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Original Article J Sasang Constitut Med 2013;25(3):180-194 http://dx.doi.org/10.7730/jscm.2013.25.3.180 한국인중년성인에서사상체질과폐기능장애, 대사증후군의연관성연구 박윤성 김제신 이준희 이의주 고병희 경희대학교한의과대학사상체질과 Abstract Association between Sasang Constitution, Impaired Lung Function and Metabolic Syndrome among Middle-aged Adults in Korea Yun-Seong Pak, Je-Shin Kim, Jun-Hee Lee, Eui-Ju Lee, Byung-Hee Koh Dept. of Sasang Constitutional Medicine, College of Korean Medicine, Kyung Hee Univ. Objectives Impaired lung function(ilf) and sasang constitution(sc) is associated with metabolic syndrome(ms). However, the relationship between ILF and SC is unclear. So, we assessed the relationship between ILF and MS according to SC, and examined whether SC is an independent risk factor for ILF. Methods This study included 1,148 subjects 40years and older who were performed the health examination at Kyung Hee University Hospital in Korea between December 2011 and February 2013. We defined ILF if FVC or FEV 1 value were less than lower limit of normal(lln), and classified ventilatory patterns as obstructive pattern and restrictive pattern. MS was assessed according to AHA/NHLBI criteria. We used multivariate logistic regression to analyze the association of ILF with MS respective to SC types, and to identify the risk of SC types for ILF. Odds ratio(or) was calculated by adjusting for age, sex, smoking status, drinking, physical activity, and BMI. Results In whole subjects, ILF was associated with MS [OR (95% CI), 1.69 (1.24-2.31) for FVC, 1.67 (1.20-2.33) for FEV 1]. And in Taeeum type(te type) and Soeum type(se type), ILF was associated with MS [1.63 (1.10-2.42) for FVC, 1.48 (1.01-2.24) for FEV 1 in TE type; 6.93 (1.14-42.00) for FVC in SE type], while in Soyang type(sy type), it wasn t. The restrictive pattern was associated with MS in TE type and SE type, while in SY type, it wasn t. Furthermore, TE type and SY type had more risk for ILF than SE type [1.71 (1.12-2.59) for SY type, 1.95 (1.23-3.08) for TE type in FVC; 2.06 (1.26-3.36) for TE type in FEV 1; 1.85 (1.21-2.85) for SY type, 2.17 (1.35-3.49) for TE type in Restrictive pattern]. Conclusions These results show that SC is an independent risk factor for ILF, especially TE type and SY type than SE type, and the prevalence of MS is an independent risk factor for ILF in TE type. Key Words : Sasang Constitution, Metabolic Syndrome, Impaired Lung Function, Risk Factor

