 10년미만인경우폐경후초기 (early postmenopause) 로, 폐경후 10년이상인경우폐경후후기 (late postmenopause) 로세분화하였다. 이에폐경기간은폐경전기, 폐경후초기, 폐경후후기로분류하였다. 3) 대사증후군과대사증후군위험요인대사증후군은미국국립심폐혈액연구소에서대사증후군진단기준지침으로제시한 National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)[11] 와아시아-태평양비만진료지침에제시된허리둘레를참조하여 5가지위험요인중 3개이상인경우를말한다 [15]. 본연구에서는대사증후군 5가지위험요인기준 [15] 에따라개별위험요인유무와대사증후군유무로각각분류하였다. 개별위험요인은다음과같다 : 높은혈압의경우수축기혈압이 130 mmhg, 이완기혈압이 85 mmhg 이상이거나혈압조절제를복용중인경우, 낮은고단백지질의경우 HDL-C 이 50 mg/dl 미만이거나이상지질혈증치료제를복용중인경우, 높은중성지방의경우중성지방이 150 mg/dl 이상이거나이상지질혈증치료제를복용중인경우, 높은공복혈당의경우공복혈당이 110 mg/dl 이상이거나당뇨치료제를복용중인경우, 큰허리둘레의경우허리둘레가 85 cm 이상인경우이다. 이후대상자의위험요인이 3개이상인경우는대사증후군이있는군, 3개미만인경우는대사증후군이없는군으로분류하였다. 4) 인구학적특성및건강관련특성문헌고찰 [7,8,23] 을통해중년이후여성의삶의질에영향을미친인구학적특성과건강관련특성을본연구의변수로선정하였다. 인구학적특성에는연령, 소득 4분위수, 교육수준, 직업유무, 배우자유무를포함하였다. 건강관련특성에는음주여부, 걷기실천여부, 체질량지수에따른비만도, 인지된스트레스정도 ( 많이느낌, 적게느낌 ), 우울감여부, 수면시간을포함하였다. 수면시간의경우선행연구 [15] 를참조하여 6시간미만을과소, 6시간이상 9시간미만을적정, 9시간이상을과다수면으로재코딩하여수면의적절성변수를만들었다. Vol. 22. 4, 2016 277

김지순 안숙희 4. 자료수집본연구는연구자가소속된기관의기관생명윤리위원회로부터승인을받은후 ( 제2013-48호 ) 수행하였다. 질병관리본부홈페이지에서제6기 1차년도 (2013년) 국민건강영양조사원시자료를다운받고연구목적에따라필요한자료를추출하여이차자료세트를만들었다. 5. 자료분석수집된자료는연구목적을달성하기위하여 SPSS/WIN 22.0을사용하여복합표본설계프로시저에따라분석하였다. 유의수준은.05로설정하였다. 첫째, 폐경기간에따른대상자의인구학적특성, 건강관련특성, 대사증후군유무및위험요인과의관련성검정은빈도분석및교차분석을통해 x 2 test로분석하였다. 둘째, 대상자의폐경기간, 대사증후군유무및위험요인에따른삶의질차이검정은일반선형모델분석을통해분석하였다. 셋째, 대상자의삶의질저하에따른인구학적특성, 건강관련특성, 폐경기간, 대사증후군유무및위험요인과의관련성은단변량적로지스틱회귀분석으로검정하였다. 넷째, 삶의질저하를설명할수있는영향요인을통합적으로탐색하기위하여, 다변량적로지스틱회귀분석으로분석하였다. 폐경기간과대사증후군에유의한관련성을보인인구학적특성을모델 I에입력하여변수들의영향력을평가하였고, 건강관련특성, 폐경기간, 대사증후군및위험요인은모델 II에입력하여추가영향력을평가하였다. 연구결과 1. 폐경기간에따른대상자의인구학적특성, 건강관련특성, 대사증후군유무및위험요인 33.7%, 걷기운동실천자가 27.6%, 스트레스경험자가 24.1%, 우울경험자가 16.0%, 과소수면자가 22.4%, 과다수면자가 6.2 % 로나타났다. 폐경후후기여성이다른두집단에비해비음주자와비만인대상자가많았고, 스트레스와우울감을많이느끼고, 과소및과다수면을보고한대상자가유의하게많았다 (p<.05). 또한대사증후군유병률은 22.9% 였고, 폐경전기여성의 11% 대비폐경후초기여성은 22.8%, 폐경후후기여성은 36.5% 의유병률을보였다. 위험요인보유율은고혈압이 32.1 %, 낮은 HDL-C가 55.3%, 높은중성지방이 27.9%, 공복시고혈당이 16.8%, 복부비만이 26.0% 였다. 폐경후후기여성이다른두집단에비해대사증후군진단자와 5가지위험요인보유자가유의하게많았다 (p<.05)(table 1). 2. 대상자의폐경기간, 대사증후군유무및위험요인에따른삶의질수준삶의질점수는평균 0.91 (.00) 로나타났다. 폐경기간에따른삶의질점수를비교한결과폐경전기여성의경우 0.96 (.00) 인반면, 폐경후초기, 폐경후후기에각각 0.94 (.01), 0.83 (.01) 으로나타나폐경전기대비두집단의삶의질수준이유의하게감소되었고, 폐경후초기보다폐경후후기에삶의질저하가크게나타났다 (p<.05). 또한대사증후군을보유한여성의삶의질은평균 0.88 (.01) 로정상여성의 0.92 (.00) 에비해유의하게낮았다 (p<.05). 대사증후군위험요인역시 5가지모든요인에대해대사증후군을보유한여성이정상여성에비해삶의질수준이유의하게낮았다 (p<.05)(table 2). 