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Original Article 대한영양사협회학술지 J Korean Diet Assoc 22(4):292-309, 2016 https://doi.org/10.14373/jkda.2016.22.4.292 갈색거저리를이용한식사섭취에따른영양섭취및영양상태변화 : 수술후환자를대상으로 김성현 손진영 박준성 1 김종원 1 강정현 1 윤은영 2 황재삼 3 김형미 강남세브란스병원영양팀 1 연세대학교의과대학외과학교실 2 세종대학교바이오산업융합학과 3 농촌진흥청국립농업과학원농업생물부 Change in Dietary Intake and Nutritional Status Using Mealworms as Hospital Meal in Postoperative Patients Seong Hyeon KimᐧJin Young ShonᐧJun Sung Park 1 ᐧJong Won Kim 1 ᐧJung Hyun Kang 1 ᐧ Eun Young Yun 2 ᐧJae Sam Hwang 3 ᐧHyung Mi Kim Dept. of Nutrition and Dietetics, Gangnam Severance Hospital, Seoul 06273, Korea 1 Dept. of Surgical, Yonsei University College of Medicine, Seoul 03722, Korea 2 Dept. of Integrated Bioindustry, Sejong University, Seoul 05006, Korea 3 Dept. of Agricultural Biology, National Institute of Agricultural Science, Rural Development Administration, Jeolabuk-do 55365, Korea ABSTRACT The purpose of this study was to verify the validity of Mealworms as a hospital meal with increased nutrition density. We provided a meal for postoperative patients and conducted analysis of dietary intake and nutritional status of patients and assessment of acceptability of the meal. This study was carried out as a randomized control trial. Patients were supplied either a hospital meal using Mealworms (Experimental group) or a regular hospital meal (Control group). We investigated the administration amounts of parenteral nutrition (PN) and food intake of patients after surgery and measured anthropometry, body composition, and blood tests before surgery and at hospital discharge. We included 34 postoperative patients who were admitted to Gangnam Severance Hospital from March to September. In the groups of patients not supplied with PN, the experimental group (964.68±284.6 kcal, 38.82±12.9 g) had significantly higher dietary calorie and protein intake than the control group (666.62±153.7 kcal, 24.47±4.9 g)(p<0.05). Additionally in the group of patients not supplied with PN, the experimental group (1.37%) showed a significantly higher increase in fat free mass index than the control group ( 3.46%)(P<0.05). In all subjects, calorie density and protein density were significantly higher in the experimental group (P<0.001), and acceptability of calorie (P=0.036) and protein (P=0.001) was also significantly higher in the experimental group. Therefore, the results of this study support the validity of the introduction of hospital meals using Mealworms. Key words : Mealworm, postoperative nutrition, protein, fat free mass, soft lean mass This work was supported by Rural Development Administration (RDA), 2016. 접수일 : 2016년 9월 27일, 수정일 : 2016년 10월 14일, 채택일 : 2016년 10월 19일 Corresponding author : Hyung Mi Kim, Department of Nutrition and Dietetics, Gangnam Severance Hostpial, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel : 82-2-2019-2950, Fax : 82-2-2058-2998, E-mail : hmkimqu@yuhs.ac, ORCID : http://orcid.org/0000-0002-3707-4033

J Korean Diet Assoc 22(4):292-309, 2016 293 서론최근국제식량농업기구 (Food and Agriculture Organization of the United Nations, FAO) 에서는지구의식량수급문제의해결방안으로곤충을인류의단백질공급식품으로지목하였다 (Van Huris 등 2013). FAO 보고서에의하면갈색거저리 (Tenebrio molitor, mealworm) 는가축에비해사육면적이좁아높은토지이용효율을보이고, 약 3개월정도의짧은생활사로 1년에 4회정도새로운세대가나오므로생산성이매우높으며, 1kg 생산시소요되는사료가육류에비해매우낮다. 또한현재지구의온난화가가속화되는시점에서소, 돼지등이배출하는온실가스가지구전체온실가스의 18% 를차지하므로환경적인측면에서도이들을대체할수있는대체식재료개발이매우시급하다 (Van Huris 등 2013). 이에따라미국, 네덜란드, 덴마크등많은국가에서곤충의식용화에대한연구가활발하게진행중에있다 (Ramos-Elorduy 2009; Miglietta 등 2015; Biasato 등 2016; Gasco 등 2016). 갈색거저리유충 ( 갈색거저리 ) 은국내에서유해물질분석및독성평가를통해인체에대한안전성을규명함으로써식품의약품안전처 (Ministry of Food and Drug Safety, MFDS) 로부터 2014년에새로운식품원료로한시적인정을거쳐 2016년 3월에식품공전까지등재된식품원료이다 (Yoo 등 2013; Han 등 2014; Han 등 2016; Ministry of Food and Drug Safety 2016). 식품으로이용되는갈색거저리는야생에서채집하지않고실내대량사육을통해생산된것이며밀겨, 쌀겨, 각종채소등을기반으로하는사료로사육되므로사람이식용하기에위생적이며안전한것이특징이다 (Rural Development Administration 2014). 갈색거저리 (Tenebrio molitor, mealworm) 는단백질함량이풍부하며단백질의필수아미노산조성이좋고, 지방의경우불포화지방산의함량이풍부하다. 이외에도칼슘, 철분, 마그네슘등의무기질함량또한풍부하다 (Kim & Jung 2013; Simon 등 2013). 동결건조된갈 색거저리분말을이용할경우육류나달걀보다영양섭취효율이좋다 (Youn 등 2014; Lee 등 2015). 갈색거저리는풍부한영양소와더불어새우와같은고소한맛을내어음식에영양과고소함을더한것이특징이기에갈색거저리를이용한다양한조리방법별특성및레시피가보고된바있다 (Kim 등 2014; Hwang 등 2015; Kim 등 2015; Yun 등 2015a; Yun 등 2015b; Baek 등 2016; Jeon 등 2016; Yun 등 2016). 또한새로운기능성을발굴하기위한연구가진행되어갈색거저리추출물의간암세포의세포독성효능및갈색거저리로부터분리한올레산및리놀레산의 β-secretase 1 효소활성저해를통한항치매효능이보고된바있다 (Youn 등 2014; Lee 등 2015). 이러한갈색거저리의영양적가치는수술환자등고영양이필요한환자에게적은양으로도양질의영양공급이가능할것으로생각한다. 수술전후의적절한영양공급은위장관수술을받는환자의임상적결과를효과적으로개선시킨다 (Bozzetti 등 2001; Correia & Waitzberg 2003). 최근수술환자에게 ERAS(Enhanced Recovery After Surgery) 의개념이적용되면서수술전후관리의중요성이부각되고있다. ERAS는수술후환자의빠른회복과재원일수감소및수술예후를개선시키기위한다양한관리방법들의조합이다 (Lassen 등 2012). ERAS에서의영양관리개념은수술후환자의위장관기능회복을도와가급적빠르게경구식사를할수있도록하며, 회복과정에서적절하게영양공급이될수있도록영양관리를수행하는것이다 (Han 2012). 위장관수술 2 4일후에일반영양지표인혈중프리알부민, 트랜스페린, 알부민등이회복되는경향을보이나, 단백질섭취량을대변하는질소평형은감소추세를보인다 (Kim 등 2012). 특히위장관암환자의경우늦게시작하는경구식사와적은식사량으로인해수술후 10일까지단백질이화작용이증가하는반면, 단백질동화작용은감소한다 (Souba & Austgen 1990). 이로인해체내의장단백, 골격근단백등근육이감소되고, 지방조직감소를초래하게