YS Pak et al. 181 Received August 23, 2013 Revised August 28, 2013 Accepted September 17, 2013 Corresponding Author Byung-Hee Koh Dept. of Sasang Constitutional Medicine, Kyung Hee Univ. Korean medical center,1 Heogi-dong, Dongdaemun-gu, Seoul, 130-702, Republic of Korea Tel : +82-2-958-9231 Fax: +82-2-958-9234 E-mail: kohbh@khu.ac.kr C The Society of Sasang Constitutional Medicine. All rights reserved. This is an open acess article distributed under the terms of the Creative Commons attribution Non-commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) I. 緖論 Spirometry는폐기능의이상유무를선별하기위해임상에서널리사용되는검사로, 노력성폐활량 (Forced Vital Capacity, FVC) 와 1초간노력성폐활량 (Forced Expiratory Volume in 1sec, FEV 1) 등의측정값이정상치보다감소된경우폐기능장애로정의한다 1. 다수집단을대상으로한몇몇연구에따르면폐기능장애는협심증, 심근경색등심혈관계질환으로인한사망과밀접한관계가있으며 2-5, 심혈관계질환의위험인자인고혈압 6,7, 당뇨 8,9, 이상지질혈증 7,10, 동맥경화 11-13 와도관련이있다. 그리고최근연구에따르면증가된혈압, 인슐린저항성, 이상지질혈증, 복부비만으로구성된대사증후군또한폐기능장애의위험도를유의하게증가시키는것으로밝혀졌다 13-16. 사상체질의학은 19세기말이제마 (1837-1900) 에의해창안된한국전통의학으로, 각체질마다신체적, 심리적, 생리적, 병리적특성이다르며약물이나침과같은치료방법에도차이가있다 17. 몇몇단면연구에서는체질에따라고혈압 18, 당뇨 19, 인슐린저항성 20, 고지혈증 21, 대사증후군 22 등만성질환의유병율에차이가있으며, 사상체질이이들질환의독립적인위험인자로작용함을밝혔다. 특히태음인이만성질환의위험도가다른체질에비해높은것으로보고되었다. 그러나사상체질에따른폐기능에관한연구는만성폐쇄성폐질환연구 23 와남성의폐기능비교연구 24 외에는전무한실정이다. 앞서서술한대로, 폐기능장애와대사성질환의관계는많은연구를통해밝혀졌으며, 대사성질환과사상체질의관계도상당수밝혀졌다. 그러나사상체질과폐기능장애의관계는아직밝혀지지않았다. 따라서우리는 40세이상의한국인중년성인을대상으로단면연구를시행하여체질별로대사증후군과폐기능 장애의관련성을조사하고사상체질이폐기능장애의독립적인위험인자인지확인하였다. II. 硏究對象및方法 1. 연구대상 2011년 12월 1일부터 2013년 2월 28일까지경희의료원동서건강증진센터에서건강검진을받은남녀 8655명을대상으로하였다. 총대상자중 40세이상 64세이하한국인남녀로사상체질이진단된자를연구에포함시켰다. 제외기준은다음과같다 : 1) 협심증, 심근경색등심혈관질환의과거력이있는자 ; 2) 연구기간동안중복으로건강검진을받은자 ( 첫방문한검진자료만분석에포함함 ); 3) 폐기능검사미실시자또는협조가안되어검사하지못한자 ; 4) 단순흉부방사선촬영에서폐조직에이상이발견된자 ( 폐결절, 섬유화, 육아종, 늑막비후, 무기폐, 폐기종, 기관지확장증, 폐결핵, 폐렴, 만성기관지염등 ) 또는판독이없는자 ; 5) 천식, 폐결핵, 기흉, 폐암등폐질환의과거력이있는자 ; 6) 신체계측, 폐기능검사의기록이누락된자. 단순흉부방사선촬영의판독은 1명의영상의학과전문의에의해시행되었다. 총대상자중 1134명이위의기준을만족하였고, 이중태양인대상자수 (n=1) 가희소하여제외하였다. 최종적으로 1133명이연구대상자로선정되었다 (Figure 1). 이연구는경희대학교한방병원 IRB의승인을받았다 (KOMCGIRB-2013-89호). 2. 연구방법 1) 사상체질진단사상체질진단은이전연구 18-20 방법을따랐다. 대

182 Impaired Lung Function and Sasang Constitution Figure 1. Study flow chart Definition of abbreviations: CVD=cardiovascular disease; PFT=pulmonary function test 상자는건강검진시개정된사상체질분류검사지 II(QSCC II+) 를작성하였고사상체질의학전문의의진료를받았다. QSCC II+ 는 54개의문항으로구성된자기보고식체질진단도구로, 타당도와신뢰도가확인되었다 25-29. 사상체질의학전문의는사상체질과전문의자격을대한민국정부에서부여받았으며, 10년이상의사상체질의학임상경험을가졌다. 사상체질의학전문의는문진을통해대상자의체형, 안면, 음성, 성격및행동특성, 맥진, 복진, 소증등의체질정보를수집하여체질을평가하였다. 최종적으로 QSCCII+ 의결과와사상체질의학전문의의체질진단이일치할경우피험자로선정하였다. 2) 인구학적특성및병력조사자기보고식설문지와의사의문진을통해흡연력, 음주력, 운동력및병력을조사하였다. (1) 흡연력 : 비흡연, 과거흡연, 현재흡연의 3개군으로구분하였다. 과거흡연은금연한지 1년이상경과된경우로정의하였다. (2) 음주력 : 현재음주상태에따라비음주군, 음주 군으로구분하였고, 음주군은국내시장에서유통되는술을기준으로다음의공식을이용하여주당순수알코올섭취량 (g/wk) 를구하였다. [ 알코올농도 (%)/100] x 음주량 (cc) x 0.8( 알코올비중 ) x 음주횟수 = 주당순수알코올섭취량 (g/wk) 그리고음주군은적정음주군 ( 남성 280g/wk 미만 ; 여성 140g/wk 미만 ) 과위험음주군 ( 남성 280g/wk 이상 ; 여성 140g/wk 이상 ) 으로구분하였다 30. (3) 운동력 : 운동종류와 1주당운동시간 (hour) 을조사하였다. 