3. 삶의질저하에따른대상자의인구학적특성, 건강관련특성, 폐경기간, 대사증후군유무및위험요인과의관련성 본연구대상자의연령분포는 40~96세로써평균연령은 56.73 (0.39) 세, 평균폐경연령은 48.72 (0.15) 세로나타났다. 대상자중월경을하고있는폐경전기여성은 642명 (35.5%), 폐경을경험한후 10년이내인폐경후초기여성은 543명 (27.2 %), 폐경을경험한후 10년이상인폐경후후기여성은 922명 (37.2%) 이었다. 폐경기간에따라인구학적특성을비교한결과, 폐경후후기여성은폐경후초기와폐경전기여성에비해연령이높고, 저학력자, 무직자, 무배우자가많았다 (p<.05). 대상자의건강관련특성에서는음주자가 55.5%, 비만자가 대상자의삶의질점수가 25% 이하에속한대상자의삶의질점수는평균 0.68 (.01) 로, 25% 이상에속하는대상자의경우 0.97 (.00) 에비해낮은수준을보였다 (p<.05). 삶의질저하는대상자의인구학적특성에서고연령군, 낮은학력군, 무직자, 무배우자인것과유의한관련성을보였다 (p<.05). 로지스틱회귀분석으로삶의질저하에대한개별변수의승산비를확인한결과, 연령에서는 40대여성을기준으로할때연령이 10 세씩증가할수록승산비가 2.01, 7.06, 15.23배로상승하였고, 교육수준에서는대학졸업대비고졸, 중졸, 초졸순으로갈수 278 Korean Journal of Women Health Nursing

중년이후여성에서삶의질저하에영향을미치는요인 : 폐경형태와대사증후군위험요인을중심으로 Table 1. Quality of Life and Related Factors associated with Menopausal Status Menopausal status Variables Categories Total Premenopause Early postmenopause Late postmenopause x 2 (p) M (SE) or n (%) M (SE) or n (%) M (SE) or n (%) Age Menopausal age 56.73 (0.39) 48.72 (0.15) 45.21 (0.15) - 54.70 (0.22) 50.66±0.20 69.23 (0.34) 47.29 (0.22) Demographic factors Age (yr) 40~49 50~59 60~69 70 631 (32.5) 640 (29.9) 495 (17.6) 544 (19.9) 540 (85.3) 100 (14.6) 2 (0.2) 0 (0.0) 49 (10.7) 405 (75.5) 88 (13.4) 1 (0.4) 1 (0.1) 86 (12.0) 375 (39.4) 460 (48.5) 2,457.26 Income quartile Lower Lower middle Upper middle Upper 572 (25.3) 573 (24.7) 575 (25.1) 575 (25.2) 155 (24.8) 146 (23.4) 166 (24.9) 173 (26.9) 120 (22.2) 148 (26.6) 134 (25.6) 139 (25.6) 236 (26.2) 237 (25.9) 220 (23.2) 224 (24.7) 5.22 (.692) Educational level College High school Middle school Elementary school 330 (16.8) 641 (32.5) 285 (13.2) 896 (37.5) 225 (34.6) 326 (51.5) 52 (8.6) 38 (5.2) 67 (12.0) 203 (38.2) 110 (19.9) 163 (29.9) 36 (4.0) 108 (11.6) 116 (12.4) 662 (72.1) 920.54 Occupation 960 (46.3) 1,193 (53.7) 401 (61.4) 241 (38.6) 293 (53.0) 250 (47.0) 257 (28.7) 665 (71.3) 176.29 Spouse 1,633 (73.5) 635 (26.5) 558 (90.3) 63 (9.7) 454 (83.9) 82 (16.1) 498 (52.7) 420 (47.3) 316.64 Health-related factors Drinking 1,134 (55.5) 1,012 (44.5) 458 (71.0) 184 (29.0) 326 (61.3) 217 (38.7) 338 (37.2) 584 (62.8) 187.87 Walking activity 316 (27.6) 827 (72.4) 103 (30.9) 238 (69.1) 81 (27.6) 198 (72.4) 130 (25.2) 373 (74.8) 3.29 (.280) Weight status Underweight Obesity rmal 68 (3.1) 784 (33.7) 1,450 (63.2) 27 (4.7) 169 (26.4) 445 (68.9) 7 (1.4) 184 (34.1) 352 (64.5) 28 (3.0) 347 (38.0) 546 (59.0) 33.66 Perceived stress More Less 506 (24.1) 1,636 (75.9) 142 (22.6) 500 (77.4) 106 (19.9) 437 (80.1) 243 (27.9) 677 (72.1) 12.82 (.010) Depression 344 (16.0) 1,797 (84.1) 69 (11.1) 573 (88.9) 87 (16.5) 456 (83.5) 182 (20.2) 738 (79.8) 23.93 Sleep duration Insufficient Over-sufficient Sufficient 515 (22.4) 143 (6.2) 1,482 (71.4) 74 (11.6) 25 (3.5) 543 (84.8) 116 (19.5) 26 (4.9) 401 (75.6) 317 (34.9) 84 (9.3) 518 (55.8) 165.00 Menopausal status Late postmenopause Early postmenopause Premenopause 922 (37.2) 543 (27.2) 642 (35.5) Metabolic syndrome 495 (22.9) 1,497 (77.1) 68 (11.0) 535 (89.0) 120 (22.8) 399 (77.2) 281 (36.5) 470 (63.5) 121.51 Risk factor of metabolic syndrome Blood pressure ( 130/85 mmhg) 804 (32.1) 1,491 (67.9) 125 (17.4) 513 (82.6) 177 (32.3) 366 (67.7) 435 (45.9) 487 (54.1) 142.37 HDL-C (<50 mg/dl) 1,120 (55.3) 879 (44.7) 289 (48.0) 315 (52.0) 270 (53.5) 249 (46.5) 491 (65.0) 262 (35.0) 39.96 Triglyceride ( 150 mg/dl) 573 (27.9) 1,426 (72.1) 120 (20.3) 484 (79.7) 148 (28.2) 371 (71.8) 265 (34.7) 488 (65.3) 34.42 Fasting blood glucose ( 110 mg/dl) 344 (16.8) 1,652 (83.2) 47 (8.1) 556 (91.9) 81 (15.4) 438 (84.6) 197 (27.4) 554 (72.6) 89.39 Waist circumference ( 85 cm) 633 (26.0) 1,667 (74.0) 94 (14.7) 548 (85.3) 124 (22.4) 418 (77.6) 354 (38.3) 568 (61.7) 115.59 Vol. 22. 4, 2016 279

김지순 안숙희 Table 2. Level of Quality of Life by Menopausal Status and Metabolic Syndrome Variables Menopausal status Metabolic syndrome Risk factors of metabolic syndrome Blood pressure ( 130/85 mmhg) HDL-C (<50 mg/dl) Triglyceride ( 150 mg/dl) Fasting blood glucose ( 110 mg/dl) Waist circumference ( 85 cm) Categories Premenopause Early postmenopause Late postmenopause n(%) 642 (35.5) 543 (27.2) 922 (37.2) 495 (22.9) 1,497 (77.1) 804 (32.1) 1,491 (67.9) 1,120 (55.3) 879 (44.7) 573 (27.9) 1,426 (72.1) 344 (16.8) 1,652 (83.2) 633 (26.0) 1,667 (74.0) EQ-5D Index M(SE) F/t (p) 0.96 (.00) 0.94 (.01) 0.83 (.01) 0.88 (.01) 0.92 (.00) 0.88 (.01) 0.92 (.00) 0.91 (.00) 0.92 (.01) 0.90 (.01) 0.92 (.00) 0.88 (.01) 0.92 (.00) 0.86 (.01) 0.92 (.00) t-test between premenopuase and early postmenopause group; t-test between premenopuase and late postmenopause group. -4.283-15.980-4.151-4.152-2.374 (.019) -2.434 (.016) -3.683-5.859 록승산비가 2.12, 5.44, 16.15배로상승하였다. 