294 갈색거저리환자식섭취에의한영양상태변화 되어 (Hara & Kubo 2015) 수술후체중감소와악액질 (cachexia) 이유발되고, 신체기능이저하된다 (Bae 등 1998; Kim 등 2001; Yu & Chung 2001). 따라서수술후상처및제지방량회복, 질소평형감소의회복을위해서는환자에게적절한양의식사와양질의단백질섭취가필요하나재원기간동안환자의단백질급원식품의섭취량은저조한실정이다 (Lee 등 2014). 이는수술후환자의경우장폐색, 위배출지연, 문합부누출방지등에의해경구식사섭취가지연되며 (Bozzetti 등 2007), 수술후 1회식사량의제한, 소화불량, 식후조기포만감, 팽만감, 심리적인두려움으로인해특히육류등단백질급원식품의섭취가부족한것으로보고되고있다 (Park 등 2012). 또한 Shin(2014) 에의하면환자가수술후경구섭취를할경우의료진들은환자의섭취량이나섭취상태를고려하지않고, 충분히영양공급이되는것으로판단하여부적절한영양섭취에주의를기울이지않는경우가많은것으로나타났다. 수술후제공되는미음과죽은단위부피당열량이낮아영양요구량을충족시키기어려운식사이며, 환자의섭취량이적다면단기간에영양불량이초래될수있다. 이에현재병원에서제공되는수술후환자식의영양적적절성이면밀하게검토되어야하며, 환자의식사섭취량에대한모니터링을기반으로적절한영양공급이필요하다. 본연구에서는첫째, 고단백, 고영양식품인갈색거저리를이용하여영양밀도를높인식사를구성하고이를수술후환자에게제공하여식사섭취량과열량및단백질섭취량을증가시키고자한다. 둘째, 이를통해환자영양상태개선에도움이되는지를확인하고자한다. 셋째, 갈색거저리를이용한식사에대한환자의수응도를평가하여갈색거저리를환자식에도입하는데있어가능성을살펴보고자한다. 본연구는국내에서식용곤충인갈색거저리를환자식에도입한최초의연구로써, 향후환자식에갈색거저리등식용곤충의실용화연구에대한기초자료가되고자한다. 연구방법 1. 연구대상및연구기간 2016년 3월부터 9월까지강남세브란스병원의간담췌외과, 대장항문외과, 위장관외과에입원하여위장관수술한환자들중경구로식사섭취가가능하고 7일이상입원이예상되는환자를대상으로하였다. 7일이상의식사섭취는수술후환자의영양평가시 IGF-1 등의생화학적지표가반응하게하는최소기간이다 (López-Hellin 등 2002). 또한갑각류알레르기가있는환자, 임산부, 간부전환자, 신부전환자, 이식후환자, 기대여명이 1개월미만인환자, 면역이억제된환자, 활동성혈액종양환자, 정신과환자, 문맹또는외국인환자는대상에서제외하였다. 이는다중주파수임피던스법을이용한체성분분석시발생가능한오차를줄이기위한환자군선택이며, 갑각류알레르기발생시갈색거저리식사가위험할수있다고판단되어제외대상에포함하였다. 본연구의취지를이해하여연구참여에서면으로동의한 41명의환자가대상자로등록되었고, 연구기간중동의를철회한환자 1 명, 수술후합병증발생환자 2명과기타사유 4명 ( 수술법변경 1명, 생화학적검사누락 1명, 체성분조사계측오류 2명 ) 을제외하고 34명의자료를분석했다. 본연구는전향적환자대조군연구로써, 연구참여에동의한대상환자들은단순무작위배정에의해대조군또는실험군으로배정되었다. 본연구는연세의료원강남세브란스병원연구심의위원회 (Institutional Review Board, IRB) 의승인 ( 승인번호 : 3-2016-0025) 을받았다. 2. 갈색거저리환자식구성본연구에사용한갈색거저리는농촌진흥청에서수립된갈색거저리사육및분말제조매뉴얼 (Rural Development Administration 2015) 에근거하여제조된갈색거저리분말을구입하여사용하였다. 갈색거저리

J Korean Diet Assoc 22(4):292-309, 2016 295 분말은경북예천군소재곤충나라에서사육한유충을 2일동안절식후세척하고, 액체질소를부어급속동결하여 70 o C 초저온냉동고 (NIHON freezer, Tokyo, Japan) 에서 24시간이상냉동시킨후, 동결건조기 (Eyela, Tokyo, Japan) 에서약 48 60시간동안건조시킨후다기능분쇄기 (KSP-35, Korea Medi) 를이용하여분쇄하였다. 실험군의식사는수술후환자식에적용가능한메뉴를선정하여, 갈색거저리분말을이용한메뉴로실험조리를거쳐개발하였다. 개발된메뉴를활용하여본원의식사처방지침서에근거하여맑은유동식, 일반유동식, 일반연식의 3단계식사로식단을구성하였으며, 본원에서제공중인수술후환자식, 즉대조군식사의열량과단백질양을유사하 게조정하였다. 최종확정된식단의메뉴는표준레시피를수립하여조리의지침서로활용하였다. 3. 식사제공식사는병원의수술후단계별식사프로토콜에근거한의사의식사처방에따라서제공되었다. 단순무작위로배정된실험군과대조군환자에게눈가림방식으로, 실험군환자에게는갈색거저리메뉴가포함된식사가, 대조군환자에게는현재병원에서제공되는식사가병원정규식사시간에동시에제공되었다. 본연구에서제공한수술후환자식의식단및프로토콜은다음과같다 (Table 1). Table 1. Menu plan and protocol of hospital meal for experimental and control groups. Experimental group Control group Step 1 Menu Carbohydrate-based liquid diet, Mealworm jelly Carbohydrate-based liquid diet, Juice Nutrient Energy 580 kcal 450 kcal Protein 13 g 16 g Carbohydrate 114 g 84 g Fat 8 g 6 g Step 2 Menu Mealworm soup, Mealworm shake with berry, Protein-fortified gelatin Carbohydrate-based liquid diet, Thin low fat soup, Soybean milk, Protein fortified gelatin Nutrient Energy 1,220 kcal 1,240 kcal Protein 50 g 43 g Carbohydrate 180 g 180 g Fat 34 g 39 g Step 3 Menu Deluxe rice porridge with soft side dishes, ONS 1) -based mealworm drink, Mealworm tea-confectionery Rice porridge with soft side dishes Nutrient Energy 1,629 kcal 1,600 kcal Protein 81 g 75 g Carbohydrate 225 g 235 g Fat 45 g 40 g Protocol 1) Doctor prescribes Step 1 diet (Clear liquid diet) in the first meal after surgery. Patients eat this diet for 2 3 meals 2) In the next meal, doctor prescribes Step 2 diet (Full liquid diet). Patients eat this diet for 2 3 meals 3) If diet transition goes smoothly, doctor prescribes Step 3 diet (Soft diet). Patients eat this diet until discharge 4) Doctor prescribes hospital meal. Depending on patients s condition, step of diet could be adjusted 5) Dietitian survey dietary intake every day until discharge. If there is a meal-related side effects, it is reported to the doctor 1) ONS: Oral nutritional supplement

296 갈색거저리환자식섭취에의한영양상태변화 4. 조사내용대상자들의성별, 연령, 진단명, 기저질환, 과거수술력등의일반정보는의무기록을통해수집하였다. 키와체중은조사당일측정하였고, 체질량지수 (BMI) 를사용하여표준체중을산정하였으며, 산출된표준체중을기준으로조사된체중의표준체중백분율 (Percent Ideal Body Weight, PIBW) 을산출하였다. 영양상태평가시에체중상태를지표로할경우, PIBW가 70 80% 는보통의영양불량, 80 89% 는경도의영양불량, 90 110% 는정상으로판정하였다 (Grant 등 1981). 성인영양불량환자선별시가장민감한지표로의도하지않은체중감소가보고되고있어 (Lipkin & Bell 1993; Lee 등 2013) 체중변화를면밀히모니터링하였다. 수술후식사섭취량은식사일기를사용하여연구대상자가직접기록하도록하였으며, 임상영양사가매일수거하면서환자에게구두로다시확인하였다. 기록된식사섭취량은 Can-Pro 4.0(Korean Nutrition Society, Seoul, Korea) 을사용하여열량및탄수화물, 단백질, 지질등 3 대영양소의섭취량으로산출하였다. 대상자들의식사섭취량조사는수술후시작되는식사부터퇴원전식사까지모두조사하였으며, 추가치료또는금식처방으로인하여재원기간이늘어날경우식사섭취시작후 10일기점 (7±3일) 에섭취량조사를완료하였다. 식사섭취량외에진료과에서수술후치료프로토콜에의해정맥영양 (Parentral Nutrition, PN) 을공급하는경우에는정맥영양을통한영양섭취량도산출하였다. 본연구에서경구섭취량은식사섭취량으로, 정맥영양공급과경구섭취량을포함한전체섭취량은총영양섭취량으로표기하고자한다. 본연구의 1차유효성평가항목은 1일평균식사섭취량이다. 산출방법은매일식사일기를통해조사된식사섭취량의열량및영양소양을분석하여식사섭취기간동안의총열량및영양소의양으로합산하여각환자마다의섭취끼니수로나누었다. 이렇게산출된끼니별평균열량및영양소섭취량 을근거로 1 일평균식사섭취량, 즉, 열량, 탄수화물, 단백질, 지질의양를계산하였다. 조사기간동안끼니별로섭취량을산출한이유는식사이행중에환자상태에따라갑작스럽게금식이처방될수있기때문에이를보정하기위함이다. Sasaki 등 (2011) 에의하면췌십이지장절제술을받은환자의휴식대사량 (Resting energy expenditure, REE) 을간접열량계로측정시수술후 7일째측정된 REE는 25.7±3.5kcal/kg/day 이다. 이문헌에근거하여열량요구량은현재체중당 25kcal로계산하였으며, 단백질요구량은표준체중당 1g으로계산하였다 (Weimann 등 2006). 환자의열량및단백질섭취비율은환자개개인의열량및단백질섭취량대비열량및단백질요구량의비율로각각산출하였다. 섭취된식사의영양밀도는대상자가수술후재원기간동안의식사로섭취한식품중량의합대비열량및단백질양의비율이다. 식사섭취량조사를통해식사로섭취한식품중량의총합으로분모값을사용하였고, Can-Pro 4.0으로산출한영양소섭취량을분자값으로사용하여영양밀도를계산하였다. 영양밀도 (Dietary Density) = 식사로섭취한영양소량식사로섭취한식품중량의총합 또한식사의수응도는수술후제공한식사량대비식사섭취량을백분율 (%) 로계산하였으며, 섭취한식사부피, 열량, 단백질및지질로항목을분석하였다. 프로토콜에의거하여제공한식사별식품중량의총합으로분모값인식사제공량을계산하였고, 식사섭취량조사를통해분자값을사용하여식사의수응도를계산하였다. 수응도 (Acceptability, %) = 식사섭취량 100 식사제공량