운동종류는 Ainsworth BE 31 의연구에따라 Metabolic equivalent(met) value로변환하였다. MET value는운동별에너지소비량의비율을나타내는지표로, 1MET는휴식시사용하는에너지소비량 (1.0kcal kg -1 h -1 ) 이며운동종류에따라 0.9~23METs 로나뉜다 31. 1주당운동시간 (h) 을분 (min) 으로환산한후 MET value와곱하여 MET-minutes/wk를구하였다. 그리고 WHO에서발간한 Global Physical Activity Questionnaire Analysis Guide 32 에따라저운동군

YS Pak et al. 183 Table 1. Prediction Equation and Lower Limits of the Predicted Values 34 Male Equation FVC(L) -4.8434-0.00008633*A 2 +0.05292*H+0.01095*W FEV 1(L) -3.4132-0.0002484*A 2 +0.04578*H FEV 1/FVC(%) 119.9004-0.3902*A-0.1268*H LLN(Cut-off value) FVC%pred(%) 83.5 FEV 1%pred(%) 82.3 FEV 1/FVC%pred(%) 91.1 Female Equation FVC(L) -3.0006-0.0001273*A 2 +0.03951*H+0.006892*W FEV 1(L) -2.4114-0.0001920*A 2 +0.03558*H FEV 1/FVC(%) 97.8567-0.2800*A-0.01564*H LLN(Cut-off value) FVC%pred(%) 81.6 FEV 1%pred(%) 80.4 FEV 1/FVC%pred(%) 89.9 Definition of abbreviations: FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec; LLN=lower limit of normal value; A=age(years); H=height(cm); W=weight(kg); FVC%pred=100*(measured FVC/predicted FVC); FEV 1%pred=100*(measured FEV 1/predicted FEV 1); FEV 1/FVC%pred=100*[(measured FEV 1/FVC)/(predicted FEV 1/FVC)] (MET-minutes/wk<600), 중등도운동군 (600 MET-minutes/wk<1500), 고운동군 (1500 METminutes/wk) 으로 3개의군으로나누었다. 운동을하지않는사람은저운동군으로포함시켰다. (4) 병력 : 고혈압, 당뇨, 고지혈증, 심혈관질환에대하여약물복용여부를조사하였다. 3) 폐기능측정폐기능검사는미국흉부학회 / 유럽호흡기학회 33 의기준을만족시키기위해가능한노력하였다. 검사기기로 HI-801 폐활량기 (CHEST Co., Tokyo, Japan) 를사용하였고, 폐기능검사교육을받은경험있는간호사가검사를실시하였다. 장비의질적관리를위하여매일아침 3L Syringe를사용하여보정 (Calibration) 을하였고, 필터는 5회에 1번씩교체하였다. 검사는최소 3회이상반복하여 2번이상적합성이있고재현성이있는결과가나오면최대측정값을결과값으로선택하였다. 검사를통해 FVC와 FEV 1, FEV 1/FVC의실측값을얻었고, 최등 34 이보고한정상폐활량예측식에따라 대상자의폐활량예측치 (FVCpred, FEV 1pred, FEV 1/FVCpred) 를구하였다 (Table 1). 그리고예측치로실측값을나누어백분율을구하였다 (FVC%pred, FEV 1%pred, FEV 1/FVC%pred). 그후동일연구 34 에서보고된 FVC, FEV 1, FEV 1/FVC의정상하한치 (Lower Limit of Normal, LLN) 를사용하여폐기능장애여부를판단하였다. 폐기능장애는 FVC%pred, FEV 1%pred의값이 LLN보다낮은경우로정의하였다. 또한환기양상을정상환기, 폐쇄성환기, 제한성환기로구분하였다. 폐쇄성환기는 FEV 1/FVC%pred 이 LLN보다낮은경우로정의하였고, 제한성환기는 FEV 1/FVC%pred 이 LLN보다높거나같으면서 FVC%pred이 LLN보다낮은경우로정의하였다. 4) 신체검사및혈액검사수축기혈압 (sbp) 과이완기혈압 (dbp) 은 5분이상휴식을취한후자동혈압계 (FT-700R, Jawon Medical Co., Gyeongsan, Korea) 를사용하여오른팔에서측정하였다. 키, 몸무게, 체질량지수 (BMI), 허리둘레 (WC) 는건강검진센터에서제공되는얇은옷을입고신발을