유직대비무직인경우 2.89배, 유배우자대비무배우자인경우 3.53배로승산비가높았다 (Table 3). 건강관련특성에서는비음주, 비만, 스트레스, 우울, 과소및과다수면이삶의질저하와유의한상관을보였다 (p<.05). 삶의질저하에대한승산비를확인한결과정상체중대비비만인경우승산비는 0.57배였고, 스트레스가심한대상자는스트레스가덜한경우에비해 2.39배, 우울한대상자는우울하지않은경우에비해 2.94배, 과소수면인대상자는충분한수면을하는경우에비해삶의질저하가 3.12배, 과다수면인대상자는 1.95 배높게나타났다 (Table 3). 또한폐경기간이 10년이상인대상자, 대사증후군과 5가지위험요인을갖고있는대상자가삶의질저하군에많았다 (p<.05). 폐경후후기여성은폐경전기여성대비삶의질저하에대한승산비가 10.56배, 폐경후초기여성은 1.96배높았다. 대사증후군을갖고있는여성의삶의질저하는대사증후군이없는여성대비 2.18배승산비가높았고, 개별위험요인이있는여성의삶의질저하는위험요인이없는여성대비 1.53배에서 2.63배까지높았다. 위험요인중승산비가가장높은변수는허리둘레가 85 cm 이상일때 2.63배로나타났다 (p<.05)(table 3). 4. 대상자의삶의질저하에영향을미치는요인의통합적탐색대상자의삶의질저하에영향을미치는요인을통합적으로 탐색하고자위계적다중로지스틱회귀분석을시행하였다. 모델 I에는인구학적특성을입력한후, 모델 II에는건강관련특성및폐경기간과대사증후군및위험요인을입력하였다. 모델 I의회귀식을검정한결과, 회귀식은유의하였고, 설명력은 20~30%, 분류의정확도에서민감도는 80.5% 로나타났다. 독립변수중에서연령군이 60대, 70대이상일때, 교육수준이초졸및중졸일때, 직업이없고배우자가없을때삶의질저하가발생하였다 (p<.05). 모델 II에서는회귀식이유의하였고, 설명력은 22~34%, 민감도는 74.8% 였으며. 인구학적특성에서초졸및중졸, 무직은그영향력을유지하였다. 추가입력한건강관련변수중삶의질저하승산비는스트레스가적을때대비많을때 1.92배였고, 우울감이없을때대비있을때의승산비는 1.93배였으며, 적정수면대비과소수면일때의승산비는 1.64배였다. 폐경기간에서는폐경전대비폐경후후기대상자에서삶의질저하가일어날승산비가 2.61배였고대사증후군위험요인중허리둘레요인이없을때대비있을때의승산비는 1.76배였다 (p<.05)(table 4). 논의 본연구는중년이후여성의삶의질수준을평가하고, 삶의질저하에영향을미치는인구학적특성, 건강관련특성, 폐경기간, 대사증후군및위험요인을단변량및다변량분석으로탐색하였다. 본연구의초점은폐경이라는생애주기변화와심혈관계건강위험요인으로대두되는대사증후군및위험요인의 280 Korean Journal of Women Health Nursing

중년이후여성에서삶의질저하에영향을미치는요인 : 폐경형태와대사증후군위험요인을중심으로 Table 3. Factors influencing on Impaired Quality of Life in Univariate Level Variables Categories Impaired quality of life Under 25% (n=498) M(SE) or n(%) Over 25% (n=1,542) M(SE) or n(%) t (p) or OR (95% CI) EQ-5D index 0.68 (0.01) 0.97 (0.00) 28.78 Demographic factors Age (yr) 40~49 50~59 60~69 70 Income quartile Level of education Occupation Having spouse Health-related factors Drinking Walking activity Weight status Perceived stress Depression Sleep duration Menopausal status Metabolic syndrome Risk factor of metabolic syndrome Blood pressure ( 130/85 mmhg) HDL-C (<50 mg/dl) Triglyceride ( 150 mg/dl) Fasting blood glucose ( 110 mg/dl) Waist circumference ( 85 cm) Upper Upper middle Lower middle Lower College High school Middle school Elementary school n-obesity Obesity Less More Sufficient Over-sufficient Insufficient Premenopause Early postmenopause Late postmenopause 37 (11.1) 83 (18.7) 154 (28.2) 224 (42.0) 94 (18.4) 105 (19.8) 137 (28.3) 160 (33.5) 