J Korean Diet Assoc 22(4):292-309, 2016 297 체성분분석은다중주파수임피던스법을이용한인바디 (Inbody) S-10(Biospace, Seoul, Korea) 을이용하여수술전, 퇴원전등 2차례에걸쳐수집하였다. 영양사가측정하였으며, 측정매뉴얼에따라환자가편하게누운상태에서측정하였고측정하는동안몸통과팔다리가일정간격을유지하여벌어지도록하였다. 본연구에서는체중 (Body weight), 체세포량 (Body cell mass), 제지방량 (Fat free mass), 근육량 (Soft lean mass), 체지방량 (Fat mass) 의값을분석에사용하였다. 대상환자의생화학적검사결과중영양상태와관련있는지표인인슐린유사성장인자 (Insulin-like Growth Factor-1, IGF-1), 혈청알부민 (Albumin), 콜레스테롤 (Cholesterol), 총림프구수 (Total Lymphocyte Count, TLC), C 반응성단백 (C-reactive protein, CRP) 을수술 전, 퇴원전등 2차례에걸쳐의무기록을통해수집하였다. 5. 자료처리및통계분석수집된자료는 IBM SPSS Statistics 23.0(IBM Co., Armonk, NY, USA) 을이용하여통계치를산출하였으며평균과표준편차혹은빈도와백분율로표시하였다. 영양소섭취량, 신체계측치의변화, 체성분변화, PG-SGA(Scored Patient-Generated Subjective Global Assessment) 점수, 삶의질조사점수등평균차이는조사시점에따라연속형변수에대해 Wilcoxon signed rank test, Mann-whitney test 등의비모수통계를이용하였다. 모든통계적유의성은 P<0.05 수준에서검증하였다. Table 2. Baseline characteristics of subjects between groups. Variable Experimental group (n=20) Control group (n=14) P-value Gender Male:female, N (%) 12 (60):8 (40) 10 (71.4):4 (28.6) 0.72 Age (years) 57.8±11.3 1) 65.1±11.4 0.10 Major diagnosis 0.10 Non-cancer, N (%) 2 (10.0) 5 (35.7) Cancer, N (%) 18 (90.0) 9 (64.3) Site of onset, N (%) 0.57 Upper gastrointestinal 10 (50.0) 5 (35.7) Hepatobiliary 5 (25.0) 3 (21.4) Lower gastrointestinal 2 (10.0) 1 ( 7.1) Others 3 (15.0) 5 (35.7) PIBW 2) (%) 108.3±12.7 109.0±11.6 0.90 Energy requirement 3) (kcal/d) 1,585.0±242.3 1,556.7±245.2 0.85 Protein requirement 4) (g/d) 58.22±6.9 57.56±6.9 0.96 PN 5), N (%) 12 (60.0) 7 (50.0) 0.73 PN duration (days) 2.9±2.5 3.3±3.8 0.77 Length of stay (days) 8.4±0.8 11.2±4.2 0.04* 1) Mean±standard deviation 2) PIBW: Percent Ideal Body Weight 3) Current body weight 25 kcal/day 4) Ideal body weight 1 g/day 5) PN: Parenteral nutrition *Significantly different between experimental group and control group by Mann-Whitney test at P<0.05

298 갈색거저리환자식섭취에의한영양상태변화 결과 1. 일반사항대상환자의일반사항은 Table 2에제시하였다. 분석에포함된환자총 34명중실험군은남자 12명 (60%), 여자 8명 (40%), 대조군은남자 10명 (71.4%), 여자 4명 (28.6%) 로남자의비율이높았다. 평균나이는실험군 57.8±11.3세, 대조군 65.1±11.4세였다. 실험군은대상자의 90%(18명 ) 가암환자였고, 대조군은대상자의 64.3%(9명 ) 가암환자였다. 암부위별로보면실험군은상부위장관 (10명, 50%), 간담췌 (5명, 25%), 하부위장관 (2명, 10%) 등의순이었고, 대조군은상부위장관 (5명, 35.7%), 간담췌 (3명, 21.4%), 하부위장관 (1명, 7.1%) 등의순이었다. 조사대상자의표준체중백분율 (PIBW) 의평균은실험군 108.3±12.7% 이고, 대조군 109.0±11.6% 이다. 환자의 1일열량요구량은실험군이 1,585.0±242.3kcal/d, 대조군이 1,556.7±245.2kcal/d이었으며, 환자의 1일단백질요구량은실험군이 58.22± 6.9g/d, 대조군이 57.56±6.9g/d이었다. 과별로치료프로토콜에의해정맥영양을추가로공급받은환자가실험군이 60.0%(12명 ), 대조군이 50.0%(7명 ) 이며, 정맥영양공급기간은실험군이 2.9±2.5일, 대조군이 3.3±3.8일로나타났다. 연구참여기간을포함한재원기간은실험군이 8.4±0.8일, 대조군이 11.2±4.2일로조사되었다. 2. 수술후입원기간중 1일평균식사섭취량의열량및영양소분석과별로수술후치료프로토콜에의해정맥영양을추가로공급받은환자군이있었다. 이에실험군, 대조군내에각각정맥영양을공급받은그룹과정맥영양을공급받지않은그룹으로이차분류하여결과를분석하였다 (Table 3). 단, 정맥영양을공급받지않은그룹의경우 1명을제외하고모두간담췌외과환자였기때문에동일조건으로통제하고자타과 1명을제외하고분석하였다. 실험군에서정맥영양을공급받지않은그룹의경우열량은 964.68±284.6kcal, Table 3. Average daily energy and nutrients intake between groups. Variable Experimental group Control group P-value PN 1) group n=12 n=7 Daily PN energy (kcal) 2,888.67±847.9 2) 3,677.57±2,041.1 0.773 Daily PN protein (g) 109.61±38.8 137.00±78.3 0.711 Daily PN carbohydrate (g) 311.58±96.1 409.86±262.0 0.592 Daily PN fat (g) 133.77±39.9 165.57±77.6 0.711 Daily oral intake energy (kcal) 846.67±342.9 766.49±422.6 0.773 Daily oral intake protein (g) 35.50±14.6 31.92±19.8 0.773 Daily oral intake carbohydrate (g) 113.30±40.4 110.42±55.2 0.967 Daily oral intake fat (g) 27.95±15.6 21.90±14.1 0.650 Non-PN group n=8 n=6 Daily oral intake energy (kcal) 964.68±284.6 666.62±153.7 0.043* Daily oral intake protein (g) 38.82±12.9 24.47±4.9 0.029* Daily oral intake carbohydrate (g) 138.24±38.4 114.04±33.3 0.282 Daily oral intake fat (g) 28.49±10.2 12.51±2.3 0.001** 1) PN: Parenteral nutrition 2) Mean±standard deviation *Significantly different between experimental group and control group by Mann-Whitney test at P<0.05 **Significantly different between experimental group and control group by Mann-Whitney test at P<0.01