184 Impaired Lung Function and Sasang Constitution 벗은상태에서체성분분석기 (Inbody720, Biospace Co., Seoul, Korea) 를통해측정하였다. 최근연구 35 에따르면체성분분석기를통해유추된허리둘레는직접측정한허리둘레와상관성이높으며, 대사증후군진단에실측정값보다열등하지않다고하였다. 혈액검사는 10시간공복상태후채혈하였으며, 혈액샘플은생화학자동분석장치 (TBA-200FR, Toshiba, Tokyo, Japan) 로분석하였다. 대사증후군진단을위해공복혈당 (FBS), 중성지방 (TG), HDL 콜레스테롤 (HDL-C) 측정값을이용하였다. 5) 대사증후군진단기준 American Heart Association/National Heart, Lung, and Blood Institute(AHA/NHLBI) 의기준에따라정의하였다 36. 복부비만은대한내분비학회와대한비만학회에서정한허리둘레국내기준을반영하였다 37. 아래의 5항목중 3개이상을만족할경우대사증후군으로진단하였다. (1) 복부비만 : WC 90/85 cm ( 남성 / 여성 ) (2) 고중성지방 : TG 150 mg/dl 또는고지혈증으로약물치료중인경우 (3) 저HDL- 콜레스테롤 : HDL-C < 40/50 mg/dl ( 남성 / 여성 ), 또는고지혈증으로약물치료중인경우 (4) 공복혈당상승 : FBS 100 mg/dl 또는당뇨로약물치료중인경우 (5) 혈압상승 : sbp 130mmHg 또는 dbp 85 mmhg 또는고혈압으로약물치료중인경우 6) 통계분석먼저체질별로군을나누어대상자의일반적특성을비교하였다. 연속형변수는 one-way ANOVA (post-hoc test : Scheffe s method) 로분석하였고, 범주형변수는 chi-squared test로분석하였다. 대사증후군과폐기능장애, 그리고사상체질과폐기능장애의관련성을분석하기위해다변량로지스틱 회귀분석으로 Odds ratio(or) 와 95% 신뢰구간 (95% CI) 을구하였다. OR은보정전값 (OR cru) 과함께성별, 연령, 흡연력, 흡연량, 음주력, 운동력, BMI 등혼란요인을보정한값 (OR adj) 을구하였다. 또한, 대사증후군구성요소를복부비만군, 이상지질혈증군, 공복혈당상승군, 혈압상승군으로구분하여폐기능장애와의관련성을각각분석하였다. 이상지질혈증군은고중성지방과저HDL-콜레스테롤기준중하나이상을만족하는경우로정의하였다. 사상체질과폐기능장애의관련성을분석할때소음인을기준으로소양인과태음인의 OR을계산하였다. 통계분석은 PASW/SPSS statistics Ver.18를사용하였고, p<0.05인경우통계적으로유의성이있다고판단하였다. III. 結果 1. 체질별일반적특성연령은소양인이소음인보다유의하게높았으며, 다른체질간에는유의하지않았다. 남성의빈도는소양인이가장높았고, 소음인이가장낮았다. BMI와 WC는태음인, 소양인, 소음인순으로유의하게높았다 (p<0.001). 또한, 흡연력, 음주력, 운동력에서체질간에유의한차이가있었다. 폐기능검사결과값중 FVC%pred만태음인이소음인, 소양인에비해유의하게낮았다 (p<0.001). 폐기능장애와제한성환기의유병율은태음인이가장높았으며, 소양인, 소음인순으로점차낮아졌다. 체질에따른대사증후군유병율은태음인이소양인, 소음인에비해유의하게높았으며, 대사증후군구성요소모두태음인이소양인, 소음인에비해유의하게빈도가높았다 (p<0.001) (Table 2). 2. 대사증후군과폐기능의연관성 1) 대사증후군과폐기능장애성별, 연령, 흡연력, 흡연량, 음주력, 운동력, BMI 의

YS Pak et al. 185 Table 2. Characteristics of Subjects according to Sasang Constitutional Type Soyang type Taeeum type Soeum type Total (n=400) (n=532) (n=201) (n=1133) P-value * Age(yr) 51.5±6.3 a 50.7±6.0 a,b 50.1±6.2 b 50.9±6.2 0.033 Male(%) 64.3 57.1 41.3 56.8 <0.001 BMI(kg/m 2 ) 23.4±2.2 a 26.2±2.5 b 21.9±2.0 c 24.5±2.9 <0.001 WC(cm) 83.7±6.2 a 90.8±6.7 b 79.9±5.8 c 86.4±7.7 <0.001 Smoking status(%) <0.001 Never smoker 52.3 58.3 73.1 58.8 Former smoker 21.5 19.9 13.4 19.3 Current smoker 26.3 21.8 13.4 21.9 Alcohol drinking(%) <0.001 No drinker 37.0 41.4 58.2 42.8 Moderate drinker 53.5 46.6 38.8 47.7 Heavy drinker 9.5 12.0 3.0 9.5 Physical activity(%) 0.030 Light activity 44.3 50.8 53.7 49.0 Moderate activity 30.0 30.1 30.3 30.1 Vigorous activity 25.8 19.2 15.9 20.9 FVC%pred(%) 86.1±10.9 a 84.0±10.6 b 87.4±10.4 a 85.3±10.8 <0.001 FEV 1%pred(%) 87.9±11.0 86.7±10.4 88.3±10.6 87.4±10.7 0.096 FEV 1/FVC%pred(%) 103.4±8.9 103.0±7.5 103.3±8.2 103.2±8.1 0.759 Impaired lung function(fvc, %) 41.8 48.9 24.9 42.1 <0.001 Impaired lung function(fev 1,%) 28.0 31.6 21.4 28.5 0.023 Ventilatory pattern(%) <0.001 Obstructive pattern 5.5 5.3 