15 (3.6) 59 (39.3) 64 (12.3) 360 (70.1) 136 (27.7) 362 (72.3) 267 (54.4) 227 (45.6) 191 (40.2) 307 (59.8) 66 (22.9) 222 (77.1) 285 (57.6) 212 (42.4) 309 (62.4) 186 (37.6) 355 (71.3) 139 (28.7) 263 (54.5) 41 (7.4) 191 (38.1) 41 (11.9) 73 (16.6) 368 (71.5) 249 (66.0) 149 (34.0) 281 (59.6) 217 (40.4) 134 (35.1) 265 (64.9) 255 (66.1) 144 (33.9) 300 (75.8) 98 (24.2) 289 (59.8) 208 (40.2) 551 (40.8) 504 (34.4) 284 (14.7) 203 (10.2) 426 (27.7) 399 (25.8) 380 (24.6) 330 (21.9) 312 (21.5) 571 (39.3) 205 (13.5) 453 (25.8) 785 (52.5) 757 (47.5) 1,203 (80.8) 310 (19.2) 888 (60.4) 649 (39.6) 238 (29.7) 550 (70.3) 1,082 (70.3) 460 (29.7) 1,241 (79.9) 296 (20.1) 1,353 (88.0) 184 (12.0) 1,158 (77.3) 87 (5.4) 291 (17.3) 594 (43.9) 457 (31.1) 469 (25.0) 1,125 (80.9) 288 (19.1) 1,048 (70.8) 489 (29.2) 672 (47.6) 742 (52.4) 1,052 (74.9) 362 (25.1) 1,207 (85.8) 206 (14.2) 1,211 (79.7) 330 (20.3) Statistics 2.01 (1.27~3.18) 7.06 (4.56~10.92) 15.23 (9.71~23.89) 1.15 (0.83~1.60) 1.73 (1.24~2.41) 2.29 (1.65~3.19) 2.12 (1.05~4.30) 5.44 (2.69~11.00) 16.15 (8.66~30.09) p.003.399.001.037 2.89 (2.22~3.77) 3.53 (2.72~4.60) 2.27 (1.78~2.90) 1.42 (0.97~2.08).070 0.57 (0.45~0.73) 2.39 (1.81~3.16) 2.94 (2.17~4.00) 1.95 (1.23~3.07) 3.12 (2.44~3.99) 1.96 (1.30~2.96) 10.56 (7.39~15.10).004 2.18 (1.64~2.91) 1.64 (1.31~2.06) 1.68 (1.32~2.15) 1.53 (1.15~2.04).004 1.94 (1.38~2.72) 2.63 (2.04~3.40) Vol. 22. 4, 2016 281

김지순 안숙희 Table 4. Factors influencing on Impaired Quality of Life in Women Over 40 in Multivariate Level Variables Demographic factors Categories Impaired quality of life Model I Model II OR (95% CI) p OR (95% CI) p Age 40~49 50~59 60~69 70 1.08 (0.66~1.76) 2.31 (1.37~3.89) 3.27 (1.76~6.06).758.002 0.90 (0.36~2.25) 1.14 (0.40~3.20) 1.38 (0.42~4.52).819.809.594 Educational level College High school Middle school Elementary school 1.72 (0.83~3.60) 3.46 (1.62~7.37) 6.42 (3.16~13.05).146.001 1.61 (0.76~3.42) 2.43 (1.11~5.31) 4.42 (2.18~8.94).213.027 Occupation 1.79 (1.30~2.45) 1.92 (1.37~2.70) Spouse 1.37 (1.03~1.82).033 1.17 (0.84~1.64).345 Health-related factors Drinking 1.09 (0.79~1.51).610 Perceived stress Less More 1.92 (1.30~2.84).001 Weight status n-obesity Obesity 1.02 (0.68~1.53).918 Depression 1.93 (1.30~2.87).001 Sleep duration Sufficient Over-sufficient insufficient 0.88 (0.46~1.70) 1.64 (1.19~2.27).704.003 