J Korean Diet Assoc 22(4):292-309, 2016 299 단백질은 38.82±12.9g, 탄수화물은 138.24±38.4g, 지질은 28.49±10.2g이었으며, 정맥영양을공급받은그룹의경우열량은 846.7±342.9kcal, 단백질은 35.50±14.6g, 탄수화물은 113.30±40.4g, 지질은 27.95±15.6g이었다. 대조군에서정맥영양을공급받지않은그룹의경우열량은 666.62±153.7kcal, 단백질은 24.47±4.9g, 탄수화물은 114.04±33.3g, 지질은 12.51±2.3g이었으며, 정맥영양을공급받은그룹의경우열량은 766.49±422.6kcal, Table 4. Oral intake density between groups. Variable Dietary oral intake energy denstiy (kcal/d) Dietary oral intake protein denstiy (g/d) 1) Experimental group (n=20) Control group (n=14) P-value 1.24±0.2 1) 0.85±0.1 <0.001*** 0.05±0.01 0.03±0.01 <0.001*** Mean±standard deviation ***Significantly different between experimental group and control group by Mann-Whitney test at P<0.001 단백질은 31.92±19.8g, 탄수화물은 110.42±55.2g, 지질은 21.90±14.1g이었다. 실험군이정맥영양공급유무와관계없이식사섭취만으로열량, 단백질, 지질섭취량이대조군보다많은것으로분석되었다. 또한, 정맥영양공급유무와관계없이식사섭취로단백질요구량의 80% 이상섭취한대상자수는실험군 12명, 대조군 4명이었다 (data not shown). 이를다시정맥영양공급유무에따라분석한결과정맥영양이공급된그룹의경우실험군이식사를통한열량및영양소섭취량이대조군보다전반적으로높은경향을보였으나유의적이지않았다. 반면, 정맥영양이공급되지않은그룹의경우실험군이식사를통한열량 (P<0.05), 단백질 (P <0.05), 지질 (P<0.01) 섭취량이대조군보다유의적으로높았다. 실험군, 대조군에서정맥영양을공급받은그룹간에정맥영양을통한영양섭취량은군별로유의적인차이는없었다. 전반적으로실험군, 대조군모두에서정맥영양을공급받은그룹이정맥영양을공급받지않은그룹보다총영양섭취량이많았다. Table 5. The changes of body composition between groups. Variable Experimental group (n=20) (%) 1) Control group (n=14) (%) P 2) Body weight Pre-op 62.27±9.8 3) 1.26±2.1 Pre-op 63.41±9.7 2.71±3.5 0.274 Post-op 61.43±9.5 Post-op 61.61±9.1 P 4) 0.017* P 0.018* BCM 5) Pre-op 29.87±5.7 0.23±4.4 Pre-op 30.04±5.2 2.04±4.8 0.192 Post-op 29.83±6.0 Post-op 29.36±4.8 P 0.926 P 0.108 SLM 5) Pre-op 43.40±8.2 0.45±4.6 Pre-op 44.07±7.5 1.37±5.4 0.231 Post-op 43.64±8.7 Post-op 43.37±7.0 P 0.370 P 0.279 FFM 5) Pre-op 45.97±8.5 0.62±4.7 Pre-op 46.69±7.8 1.17±5.6 0.204 Post-op 46.31±9.2 Post-op 46.04±7.4 P 0.287 P 0.382 FM 5) Pre-op 16.32±4.4 7.65±12.8 Pre-op 16.72±5.6 7.13±15.9 0.743 Post-op 15.12±4.6 Post-op 15.54±6.0 P 0.014* P 0.039* 1) (%)=[{(post-op) (pre-op)}/(pre-op)] 100 2) Mann-Whitney test at P<0.05 between experimental group and control group 3) Mean±standard deviation 4) *Significantly different between pre-op and post-op by Wilcoxon signed rank test at P<0.05 5) BCM: Body cell mass, SLM: Soft lean mass, FFM: Fat free mass, FM: Fat mass

300 갈색거저리환자식섭취에의한영양상태변화 3. 수술후입원기간중식사섭취량의영양밀도열량의영양밀도는실험군이 1.24±0.2kcal/d, 대조군이 0.85±0.1kcal/d로실험군이유의적으로높았으며 (P<0.001), 단백질의영양밀도는실험군이 0.05±0.01g/d, 대조군이 0.03±0.01g/d로실험군이유의적으로높았다 (P<0.001)(Table 4). 4. 수술전후체성분분석변화실험군, 대조군모두수술후유의적인체중감소가발생했으나대조군에서체중감소율이더높은경향을보였다 (P=0.274)(Table 5). 제지방량 (FFM), 근육량 (SLM) 은실험군에서수술후증가하는경향을, 대조군에서수술후감소하는경향을보였다. 정맥영양을공급받은그룹과정맥영양을공급받지않은그룹으로분류하여체성분분석변화량을비교하였다. 정맥영양을공급받은그룹에서는실험군이대조군보다체중감소율, 체세포량감소율, 체지방감소율이적었으나, 통계적으로유의한차이는없었다. 정맥영양을공급받지않은그룹에서는실험군이대조군보다체중감소율과체세포량감소율이적은 것으로나타났으나, 통계적으로유의한차이는없었다. 또한실험군은유의적인제지방량증가 (P<0.05) 및근육량의증가경향을보이는반면, 대조군은제지방량, 근육량이감소하였다 (Fig. 1). PIBW 100% 를기준으로대상자를분류시 PIBW가 100% 미만인실험군대상자수는 7명, 대조군은 3명이었다. 영양불량의위험이있는이대상자들의수술전후체성분분석변화량을비교하였다 (Table 6). 두군모두전반적으로체세포량, 근육량, 제지방량이감소하였으나, 실험군이유의적으로적게감소하였다 (P<0.05). 5. 제공된식사의수응도실험군이대조군에비하여식사부피의수응도가유의적으로높고 (P<0.01), 열량섭취의수응도 (P=0.036), 단백질섭취의수응도 (P=0.001), 지질섭취의수응도 (P=0.001) 모두유의적으로높았다. 즉실험군에서제공량대비섭취한식사량이많았고, 식사내용으로도열량, 단백질, 지질섭취량이유의적으로많았음을확인할수있다 (Table 7). 한편, 연구기간동안갈색거저리환자식을섭취한실험군환자에게서식사에대한이상반응발생이나섭취중단은한건도없었다. Table 6. The changes of the body composition of the group in PIBW<100%. Figure 1. Rate of change for body composition in Non-PN group. *Significantly different between experimental group and control group by Mann-Whitney test at P <0.05. BW: Body weight, BCM: Body cell mass, SLM: Soft lean mass, FFM: Fat free mass, FM: Fat mass. Variable Experimental group (n=7) Control group (n=3) P-value PIBW 1) (%) 94.77±4.1 2) 94.30±4.3 1.000 BW 1) change (kg) 3) 1.30±1.4 2.80±1.6 0.267 BCM 1) change (kg) 0.33±0.9 1.93±0.9 0.033* SLM 1) change (kg) 0.23±1.5 2.77±1.4 0.033* FFM 1) change (kg) 0.14±1.7 2.87±1.5 0.033* FM 1) change (kg) 1.16±1.9 0.07±2.6 0.383 1) PIBW: Percent Ideal Body Weight, BW: Body Weight, BCM: Body cell mass, SLM: Soft lean mass, FFM: Fat free mass, FM: Fat mass 2) Mean±standard deviation 3) Change (kg)={(post-op) (pre-op)} *Significantly different between experimental group and control group by Mann-Whitney test at P<0.05

J Korean Diet Assoc 22(4):292-309, 2016 301 6. 수술전후생화학적검사변화 고찰 영양상태와관련이있는생화학적검사결과로는전반적으로수술후 C 반응성단백 (CRP) 은증가하였고, 인슐린유사성장인자 (IGF-1), 혈청알부민 (Albumin), 콜레스테롤 (Cholesterol), 총임파구수 (TLC) 는감소하였으나두군의변화량은통계적으로유의한차이는없었다 (Table 8). Table 7. Acceptability of hospital meal. Variable Experimental group (n=20) Control group (n=14) P-value Volume (%) 62.16±18.4 1) 45.56±17.2 0.009** Energy (%) 60.25±20.2 43.57±18.4 0.036* Protein (%) 60.52±20.2 34.84±16.1 0.001** Carbohydrate (%) 61.14±20.2 68.03±68.1 0.436 Fat (%) 57.93±20.4 31.03±16.5 0.001** 1) Mean±standard deviation *Significantly different between experimental group and control group by Mann-Whitney test at P<0.05 **Significantly different between experimental group and control group by Mann-Whitney test at P<0.01 Table 8. The changes of biochemical data between groups. Variable Experimental group (n=20) Control group (n=14) P-value 1) IGF 2) change 3) (ng/ml) 28.19±42.5 4) 44.48±45.4 0.416 Alb 2) change (g/dl) 0.04±1.0 0.37±0.7 0.120 Chol 2) change (mg/dl) 13.57±35.7 12.67±26.9 0.769 TLC 2) change (10 3 /μl) 0.18±0.6 0.07±0.8 1.000 ANC 2) change (10 3 /μl) 3.09±11.6 1.95±4.7 0.169 CRP 2) change (mg/l) 35.44±42.4 36.37±26.9 0.323 1) Mann-whitney test between groups 2) IGF: Insulin-like growth factor, Alb: Albumin, Chol: Cholesterol, TLC: Total lymocyte count, ANC: Absolute neutrophil count, CRP: C-reactive protein 3) Change={(post-op) (pre-op)} 4) Mean±standard deviation 본연구는위장관수술을받은환자를대상으로갈색거저리를이용한영양밀도를높인식사를제공하여식사섭취량및환자영양상태변화를분석하고, 환자의수응도를평가하여갈색거저리의환자식활용타당도를검증하고자하였다. 본연구에서는의료진의치료프로토콜에의해정맥영양을추가로공급된환자군이발생하여, 실험군과대조군내에서각각정맥영양이공급된그룹과정맥영양이공급되지않은그룹으로이차분류하여결과를분석하였다. 본연구에서식사섭취량을통한열량및영양소섭취량을비교한결과실험군이정맥영양공급유무와관계없이식사섭취만으로열량, 단백질, 지질섭취량이대조군보다많은것으로분석되었다. 이를다시정맥영양공급유무에따라분석한결과정맥영양이공급된그룹의경우실험군이식사를통한열량및영양소섭취량이대조군보다전반적으로높은경향을보였으나유의적이지않았다. 반면, 정맥영양이공급되지않은그룹의경우실험군이식사를통한열량 (P<0.05), 단백질 (P<0.05), 지질 (P<0.01) 섭취량이대조군보다유의적으로높았다. Agarwal 등 (2012) 은급성환자에서입원기간중식사섭취량부족으로 40% 의환자들이영양불량이라보고한바있으며, 특히위암수술후입원기간동안섭취한평균열량은 1일열량필요량의 41.6% 에불과하였다고한다. Park 등 (2012) 은이러한식사섭취량의저조한원인으로수술후복부불편감등의신체적증상으로인한섭취제한과식사섭취에불편한점은없었지만심리적인두려움으로인한환자스스로의식사섭취제한이있었음을보고하였다. 따라서이점을고려하여수술환자를위한메뉴개발등의구체적인영양관리제안이필요하다고밝혔다. 이에본연구에서는갈색거저리분말을이용하여식사의부피를줄이고영양밀도를높인메뉴를개발하여, 대조군환자의식사에비해실험군환자의식사섭