4.5 5.2 Restrictive pattern 40.0 47.6 22.9 40.5 Metabolic syndrome (%) 17.5 42.9 3.5 26.9 <0.001 Waist circumference 90/85 cm(%) 20.8 66.4 10.0 40.2 <0.001 Triglycerides 150mg/dL or dyslipidemia treatment(%) 34.0 49.2 23.4 39.3 <0.001 HDL-cholesterol<40/50 mg/dl or dyslipidemia treatment(%) 17.3 28.0 11.4 21.3 <0.001 Fasting glucose 100mg/dL or diabetes treatment(%) 22.8 31.2 11.4 24.7 <0.001 sbp 130 or dbp 85mmHg or antihypertensive treatment(%) 32.8 48.5 23.4 38.5 <0.001 Definition of abbreviations: BMI=body mass index; FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec; FVC%pred=100*(measured FVC/predicted FVC); FEV 1%pred=100*(measured FEV 1/predicted FEV 1); FEV 1/FVC%pred=100*[(measured FEV 1/FVC)/(predicted FEV 1/FVC)]: WC=waist circumference; sbp=systolic blood pressure; dbp=diastolic blood pressure Data are described as mean±standard deviation or percent(%) *p value was analyzed by one-way ANOVA test and X 2 test for continuous and categorical variables, respectively. Post hoc comparison was done by Scheffe s method. Different superscript letters(a,b,c) indicate that values are significantly different among groups. Metabolic syndrome was defined according to AHA/NHLBI criteria Threshold value for male/female 혼란요인을보정후에도대사증후군은폐기능장애와유의한관계가있었다. 대사증후군의구성요소중이상지질혈증군은폐기능장애 (FVC, FEV 1) 와모두유의 한관계가있었고,. 복부비만군과공복혈당상승군은각각 FEV 1, FVC의폐기능장애와관계가있었다. 혈압상승군은유의한관계가발견되지않았다.

186 Impaired Lung Function and Sasang Constitution Table 3. Odds Ratio of Metabolic Syndrome and its Components as Risk Factor of Impaired Lung Function ILF(FVC) ILF(FEV 1) OR cru(95%ci) OR adj(95%ci) OR cru(95%ci) OR adj(95%ci) Metabolic syndrome Total 2.67 (2.04-3.50) * 1.69 (1.24-2.31) * 1.66 (1.25-2.20) * 1.67 (1.20-2.33) * Soyang type 2.46 (1.45-4.16) * 1.45 (0.80-2.62) 1.67 (0.97-2.88) 1.47 (0.81-2.69) Taeeum type 2.07 (1.46-2.94) * 1.63 (1.10-2.42) * 1.47 (1.02-2.13) * 1.48 (1.01-2.24) * Soeum type 8.27 (1.55-44.12) * 6.93 (1.14-42.00) * 1.49 (0.27-7.97) 2.81 (0.44-17.84) Abdominal obesity Total 2.06 (1.61-2.62) * 1.14 (0.79-1.64) 1.26 (0.97-1.63) 1.60 (1.08-2.36) * Soyang type 2.01 (1.23-3.28) * 1.26 (0.63-2.50) 1.73 (1.04-2.89) * 2.05 (1.01-4.16) * Taeeum type 1.63 (1.13-2.35) * 1.00 (0.61-1.62) 0.94 (0.64-1.38) 1.26 (0.75-2.11) Soeum type 1.72 (0.64-4.60) 1.26 (0.36-4.42) 0.37 (0.08-1.70) 0.60 (0.11-3.36) Dyslipidemia Total 2.10 (1.65-2.67) * 1.63 (1.26-2.12) * 1.53 (1.18-1.98) * 1.41 (1.07-1.85) * Soyang type 1.86 (1.23-2.80) * 1.44 (0.92-2.26) 1.29 (0.83-2.01) 1.21 (0.76-1.94) Taeeum type 2.14 (1.51-3.04) * 1.97 (1.35-2.86) * 1.87 (1.28-2.73) * 1.75 (1.17-2.61) * Soeum type 1.26 (0.63-2.52) 1.18 (0.57-2.46) 0.71 (0.32-1.57) 0.74 (0.32-1.70) Elevated fasting glucose Total 1.96 (1.49-2.58) * 1.46 (1.09-1.97) * 1.50 (1.12-2.00) * 1.34 (0.99-1.82) Soyang type 2.38 (1.48-3.84) * 1.80 (1.07-3.02) * 1.55 (0.94-2.56) 1.46 (0.85-2.49) Taeeum type 1.51 (1.05-2.19) * 1.24 (0.83-1.85) 1.30 (0.88-1.91) 1.07 (0.71-1.62) Soeum type 1.37 (0.53-3.55) 1.54 (0.55-4.27) 1.72 (0.66-4.50) 1.79 (0.62-5.13) Elevated blood pressure Total 1.64 (1.28-2.09) * 1.12 (0.86-1.47) 1.28 (0.98-1.66) 1.18 (0.89-1.57) Soyang type 1.61 (1.05-2.45) * 1.14 (0.71-1.83) 1.07 (0.67-1.71) 0.97 (0.59-1.60) Taeeum type 1.43 (1.01-2.01) * 1.10 (0.76-1.61) 1.34 (0.93-1.94) 1.17 (0.78-1.75) Soeum type 1.20 (0.57-2.53) 1.04 (0.47-2.30) 0.99 (0.44-2.20) 1.21 (0.51-2.83) Definition of abbreviations: ILF=Impaired lung function; FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec; OR cru=crude odds ratio; OR adj=odds ratio adjusted for age, sex, smoking status, drinking, physical activity, and BMI; CI=confidence interval *p<0.05 체질별로대사증후군과폐기능장애의관계를분석한결과, 태음인과소음인에서혼란요인에상관없이대사증후군과폐기능장애간에유의한관계가있었다. 태음인에서는 FVC, FEV 1 에서모두유의성이있었으나, 소음인에서는 FVC에서만유의성이있었다. 그리고태음인의경우대사증후군의구성요소중이상지질혈증군이폐기능장애 (FVC, FEV 1) 와유의한관계가있었고, 소양인의경우복부비만군과혈당상승군이각각 FEV 1, FVC의폐기능장애와유의한관계가있었다 (Table 3). 2) 대사증후군과환기장애전체대상자에서대사증후군은폐쇄성환기와관계 가없었으나제한성환기와유의한관계가있었다. 대사증후군구성요소에서혈압상승군은폐쇄성환기와관련이있었고, 이상지질혈증군과혈당상승군은제한성환기와관련이있었다. 체질별로분석한결과, 태음인의경우대사증후군과이상지질혈증군이제한성환기와유의한관계가있었다. 소양인의경우혈당상승군만제한성환기와관계가있었다 (Table 4). 3. 사상체질과폐기능의연관성 1) 사상체질과폐기능장애사상체질을독립변수로설정하여종속변수인폐기능장애와관계가있는지확인하였다. 성별, 연령, 흡연

YS Pak et al. 187 Table 4. Odds Ratio of Metabolic Syndrome and its Components as Risk Factor of Ventilatory Impairment Obstructive pattern Restrictive pattern OR cru(95%ci) OR adj(95%ci) OR cru(95%ci) OR adj(95%ci) Metabolic syndrome Total 1.21 (0.63-2.32) 0.92 (0.42-1.99) 2.67 (2.03-3.52) * 1.70 (1.24-2.34) * Soyang type 1.11 (0.31-4.02) 0.89 (0.21-3.78) 2.35 (1.37-4.04) * 1.39 (0.76-2.54) Taeeum type 0.89 (0.38-2.05) 0.86 (0.32-2.35) 2.05 (1.43-2.94) * 1.65 (1.10-2.46) * Soeum type 9.00 (0.73-110.06) 40.21 (0.80-2014.97) 6.85 (1.21-38.75) * 6.50 (1.05-40.03) * Abdominal obesity Total 0.96 (0.54-1.70) 0.84 (0.35-1.97) 2.11 (1.64-2.70) * 1.16 (0.80-1.69) Soyang type 0.48 (0.11-2.18) 0.28 (0.04-1.81) 1.85 (1.13-3.04) * 1.06 (0.52-2.16) Taeeum type 0.72 (0.33-1.59) 1.12 (0.36-3.47) 1.68 (1.15-2.44) * 1.06 (0.64-1.75) Soeum type 3.19 (0.59-17.09) 20.42 (1.05-394.78) 1.67 (0.59-4.74) 1.61 (0.43-5.97) Dyslipidemia Total 1.79 (1.04-3.06) * 1.52 (0.85-2.71) 2.11 (1.64-2.70) * 1.64 (1.26-2.14) * Soyang type 1.72 (0.71-4.18) 1.48 (0.55-3.95) 1.87 (1.23-2.85) * 1.46 (0.92-2.30) Taeeum