Menopausal status Pre-menopause Early-menopause Late-menopause 1.27 (0.56~2.87) 2.61 (1.03~6.64).561.044 Metabolic syndrome 0.81 (0.49~1.34).407 Risk factor of metabolic syndrome Blood pressure 130/85 mmhg 1.01 (0.72~1.41).968 HDL-C <50 mg/dl 1.10 (0.79~1.53).556 Triglyceride 150 mg/dl 1.04 (0.69~1.58).853 Fasting blood glucose 110 mg/dl 0.95 (0.64~1.41).797 Waist circumference 85 cm 1.76 (1.15~2.70).010 영향력을평가하는것으로, 그결과여성의스트레스, 우울, 수면부족, 폐경기간이 10년이상인것과건강위험요인중에서는대사증후군위험요인의하나인복부비만이삶의질저하에영향을미치는요인이었다. 대상자의 35.5% 는폐경전여성이고, 폐경후초기여성이 27.2%, 폐경후후기여성이 37.2% 를차지하였다. 이중폐경을경험한여성의평균폐경연령은 48.72세였다. 이는대한폐경학회와한국갤럽연구소에서조사한한국인의평균폐경연령인 49.7세 [24] 와, 2012년검진센터에방문한여성의폐경연령인 48.8세 [5] 와유사한수치이다. 282 Korean Journal of Women Health Nursing

중년이후여성에서삶의질저하에영향을미치는요인 : 폐경형태와대사증후군위험요인을중심으로 대사증후군유병률은 22.9% 로폐경전여성에서는 11% 인것에반해, 폐경후초기여성에서는 22.8%, 폐경후후기여성에서는 36.5% 로증가하였다. 대사증후군위험요인의보유율은낮은 HDL-C가 55.3%, 고혈압이 32.1%, 높은중성지방이 27.9 %, 복부비만이 26.0%, 공복시고혈당이 16.8% 로나타났고폐경전여성대비폐경후초기와후기여성에서위험요인유병률이역시높게나타났다. 특히낮은 HDL-C 보유율은위험요인중그비율이가장높고, 폐경전여성의경우 48.0% 대비폐경후초기및후기에는각각 53.5%, 65.0% 까지상승하는패턴을보였다. 이는 19세이상성인여성에서대사증후군유병률이폐경전대비폐경후여성에서높고연령증가에따라유병률이상승한연구 [12] 와유사하다. 그이유는폐경기후호르몬영향으로지질대사가변화하고, 노화에따른에너지소비량과활동량의감소에따라체내지방이증가하고인슐린저항성이증가하기때문에 [10] 폐경특성과노화의특성이복합적으로반영되어대사증후군유병률이상승한것이라생각한다. 반면폐경과연령군을동시에고려할때폐경유무보다는연령군이높아질수록대사증후군발생승산비가상승한연구 [25] 는여성의연령을보정한후에도폐경전보다폐경후에대사증후군유병률이높아진연구 [13,14] 가상반되게보고되고있어추후확률표집된대형자료를이용하여폐경과연령증가에따른대사증후군유병률에대한연구가계속해서필요하다. 중년이후여성의건강관련삶의질수준은평균 0.91로높은편이었고, 단변량분석에서인구학적특성에서는고령군, 저소득층, 저학력군, 무직, 배우자가없는경우, 건강관련특성에서는비음주, 걷기운동비참여, 비만, 많은스트레스, 우울감, 수면부족또는수면과다인경우삶의질저하군이유의하게많았다. 이는기존연구 [7-9] 에서여성의삶의질관련요인으로보고된특성들과유사하다. 이를다변량분석으로평가한결과, 인구학적요인에서는저학력과무직이, 건강관련특성에서는스트레스, 우울및수면부족이삶의질저하에영향력을유지하였다. 이는스트레스와우울자체가성인여성의삶의질에영향을미치는요인이며, 폐경기주요심리적변화가스트레스와우울감인점 [7,9,26] 을고려할때이들을위한사회심리적중재의필요성을시사한다. 또한중년이후수면장애는폐경기주요신체적불편감의하나이자, 스트레스및우울의요인이되어삶의질저하에영향을미치고 [26], 폐경기가되면여성호르몬감소와복부비만의영향으로수면호흡장애와같은수면부족문제가발생하고주관적건강상태가낮아진다는연구와유사하다 [9]. 또한수면부족의영향력을고려할때, 추후연구에서수면시간뿐아니라수면에대한질평가를병행한다면수면 장애가삶의질에미치는영향력을보다강력하게확인할수있을것이다. 폐경상태에따른삶의질을비교하면, 폐경후후기여성의삶의질이 0.83, 폐경후초기여성의경우 0.94를보여폐경전여성 0.96보다낮아, 폐경경과기간에따라특히폐경전대비폐경후여성에서삶의질이저하된다는연구 [3-5,27] 를지지한다. 다변량적접근에서는폐경후후기여성의평균연령이 69.23세인점을고려함에도불구하고, 고연령과무배우자효과가사라지면서폐경후후기의효과가삶의질저하에대한영향력을유지하였다. 이는폐경을전후한차별화된간호중재가필요함을의미하는데폐경전여성에게는폐경기이행과관련된건강교육과정보제공의필요성을, 폐경후여성에게는건강한폐경후삶과노년기삶을준비하는데초점을둔간호전략이필요하겠다. 건강관련삶의질저하는또한대사증후군및위험요인을갖고있는것과유의한연관성을보였다. 