302 갈색거저리환자식섭취에의한영양상태변화 취량을증가시켜열량및영양소의섭취량을증가시킨것으로생각된다. 특히수술후식사를통한단백질섭취량조사결과실험군이대조군보다단백질섭취량이높았다 (38.82±12.9g vs. 24.47±4.9g, P=0.029). 수술전후의열량및단백질섭취는수술후근육분해와영양상태악화를예방할수있다 (Faria 등 2011; Braga & Sandrucci 2016). 위소매절제술을받은비만환자들을대상으로하여제지방량유지를위한적절한단백질섭취는하루 60g 이상섭취하는것이권고된다 (Dagan 등 2016). 또한, 최근 A.S.P.E.N 가이드라인 (McClave 등 2016) 에의하면수술환자와같은중환자관리시단백질공급은상처회복, 면역기능보강, 제지방량유지를위해매우중요하며, 영양불량위험이있는환자에게는 2 3일이내에열량및단백질요구량대비 80% 이상제공해야한다고제시하고있다. 본연구에서정맥영양공급유무와관계없이식사섭취로단백질요구량의 80% 이상섭취한대상자수는실험군 12명, 대조군 4명이었다. 이는갈색거저리의높은단백질함량과분말형태의제형으로환자가섭취하기용이한형태로메뉴가개발되어실험군의식사가단백질섭취가용이하였으며, 섭취량에비하여단백질의영양밀도가높은것과관계가있는것으로생각된다. 즉본연구에서대상자들이섭취한식사의영양밀도를비교시실험군이대조군보다열량의영양밀도 (P<0.001) 및단백질의영양밀도가유의적으로높았다 (P<0.001). 병원에서수술후환자에게제공되는식사는초기에는미음으로시작하여점차죽의형태로이행한다. 미음과죽식은수분량이많고단백질등영양소의함유량이적다. 위에서기술한경구섭취를통한열량및단백질양이부족하지않기위해서는현실적으로환자의저조한식사섭취량을감안하여영양밀도는높이고수분량은줄인경구식사의제공이필요하다. 이러한측면에서실험군식사의경우갈색거저리자체의높은영양소함량을이용하여단위부피당열량및단백질함량을높인식사구성이 가능하였다. 또한갈색거저리식사는환자가제공량대비섭취량이많았으며, 현재병원에서제공되는대조군식사에비해유의적으로높은수응도를나타냈다. 뿐만아니라연구기간동안갈색거저리식사에대한알레르기반응등이상반응은관찰되지않았다. 본연구에서다중주파수임피던스법을이용한체지방분석기 (Inbody S-10) 를이용하여측정한체성분분석결과비교시실험군중정맥영양을공급받지않은그룹에서는제지방량이유의적으로증가하였고 (P<0.05), 동시에근육량이증가하는경향을보였다. 실험군중정맥영양을공급받은그룹에서는제지방량및근육량이다소증가하는경향을보였다. 반면대조군에서는정맥영양을공급받은그룹과공급받지않은두그룹모두에서수술후체성분이감소하였다. 이를통해정맥영양공급유무와관계없이갈색거저리식사섭취가제지방량의증가에기여한것으로생각된다. 체구성성분중제지방조직은주로골격과근육으로구성되는데 (Steen 1988), 제지방량의감소는수술환자, 중환자와같이영양불량위험이있는환자에서상처회복지연, 감염률증가, 이환율증가, 재원기간증가및의료비용증가와연관되며 (You 등 2013; Reisinger 등 2016), 특히사망률증가, 장기부전과강한상관관계가있는것으로보고되고있다 (Ghorabi 등 2016). 또한, 제지방량의감소는근감소증 (sarcopenia) 의결과로 (Evans 1999), 근감소증은근육조직의감소로악액질의일부이며 (Mariette 등 2012), 수술후환자에게이환율및사망률증가와함께수술후단기간의임상결과에영향을미친다 (Peng 등 2011). 뿐만아니라근감소증은위장관암수술후환자의불량한임상결과를예측하게한다 (Robinson 등 2011; Peng 등 2012; Tan 등 2012; Van Vledder 등 2012; Reisinger 등 2015). 수술후환자의적은근육량은수술후염증반응증가를초래하며, 이는근감소증환자의수술후합병증증가와연결된다 (Reisinger 등 2016). 특히, 암환자의근감소증은부정적인임상결과를초래한다. 근감소증은위암환자의 57%, 진행성간암환자의

J Korean Diet Assoc 22(4):292-309, 2016 303 27.5%, 전이성신장암환자의 29% 에서주로발생하며 (Mir 등 2012; Tegels 등 2015; Sharma 등 2015), 암환자의근감소증은항암치료의독성증가, 수술후합병증증가, 생존율감소와연관된다 (Kazemi- Bajestani 등 2016). Shachar 등 (2016) 에의하면고형암환자대상으로메타분석결과암종류와병기별로차이는있지만, 근육량의감소는전체생존율감소및암특이생존율감소와연관된다. Weed 등 (2011) 은두경부암환자를대상으로수술전 2주와수술후재원기간인평균 11일동안 EPA(Eicosapentaenoic acid) 가함유된영양보충음료를제공한결과퇴원시에제지방량이유의적으로증가했음을보고하였다. 또한 Ryan 등 (2009) 은식도암환자를대상으로수술전 5일동안경구로, 수술후재원기간인 21일간공장루로영양보충음료를제공하여제지방량의감소를줄였음을보고하였다. 이렇듯수술전후로대략 1개월간의영양중재를통해제지방량변화에긍정적효과를보인연구는보고되었으나, 수술후단기간의제지방량변화를보고한연구는없었다. 이러한연구결과들을토대로보았을때, 갈색거저리식사를한그룹에서환자의제지방량및근육량증가는매우의미있는결과로생각된다. 본연구대상자의표준체중백분율의평균은 108.6± 12.1% 로대부분정상에속하여 PIBW 100% 를기준으로군을분류하여분석하였다. PIBW가 100% 이상인군에서는실험군이대조군보다체세포량, 근육량, 제지방량이적게감소하였으나두군간차이가유의적이지않았다. 반면, PIBW가 100% 미만인군에서실험군이대조군보다체세포량, 근육량, 제지방량이유의적으로적게감소하였다. 특히체성분중체세포량은세포외액으로부터독립적인요인으로부종의영향이비교적적은항목으로영양상태를반영한다 (Frankenfield 등 1999). 따라서수술환자의초기영양평가를통해영양불량위험군환자를선별하여이환자를대상으로갈색거저리를이용한환자식제공의의미도클것으로생각되며, 이를통한임상적효과개선에대한연구도필요하다. López-Hellin 등 (2002) 에의하면수술후환자의경우대사적인변화가빠르기때문에정상적인영양지표가무의미하지만, IGF-1은스트레스상황에비교적영향을적게받기때문에영양공급에반응하여질소평형과유사하게움직인다. 수술후환자에게 7일간영양공급한결과반감기가 12시간인트랜스타이레틴 (transthyretin) 과레티놀결합단백질 (retinol binding protein) 은대사반응에더예민하게반응한반면반감기가 24시간인 IGF-1은영양공급에예민하게반응하였다. 이러한스트레스상황에서 IGF-1은농도가감소하여골격근의단백질합성을감소시킨다 (Ann 2014). 본연구에서수술후환자를대상으로단기간단백질의영양상태를반영하는지표로 IGF-1 을선정하였고식사섭취에따른 IGF-1의변화를관찰하기위해수술후 7일간영양공급후 IGF-1을검사하도록계획하였다. 하지만각과의수술프로토콜이다양하여수술후 7일이전에퇴원하는환자가발생하는등환자들의 IGF-1에대한동일한검사기간이확보되지못하였다. 이에실험군, 대조군모두환자의 IGF-1 수치변화가일관되게나오지못하였다. 또한, IGF-1은영양불량환자에게서더예민하게반응한다고밝혀졌으나 (Unterman 등 1985; Minuto 등 1989; Thissen 등 1994), 본연구의대상자가대부분영양불량위험이비교적적은정상체중범위의환자군이었기에 IGF-1이단백질영양상태평가지표로써의미가낮은것으로생각된다. 갈색거저리환자식제공에따른환자들의영양상태평가를위해 PG-SGA를사용하고삶의질평가를위해 EORTC QLQ-C30을사용하였으나환자들의재원기간 (8.4±0.8일) 이짧고환자들간에재원기간이일정하지않아의미있는결과값이측정되지않았다. 향후장기간연구진행시동일한도구로재평가가필요하다고생각된다. 본연구에서갈색거저리를별도의재료로사용한것과유사하게과거에수술후환자에게별도의재료를제공하는연구도보고되고있다. Heo 등 (2015) 은경증의간기능이상소견을보이는환자를대상으