type 2.19 (0.97-4.95) 2.12 (0.86-5.23) 2.17 (1.52-3.10) * 1.98 (1.35-2.91) * Soeum type 0.73 (0.14-3.66) 0.69 (0.11-4.06) 1.12 (0.54-2.31) 1.11 (0.52-2.35) Elevated fasting glucose Total 1.05 (0.54-2.04) 0.84 (0.41-1.72) 1.96 (1.48-2.59) * 1.46 (1.08-1.98) * Soyang type 1.53 (0.53-4.44) 1.20 (0.35-4.03) 2.44 (1.49-3.99) * 1.86 (1.09-3.18) * Taeeum type 0.71 (0.28-1.84) 0.56 (0.20-1.61) 1.48 (1.01-2.16) * 1.21 (0.80-1.81) Soeum type 1.01 (0.11-8.65) 0.92 (0.07-11.81) 1.21 (0.44-3.32) 1.40 (0.48-4.07) Elevated blood pressure Total 0.42 (0.21-0.84) * 0.34 (0.16-0.70) * 1.59 (1.24-2.04) * 1.11 (0.84-1.46) Soyang type 0.23 (0.05-1.03) 0.20 (0.04-0.96) * 1.56 (1.02-2.41) * 1.14 (0.70-1.83) Taeeum type 0.38 (0.15-0.94) * 0.29 (0.11-0.79) * 1.33 (0.93-1.89) 1.04 (0.70-1.54) Soeum type 0.97 (0.19-4.93) 1.45 (0.19-10.82) 1.20 (0.56-2.59) 1.11 (0.49-2.48) Definition of abbreviations: ILF=Impaired lung function; FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec; OR cru=crude odds ratio; OR adj=odds ratio adjusted for age, sex, smoking status, drinking, physical activity, and BMI; CI=confidence interval *p<0.05 Table 5. Association between Sasang Constitution and Impaired Lung Function by Multivariate Logistic Regression Analysis ILF(FVC) ILF(FEV 1) Model I Soyang type 2.16 (1.48-3.15) * 1.42 (0.95-2.13) Taeeum type 2.88 (2.01-4.14) * 1.69 (1.15-2.48) * Model II Soyang type 1.88 (1.27-2.78) * 1.35 (0.89-2.04) Taeeum type 2.82 (1.94-4.08) * 1.52 (1.03-2.25) * Model III Soyang type 1.71 (1.12-2.59) * 1.46 (0.94-2.26) Taeeum type 1.95 (1.23-3.08) * 2.06 (1.26-3.36) * Model IV Soyang type 1.64 (1.07-2.49) * 1.41 (0.91-2.19) Taeeum type 1.79 (1.12-2.85) * 1.93 (1.17-3.17) * Definition of abbreviations: ILF=impaired lung function; FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec Values are described as odds ratio (95% confidence interval) Soeum type was used as the reference group when conducting the multivariate logistic regression analysis. Model I - crude ; Model II - adjusted for age, sex, and smoking status ; Model III - adjusted for age, sex, smoking status, drinking, physical activity, and BMI ; Model IV - adjusted for age, sex, smoking status, drinking, physical activity, BMI, and Metabolic syndrome * p<0.05