대사증후군대상자의삶의질은 0.88로대사증후군이없는대상자의점수 0.92에비해낮았다. 이는대사증후군이있는 19세이상여성의삶의질수준과비교시낮은편이고, 대사증후군을갖고있는것이삶의질에영향을미친다는연구결과 [18,20,28] 와유사하다. 또한대사증후군위험요인을갖고있을때삶의질이낮다는기존연구 [5,9,10,18,20,28] 와맥을같이한다. 반면폐경유무에따라대사증후군과삶의질의관련성을보고한연구에서는폐경전여성에서는대사증후군이삶의질을낮춘반면, 폐경후여성에서는대사증후군유무가삶의질과상관이없었다 [18,19]. 이에본연구에서는폐경유무와대사증후군유무또는위험요인유무가삶의질에미치는영향력을다변량분석으로확인한결과, 폐경의효과는유지된반면대사증후군이독립적으로삶의질저하에미치는영향력을상실하였다. 이는성인여성의대사증후군위험요인인고혈압, 낮은고밀도단백지질, 고혈당, 높은허리둘레를통제한후에도대사증후군이삶의질저하를설명한다는연구 [18] 와상반되나, 위연구에서는폐경의효과를고려하지않았기때문에차이가있는것으로보인다. 대사증후군위험요인에대한다변량분석에서는폐경효과와더불어대사증후군위험요인중 85 cm 이상의허리둘레요인만이삶의질저하에미치는영향력을유지하였다. 이는폐경이후복부둘레가증가하는점을고려할때, 65~ 74세노인여성의경우만성질환을통제한후에도복부둘레가삶의질을낮춘연구와유사하다 [20]. 반면복부비만이있는성인여성에서는대사증후군자체보다는대상자의비만도와우울에의해삶의질이영향을받았다 [29]. 이는중년이후여성의 Vol. 22. 4, 2016 283

김지순 안숙희 삶의질에는대사증후군유무자체보다는대상자를둘러싸고있는인구학적및신체적 정신적건강관련특성과더불어폐경유무가복합적으로연계되어영향을미치고있음을의미한다. 종합하면중년이후여성이폐경기변화라는여성고유의특수한경험을하는과정에서폐경기및폐경이후여성의건강과전반적인삶의질증진을위해폐경기적응을위한간호중재가중요하다. 폐경을앞둔여성을대상으로폐경에대한신체적 정신적 정서적변화에대한정보를제공하여폐경기변화에대해긍정적인인식과수용을도모할필요가있겠다. 이를위해폐경전기여성의삶을이해하는자세와긍정적인지지를제공한다. 또한폐경기건강증진과질병예방을위한건강증진행위를수행할때건강관련생활습관을형성하기위해적극적인신체활동과균형잡힌영양섭취를포함하고, 수면부족, 우울과스트레스를감소시키기위해가족지지와사회심리적프로그램및주기적인건강검진을격려하여인간의기본욕구인건강관련삶의질을향상시키고자노력하여야한다. 또한폐경기를경험하고폐경후기에접어든여성을위해서는폐경기적응을돕기위한폐경기대처건강증진프로그램과노년기를준비하면서신체적 정신적건강유지와질병의조기발견에초점을둔교육과상담이요구된다. 폐경후여성의삶의질향상을위해스트레스, 우울, 과소수면, 복부비만의위험요인을사정하고, 위험요인에대한주기적인건강검진과건강행위를실천할수있도록통합적인건강관리교육과상담을제공할필요가있다. 본연구는국민건강영양조사를바탕으로한 2차자료분석연구이자횡단적조사연구이기때문에결과해석시인과관계를설명하기에는제한점이있다. 또한여성의삶의질에영향을미칠수있는폐경특성에는폐경여부, 폐경경과기간뿐아니라폐경기신체불편감을들수있는데연구자료에서는폐경기증상을이용할수없었기에이러한요인이삶의질에미치는영향을해석하는데제한이있다. 추가로폐경기여성에서가족과부부관련특성및사회관계특성이삶의질에중요한영향을미친다는연구 [30] 에도불구하고본연구자료에서는이런특성을추출할수없었다. 추후연구에서는가족의지지, 결혼만족도, 성생활만족도, 사회활동참여도및사회적지지변수를포함하여이들의삶의질에미치는영향을탐색할필요가있다. 결론 본연구는제6기국민건강영양조사를원자료로하여중년이후폐경기이행을경험하고있는여성을대상으로삶의질수 준을파악하고, 삶의질저하에미치는영향요인을인구학적특성, 건강관련특성, 폐경기간, 대사증후군유무및위험요인에따라탐색하였다. 연구결과삶의질수준은높은편이었으나폐경후후기여성이폐경전여성과폐경후초기여성에비해낮은삶의질을보였다. 대상자의삶의질저하에영향을미치는요인을통합적으로탐색한결과, 교육수준이낮을때, 무직일때, 스트레스가많을때, 우울할때, 과소수면을취할때, 폐경후후기일때, 대사증후군위험요인인허리둘레가 85 cm 이상일때삶의질이낮게나타났다. 본연구결과를바탕으로중년이후여성의삶의질저하를향상시키고폐경기건강증진을위해폐경기전여성에게는폐경기적응을위한충분한정보제공과생활습관개선및수면장애, 우울감과스트레스관리를위한건강증진프로그램에참여를독려할필요가있다. 폐경기이후에는복부비만으로진행하기쉬운신체및정서적특성이증가하기때문에보다적극적인건강관리를수행하고위험요인을확인하기위한건강검진이필요하다. 또한폐경기여성의삶의질에영향을미치는폐경기증상과가족관련특성을포함한후속연구가필요하다. REFERENCES 1. Nam HS. South Korean time trade-off values for EQ-5D health states [Internet]. Seoul: Korea Center for Disease Control and Prevention. 