304 갈색거저리환자식섭취에의한영양상태변화 로 8주동안동충하초추출물제공여부에따른환자-대조군연구를진행하였다. 동충하초추출물을섭취한군에서지방축적을방지하여지방간, 간경화를억제하였다는결과를보고하였다. Niitsu 등 (2016) 은골반골절환자를대상으로수술전후로 2주동안유청단백질제공여부에따른환자- 대조군연구를진행하였다. 유청단백질을섭취한군에서무릎신전강도, 바델척도 ( 이동하기, 걷기, 화장실사용등 ) 가유의적으로개선되었음을보고하였다. Moya 등 (2016) 은대장절제술을받은환자를대상으로수술전후로 12일동안표준영양보충음료와면역영양소가포함된영양보충음료제공여부에따른환자- 대조군연구를진행하였다. 면역영양소가포함된영양보충음료를섭취한군이수술후부작용발생률이감소하였음을보고하였다. Giles 등 (2016) 은두경부암환자를대상으로치료기간및 2.5개월간의추구관리기간동안영양보충음료제공여부에따른환자-대조군연구를진행하였다. 영양보충음료를섭취하더라도치료기간및추구관리기간동안체중감소가발생하였음을보고하였다. 본연구의제한점은대상환자가다양한과에서참여되어각과마다수술후프로토콜이다양하였고, 이에정맥영양공급을동일조건으로통제하지못하여각실험군및대조군이정맥영양공급유무에따라이차분류되어분석되었다. 이에실험군및대조군내각그룹간에표본수가축소되었다. 또한수술후영양상태변화를반영하는다양한지표를선정하였으나초기수술전환자의영양상태가달랐고, 입원일수가통제되지못하였으며연구기간이짧았기때문에모든지표를활용하여분석하는데한계가있었다. 하지만, 본연구는국내에서식용곤충인갈색거저리를환자식에도입한최초의연구로써, 수술후회복기간동안갈색거저리식사를제공하여구체적인식사섭취량변화및영양상태변화에서의미있는결과를도출함에따라향후갈색거저리등식용곤충의환자식이용에대한근거자료로의의가있을것으로생각된다. 요약및결론본연구는전향적환자대조군연구로써갈색거저리를이용하여수술후환자에게적절한메뉴및식사를구성하고, 2016년 3월에서 9월까지강남세브란스병원간담췌외과, 대장항문외과, 위장관외과에입원하여위장관수술을받은환자중본연구의취지를이해하고동의한연구참가자 34명을대상으로, 갈색거저리환자식을섭취하는실험군과일반환자식을섭취하는대조군으로분류하여식사를제공하였다. 연구대상자들의신체계측, 식사섭취량조사, 체성분분석, 생화학적검사결과, PG-SGA 평가, 삶의질평가등을조사하여입원기간동안각변수들의변화를분석하였다. 아래에본연구의결과를요약하였다. 1. 대상자들은총 34명중실험군은남자 12명 (60%), 여자 8명 (40%), 대조군은남자 10명 (71.4%), 여자 4명 (28.6%) 이었고, 나이는실험군 57.8±11.3세, 대조군은 65.1±11.4세였다. 진단명은암이실험군 90%, 대조군 64.3% 로대다수를차지했다. 대상자들의평균 PIBW(%) 는실험군이 108.3±12.7%, 대조군이 109.0±11.6% 이었다. 1일열량요구량은실험군이 1,585.0±242.3kcal/d, 대조군이 1,556.7±245.2kcal/d이었으며, 1일단백질요구량은실험군이 58.22±6.9g/d, 대조군이 57.56±6.9g/d이었다. 2. 식사섭취량을통한열량및영양소섭취량을비교한결과실험군에서정맥영양을공급받지않은그룹의경우열량은 964.68±284.6kcal, 단백질은 38.82±12.9g, 탄수화물은 138.24±38.4g, 지질은 28.49± 10.2g이었으며, 정맥영양을공급받은그룹의경우열량은 846.7±342.9kcal, 단백질은 35.50±14.6g, 탄수화물은 113.30±40.4g, 지질은 27.95±15.6g이었다. 대조군에서정맥영양을공급받지않은그룹의경우열량은 666.62±153.7kcal, 단백질은 24.47±4.9g, 탄수화물은 114.04±33.3g, 지질은 12.51±2.3g이었으며, 정맥영양을공급받은그룹의경우, 열량은 766.49±422.6kcal, 단백질은 31.92±19.8g, 탄수화물

J Korean Diet Assoc 22(4):292-309, 2016 305 은 110.42±55.2g, 지질은 21.90±14.1g이었다. 실험군이정맥영양공급유무와관계없이식사섭취만으로열량, 단백질, 지질섭취량이대조군보다많은것으로분석되었다. 특히정맥영양이공급되지않은그룹의경우실험군이식사를통한열량 (P<0.05), 단백질 (P<0.05), 지질 (P<0.01) 섭취량이대조군보다유의적으로높았다. 반면실험군, 대조군모두정맥영양을공급받은그룹이공급받지않은그룹에비해총영양소섭취량이많았다. 3. 식사섭취량에서열량의영양밀도는실험군이 1.24±0.2kcal/d, 대조군이 0.85±0.1kcal/d로실험군열량의영양밀도가유의적으로높으며 (P<0.001), 단백질의영양밀도는실험군이 0.05±0.01g/d, 대조군이 0.03±0.01g/d로실험군단백질의영양밀도가유의적으로높았다 (P<0.001). 4. 실험군중정맥영양을공급받지않은그룹에서는제지방량이유의적으로증가하였고 (P<0.05) 동시에근육량이증가하는경향을보였다. 실험군중정맥영양을공급받은그룹에서는제지방량및근육량이다소증가하는경향을보였다. 반면대조군에서는정맥영양을공급받은그룹과공급받지않은두그룹모두에서수술후제지방량및근육량이감소하였다. 5. PIBW가 100% 미만인그룹에서실험군과대조군모두전반적으로체세포량 (BCM), 근육량 (SLM), 제지방량 (FFM) 이감소하였으나, 실험군이유의적으로적게감소하였다 (P<0.05). 6. 실험군이대조군에비해제공량대비열량섭취의수응도 (P=0.036), 단백질섭취의수응도 (P=0.001), 지질섭취의수응도 (P=0.001) 모두유의적으로높았다. 또한갈색거저리식사를섭취한실험군대상자들에서식사에의한이상반응은한건도없었다. 결론적으로본연구는이상과같은연구결과를통해수술후입원기간동안갈색거저리식사를제공하여열량및영양소의섭취량변화및영양상태변화에서의미있는결과를도출하여고단백및고 영양식품인갈색거저리를이용한환자식사의도입에대한타당성을확인하였다. 본연구는국내에서식용곤충인갈색거저리를환자식에도입하여식용곤충의환자식적용에대한가능성을검증한최초의연구이다. 향후다양한환자군에서필요한열량과영양소에따라갈색거저리등식용곤충을이용한적절한메뉴와식단을지속적으로개발하며, 이를해당환자군에적용하고, 본연구의제한점을보완하여환자의영양상태변화및임상적결과에대한지속적이고중ㆍ장기적인연구가필요하다. 감사의글본연구는농촌진흥청에서지원하는어젠다프로그램 (PJ010022) 의연구수행으로인한결과물임을밝힙니다. REFERENCES Agarwal E, Ferguson M, Banks M, Bauer J, Capra S, Isenring E (2012): Nutritional status and dietary intake of acute care patients: results from the nutrition care day survey 2010. Clin Nutr 31(1):41-47 Ann SH (2014): Protein metabolism in stress condition. The 13rd KSPEN regular general meeting symposium. The Korean Society for Parenteral and Enteral Nutrition. pp.3-4 Bae JM., Park JW, Yang HK, Kim JP (1998): Nutritional status of gastric cancer patients after total gastrectomy. World J Surg 22(3):254-260; discussion 260-261 Baek MH, Yoon YI, Kim MA, Hwang JS, Goo TW, Yun EY (2016): Physical and sensory evaluation of Tenebrio molitor Larvae cooked by various cooking methods. Korean J Food Cook Sci 31(5):534-543 Biasato I, De Marco M, Rotolo L, Renna M, Lussiana C, Dabbou S, Capucchio MT, Biasibetti E, Costa P, Gai F, Pozzo L, Dezzutto D, Bergagna S, Martínez S, Tarantola M, Gasco L, Schiavone A (2016): Effects of dietary Tenebrio molitor meal inclusion in free range chickens. J Anim Physiol Anim

306 갈색거저리환자식섭취에의한영양상태변화 Nutr (Berl) doi: 10.1111/jpn.12487. [in press] Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L (2001): Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 358(9292):1487-1492 Bozzetti F, Gianotti L, Braga M, Di Carlo V, Mariani L (2007): Postoperative complications in gastrointestinal cancer patients: the joint role of the nutritional status and the nutritional support. Clin Nutr 26(6):698-709 Braga M, Sandrucci S (2016): Perioperative nutrition in cancer patients. European J Surg Oncol (EJSO) 42(6):751-753 Correia MI, Waitzberg DL (2003): The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 22(3):235-239 Dagan SS, Tovim TB, Keidar A, Raziel A, Shibolet O, Zelber-Sagi S (2016): Inadequate protein intake after laparoscopic sleeve gastrectomy surgery is associated with a greater fat free mass loss. Surg Obes Relat doi: 10.1016/j.soard. 2016.05.026. [in press] Evans WJ (1999): Nutrition: exercise and healthy aging. In: Korean Nutrition Society. Program 8th Asian congress of nutrition: good nutrition for all, new era for nutrition rights. Korean Nutrition Society. Seoul. pp.100-108 Faria SL, Faria OP, Buffington C, de Almeida Cardeal M, Ito MK (2011): Dietary protein intake and bariatric surgery patients: a review. Obes Surg 21(11):1798-1805 Frankenfield DC, Cooney RN, Smith JS, Rowe WA (1999): Bioelectrical impedance plethysmographic analysis of body composition in critically injured and healthy subjects. Am J Clin Nutr 69(3):426-431 Gasco L, Henry M, Piccolo G, Marono S, Gai F, Renna M., Lussiana C, Antonopoulou E, Mola P, Chatzifotis S (2016): Tenebrio molitor meal in diets for European sea bass (Dicentrarchus labrax L.) juveniles: growth performance, whole body composition and in vivo apparent digestibility. Anim Feed Sci Technol 220:34-45 Ghorabi S, Ardehali H, Amiri Z, Vahdat Shariatpanahi Z (2016): Association of the adductor pollicis muscle thickness with clinical outcomes in intensive care unit patients. Nutr Clin Pract 31(4):523-526 Giles KH, Kubrak C, Baracos VE, Olson K, Mazurak VC (2016): Recommended european society of parenteral and enteral nutrition protein and energy intakes and weight loss in patients with head and neck cancer. Head Neck 38(8): 1248-1257 Grant JP, Custer PB, Thurlow J (1981): Current techniques of nutritional assessment. Ann J Clin Nutr 61(3):437-463 Han MS (2012): Artificial nutrition in surgical patients. 54th the Korean Surgical Society autumn symposium. The Korean Surgical Society. pp.295-296 Han SR, Lee BS, Jung KJ, Yu HJ, Yun EY, Hwang JS, Moon KS (2016): Safety assessment of freeze-dried powdered Tenebrio molitor larvae (yellow mealworm) as novel food source: evaluation of 90-day toxicity in Sprague-Dawley rats. Regul Toxicol Pharmacol 77:206-212 Han SR, Yun EY, Kim JY, Hwang JS, Jeong EJ, Moon KS (2014): Evaluation of genotoxicity and 28-day oral dose toxicity on freeze-dried powder of tenebrio molitor larvae (Yellow Mealworm). Toxicol Res 30(2):121-130 Hara T, Kubo A (2015): The perioperative changes in physical function and physique of patients with gastrointestinal cancer. J Phys Ther Sci 27(3):693-695 Heo JY, Baik HW, Kim HJ, Lee JM, Choi YS, Won JH, Kim HM, Park WI, Kim CY (2015): The efficacy and safety of Cordyceps militaris in Korean adults who have mild liver dysfunction. J Clin Nutr 7(3):81-86 Hwang SY, Bae KK, Choi SK (2015): Preferences and purchase intention of tenebrio molitor (Mealworm) according to cooking method. Korean J Culin Res 21(1):100-115 Jeon YH, Son YJ, Kim SH, Yun EY, Kang HJ, Hwang IK (2016): Physicochemical properties and oxidative stabilities of mealworm (Tenebrio molitor) oils under different roasting conditions. Food Sci Biotechnol 25(1):105-110 Kazemi-Bajestani SM, Mazurak VC, Baracos V (2016): Computed tomography-defined muscle and fat wasting are associated with cancer clinical outcomes. Semin Cell Dev Bio 54:2-10 Kim HM, Kim JN, Kim JS, Jeong MY, Yun EY, Hwang JS, Kim AJ (2015): Quality characteristics of patty prepared with mealworm powder. Korean J Food Nutr 28(5):813-820 Kim HS, Jung CE (2013): Nutritional characteristics of edible insects as potential food materials. Korean J Apiculture 28:1-8 Kim JY, Park MS, Lee YH, Jo SJ, Yang HK (2001): A study of dietary intakes and nutritional status after total gastrectomy of early gastric cancer patients. J Korean Diet Assoc 7(1):72-79