2007 [cited 2016 May 16]. Available from: http://www.cdc.go.kr/cdc/info/cdckrinfo0301.jsp?menu Ids=HOME001-MNU1132-MNU1138-MNU0037-MNU1380& cid=12449 2. Statistics Korea. 2014 Life tables for Korea [Internet]. Daejeon: Statistics Korea; 2014 [cited 2016 January 8]. Available from: http://kosis.kr/nsportalstats/nsportalstats_0102body.jsp? menuid=6 3. Ko HY, Lee JK, Shin JY, Jo EI. Health-related quality of life and cardiovascular disease risk in Korean adults. Korean Journal of Family Medicine. 2015;36(6):349-356. 4. Mohamed HA, Lamadah SM, Zamil LG. Quality of life among menopausal women. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2014;3(3):552-561. 5. Leem GY. The study of menopause-related quality of life and management of climacteric in a middle-aged female population in Korea. Public Health Weekly Report, KCDC. 2013;6 (31):609-613. 6. Shyu YK, Pan CH, Lin WM, Hsueh JY, Hsu CS, Tasi PS. Healthrelated quality of life and healthcare resource utilization in Taiwanese women with menopausal symptoms: A nationwide survey. Journal of Nursing Research. 2012;20(3):208-218. 7. Kim HS. The affecting factors of mental health and quality of 284 Korean Journal of Women Health Nursing

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김지순 안숙희 Summary Statement What is already known about this topic? Some studies have shown that transitioning through menopause have negatively impacted health-related quality of life, while others reported metabolic syndrome impacting quality of life for menopausal women. Moreover, quality of life is related to biological(age, obesity), psychological(stress, depression), and social(having spouse and jobs) factors. What this paper adds? Women with postmenopausal status with metabolic syndrome and its risk factors obtained worse scores in quality of life. With multivariate analysis, being late postmenopause, higher waist circumference, increased stress, depression, and insufficient sleep were significant influencing factors. Implications for practice, education and/or policy There is a need to develop nursing strategies to manage levels of stress, depression, insufficient sleep, and abdominal obesity through health education, nutritional counselling, and the need for physical activity programs developed for women who go through menopause. 286 Korean Journal of Women Health Nursing