J Korean Diet Assoc 22(4):292-309, 2016 307 Kim SH, Kim KB, Noh JS, Yun EY, Choi SK (2014): Quality characteristics of pasta with addition of mealworm(tenebrio molitor). Foodserv Ind J 10(3):55-64 Kim TH, Yook JH, Lee YJ, Hong SK (2012): Evaluation of the usefulness of nutrition indicator after gastric and pancreatic duodenal resection surgery. KSPEN 2-4:95 Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga, M, Ljungqvist O, Dejong CH (2012): Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS R ) Society recommendations. Clin Nutr 31(6):817-830 Lee H, Shim H, Jang JY, Jung AR, Kim SH, Kim H, Kim KS, Lee JG (2013): Development of a new nutrition screening tool for use in an acute care hospital. J Korean Soc Parenter Enter Nutr 5(2):82-88 Lee HS, Shin KH, Rha SY, Chung MJ, Song SY, Song SE, Ham HJ, Kim HM (2014): Changes in nutrient intake in patients at nutritional risk. J Korean Diet Assoc 20(4):285-295 Lee JE, Lee AJ, Jo DE, Cho JH, Youn KJ, Yun EY, Hwang JS, Jun MR, Kang BH (2015): Cytotoxic effects of Tenebrio molitor larval extracts against hepatocellular carcinoma. J Korean Soc Food Sci Nutr 44(2):200-207 Lipkin EW, Bell S (1993): Assessment of nutritional status. The clinician's perspective. Clin Lab Med 13(2):329-352 López-Hellin J, Baena-Fustegueras JA, Schwartz-Riera S, García-Arumí E (2002): Usefulness of short-lived proteins as nutritional indicators surgical patients. Clin Nutr 21(2):119-125 Mariette C, De Botton ML, Piessen G (2012): Surgery in esophageal and gastric cancer patients: what is the role for nutrition support in your daily practice? Ann Surg Oncol 19(7):2128-2134 McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition (2016): Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN J Parenter Enteral Nutr 40(2):159-211 Miglietta PP, De Leo F, Ruberti M, Massari S (2015): Mealworms for food: a water footprint perspective. Water 7(11):6190-6203 Ministry of Food and Drug Safety. Ministry of Food and Drug Safety notice 2016-18. Available from: http://www.mfds.go.kr/ index.do?searchkey=title:contents&division=&y=0&searchword= %BD%C4%C7%B0%C0%C7&x=0&mid=686&pageNo=10& seq=10532&cmd=v. Accessed March 7, 2016 Minuto F, Barreca A, Adami GF, Fortini P, Del Monte P, Cella F, Scopinaro N, Giordano G (1989): Insulin-like growth factor-i in human malnutrition: relationship with some body composition and nutritional parameters. JPEN J Parenter Enteral Nutr 13(4):392-396 Mir O, Coriat R, Blanchet B, Durand JP, Boudou-Rouquette P, Michels J, Ropert S, Vidal M, Pol S, Chaussade S, Goldwasser F (2012): Sarcopenia predicts early dose-limiting toxicities and pharmacokinetics of sorafenib in patients with hepatocellular carcinoma. PLoS One 7(5):e37563 Moya P, Soriano-Irigaray L, Ramirez JM, Garcea A, Blasco O, Blanco FJ, Brugiotti C, Miranda E, Arroyo A (2016): Perioperative standard oral nutrition supplements versus immunonutrition in patients undergoing colorectal resection in an enhanced recovery (ERAS) protocol: a multicenter randomized clinical trial (SONVI study). Medicine (Baltimore) 95(21):e3704 Niitsu M, Ichinose D, Hirooka T, Mitsutomi K, Morimoto Y, Sarukawa J, Nishikino S, Yamauchi K, Yamazaki K (2016): Effects of combination of whey protein intake and rehabilitation on muscle strength and daily movements in patients with hip fracture in the early postoperative period. Clin Nutr 35(4):943-949 Park YO, Yoon SY, Kang SS, Han SM, Kang EH (2012): Nutritional status and dietary change after gastrectomy of gastric cancer patients. Korean J Community Nutr 17(1): 101-108 Peng P, Hyder O, Firoozmand A, Kneuertz P, Schulick RD, Huang D, Makary M, Hirose K, Edil B, Choti MA, Herman J, Cameron JL, Wolfgang CL, Pawlik TM (2012): Impact of sarcopenia on outcomes following resection of pancreatic adenomacarcinoma. J Gastrointest Surg 16(8):1478-1486 Peng PD, van Vledder MG, Tsai S, de Jong MC, Makary M, Ng J, Edil BH, Wolfgang CL, Schulick RD, Choti MA, Kamel I, Pawlik TM (2011): Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. HPB (Oxford) 13(7):439-446 Ramos Elorduy J (2009): Anthropo entomophagy: cultures, evolution and sustainability. Entomol Res 39(5):271-288

308 갈색거저리환자식섭취에의한영양상태변화 Reisinger KW, Derikx JP, van Vugt JL, Von Meyenfeldt MF, Hulsewé KW, Olde Damink SW, Stoot JH, Poeze M (2016): Sarcopenia is associated with an increased inflammatory response to surgery in colorectal cancer. Clin Nutr 35(4):924-927 Reisinger KW, van Vugt JL, Tegels JJ, Snijders C, Hulsewé KW, Hoofwijk AG, Stoot JH, Von Meyenfeldt MF, Beets GL, Derikx JP, Poeze M (2015): Functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery. Ann Surg 261(2):345-352 Robinson TN, Wu DS, Stiegmann GV, Moss M (2011): Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults. Am J Surg 202(5):511-514 Rural Development Administration (2014): Standard guideline for rearing edible insects. Rural Development Administration. Jeonju. pp.46-63 Rural Development Administration (2015): Standard guideline for edible insects. Rural Development Administration. Jeonju. pp.54-69 Ryan AM, Reynolds JV, Healy L, Byrne M, Moore J, Brannelly N, McHugh A, McCormack D, Flood P (2009): Enteral nutrition enriched with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded randomized controlled trial. Ann Surg 249(3):355-363 Sasaki M, Okamoto H, Johtatsu T, Kurihara M, Iwakawa H, Tanaka T, Shiomi H, Naka S, Kurumi Y, Tani T (2011): Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors. J Clin Biochem Nutr 48(3):183-186 Shachar SS, Williams GR, Muss HB, Nishijima TF (2016): Prognostic value of sarcopenia in adults with solid tumours: a meta-analysis and systematic review. Eur J Cancer 57:58-67 Sharma P, Zargar-Shoshtari K, Caracciolo JT, Fishman M, Poch MA, Pow-Sang J, Sexton WJ, Spiess PE (2015): Sarcopenia as a predictor of overall survival after cytoreductive nephrectomy for metastatic renal cell carcinoma. Urol Oncol 33(8):339. e17-e23 Shin D (2014): Perioperative nutritional therapy for surgical patients. J Korean Med Assoc 57(6):500-507 Simon E, Baranyai E, Braun M, Fábián I, Tóthmérész B (2013): Elemental concentration in mealworm beetle (Tenebrio molitor L.) during metamorphosis. Biol Trace Elem Res 154(1): 81-87 Souba WW, Austgen TR (1990): Interorgan glutamine flow following surgery and infection. JPEN J Parenter Enteral Nutr 14(4 Suppl):90S-93S Steen B (1988): Body composition and aging. Nutr Rev 46(2): 45-51 Tan KY, Kawamura YJ, Tokomitsu A, Tang T (2012): Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg 204(2): 139-143 Tegels JJ, van Vugt JL, Reisinger KW, Hulsewé KW, Hoofwijk AG, Derikx JP, Stoot JH (2015): Sarcopenia is highly prevalent in patients undergoing surgery for gastric cancer but not associated with worse outcomes. J Surg Oncol 112(4):403-407 Thissen JP, Ketelslegers JM, Underwood LE (1994): Nutritional regulation of the insulin-like growth factors. Endocr Rev 15(1):80-101 Unterman TG, Vazquez RM, Sla AJ, Martyn PA, Phillips LS (1985): Nutrition and somatomedin. XII. Usefulness of somatomedin-c in nutritional assessment. Am J Med 78(2): 228-234 Van Huris A, Van Itterbeeck J, Klunder H, Mertens E, Halloran A, Muir G, Vantomme P (2013): Edible insects: future prospects for food and feed security. Food and Agriculture Organization of the United Nations. Rome. pp.1-201 Van Vledder MG, Levolger S, Ayez N, Verhoef C, Tran TC, Ijzermans JN (2012): Body composition and outcome in patients undergoing resection of colorectal liver metastases. Br J Surg 99(4):550-557 Weed HG, Ferguson ML, Gaff RL, Hustead DS, Nelson JL, Voss AC (2011): Lean body mass gain in patients with head and neck squamous cell cancer treated perioperatively with a protein and energy dense nutritional supplement containing eicosapentaenoic acid. Head Neck 33(7):1027-1033 Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P; DGEM (German Society for Nutritional Medicine), Jauch KW, Kemen M, Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH; ESPEN (European Society for Parenteral and Enteral Nutrition) (2006): ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 25(2):224-244 Yoo JM, Hwang JS, Goo TW, Yun EY (2013): Comparative

J Korean Diet Assoc 22(4):292-309, 2016 309 analysis of nutritional and harmful components in Korean and Chinese mealworms (Tenebrio molitor). J Korean Soc Food Sci Nutr 42(2):249-254 You JW, Lee SJ, Kim YE, Cho YJ, Jeong YY, Kim HC, Lee JD, Kim JR, Hwang YS (2013): Association between weight change and clinical outcomes in critically ill patients. J Crit Care 28(6):923-927 Youn K, Yun EY, Lee J, Kim JY, Hwang JS, Jeong WS, Jun M (2014): Oleic acid and linoleic acid from Tenebrio molitor larvae inhibit BACE1 activity in vitro: molecular docking studies. J Med Food 17(2):284-289 Yu W, Chung HY (2001): Nutritional status after curative surgery in patients with gastric cancer: comparison of total versus subtotal gastrectomy. J Korean Surg Soc 60(3):297-301 Yun EY, Hwang JS, Kim MA, Baei MH, Kang PD, Kim SH, Choi SG, Kim AN, Hwang IK, Shon YJ (2015a): Edible insects cooking class for children. Rural Development Administration. Jeonju. pp.1-87 Yun EY, Hwang JS, Kim MA, Baei MH, Kang PD, Kim SH, Choi SG, Kim AN, Hwang IK, Shon YJ (2015b): Korean food with edible insects. Rural Development Administration. Jeonju. pp.1-51 Yun EY, Hwang JS, Kim MA, Baei MH, Kang PD, Kim SH, Choi SG, Kim AN, Hwang IK, Shon YJ (2016): Edible insects cuisine for commercialization. Rural Development Administration. Jeonju. pp.1-88