188 Impaired Lung Function and Sasang Constitution Table 6. Association between Sasang Constitution and Ventilation Impairment by Multivariate Logistic Regression Analysis Obstructive pattern Restrictive pattern Model I Soyang type 1.63 (0.73-3.65) 2.32 (1.57-3.43) * Taeeum type 1.81 (0.83-3.94) 3.19 (2.20-4.65) * Model II Soyang type 1.36 (0.59-3.11) 2.04 (1.36-3.05) * Taeeum type 1.56 (0.70-3.47) 3.10 (2.11-4.55) * Model III Soyang type 1.13 (0.47-2.69) 1.85 (1.21-2.85) * Taeeum type 1.76 (0.63-4.88) 2.17 (1.35-3.49) * Model IV Soyang type 1.11 (0.46-2.67) 1.78 (1.15-2.74) * Taeeum type 1.77 (0.63-4.90) 1.98 (1.22-3.21) * Definition of abbreviations: ILF=impaired lung function; FVC=forced vital capacity; FEV 1=forced expiratory volume in 1sec Values are described as odds ratio (95% confidence interval) Soeum type was used as the reference group when conducting the multivariate logistic regression analysis. Model I - crude ; Model II - adjusted for age, sex, and smoking status ; Model III - adjusted for age, sex, smoking status, drinking, physical activity, and BMI ; Model IV - adjusted for age, sex, smoking status, drinking, physical activity, BMI, and Metabolic syndrome * p<0.05 력, 음주력, 운동력, BMI 의혼란요인을보정한후태음인과소양인은소음인보다폐기능장애의위험도가유의하게높았다. 특히태음인은 FVC, FEV 1 에서모두유의한반면, 소양인은 FVC에서만유의하였다. 대사증후군을추가로보정한후에도유의한결과는변함이없었다 (Table 5). 2) 사상체질과환기장애태음인과소양인은소음인보다제한성환기의위험도가유의하게높았다. 특히태음인은 FVC, FEV 1 에서모두유의한반면, 소양인은 FVC에서만유의하였다. 대사증후군을추가보정하여도유의한결과는변하지았았다. 폐쇄성환기는사상체질과관계가없었다 (Table 6). Ⅳ. 考察 이번연구는중년성인에서사상체질중태음인과소양인이연령, 성별, 흡연력, 음주력, 운동력, BMI의혼란요인을보정후에도폐기능장애의독립적인위 험인자로작용하며. 체질중태음인에서대사증후군과폐기능장애사이에유의한관계가있음을보여주고있다. 그리고환기장애중제한성환기가이와동일한양상으로사상체질과연관이있음을보여주고있다. 이번연구는정상하한치로정의한폐기능장애와사상체질의관계를분석한첫연구이다. 정상하한치란호흡기능이정상인집단에서하위 5 th percentile에해당하는기준값으로, 이값보다낮은경우정상범주에서벗어난것으로본다 38. 이번연구에서는한국인정상집단을대상으로개발된폐활량예측식과정상하한치 34 을사용하여폐기능검사결과를평가하였다. 현재까지사상체질에대해폐기능검사결과를분석한연구는드물었다. 이 24 는남성에서사상체질별폐기능을분석하였는데, BMI 정상군 (18.5 BMI<23) 에서태음인의경우 FVC%pred와 FEV 1%pred가다른체질에비해낮은것을확인하였다. 정등 23 은지역사회거주민 1,545명을대상으로만성폐쇄성폐질환 (FEV 1/FVC< 0.7) 의유병율을조사하였으며, 소음인에서유병율이가장높았으나체질이위험인자로는유의하지않다고보고하였다. 이번연구에서는 FVC%pred에서태음인

YS Pak et al. 189 이다른체질에비해유의하게낮았으며 (p<0.001), FEV 1%pred는유의하지않았다 (p=0.083). 또한, 폐쇄성환기 (FEV 1/FVC%pred<LLN) 의유병율이오히려소음인에서가장낮았으며 (4.4%), 체질과폐쇄성환기의관계는이전연구와같이통계적으로유의하지않았다. 현연구에서중요한시사점은중년성인에서사상체질이폐기능장애와밀접한연관성이있다는것이다. 성별, 연령, 흡연력, 음주력, 운동력, BMI 의혼란요인을보정한후에도태음인과소양인이소음인보다폐기능장애의위험도가유의하게높았다. 그리고소양인이폐기능측정치중 FVC만유의한관계인것에비해태음인은 FVC와 FEV 1 에서모두유의하게관계있었다. 이로볼때폐기능장애의양상이태음인에서보다뚜렷하게나타나고있음을알수있다. 그리고로지스틱회귀분석을통한태음인과소양인의비교는연구결과에서기술하지않았으나, 혼란요인을보정한결과두체질간에유의한차이는발견되지않았다. 비록태음인이소양인에비해 FVC%pred가유의하게낮고폐기능장애의유병율이 FVC와 FEV 1 에서모두유의하게높았으나, 성별 BMI 등의혼란요인으로인해유의한차이가나타나지않은것으로보인다. 이번연구에서호흡기질환의가능성이있는피험자는대상자에서최대한제외되었다. 따라서사상체질과폐기능장애간에다른메커니즘이관여한다고볼수있다. 첫째로, 몇몇연구에서제시된 systemic inflammation과폐기능의밀접한관계이다. 박등 13 은한국인중년남성 4905명에서염증지표인 C-reactive protein(crp) 이 FVC, FEV 1 와역의상관관계가있음을말하였고, Gan 등 39 은 FEV 1 의가장높은 quartile 에비해가장낮은 quartile에서 CRP, Leukocytes, Fibrinogen 이증가되어있음을발견하였다. Mannino 등 40 은 CRP 와 Fibrinogen 이폐쇄성, 제한성폐질환에서정상보다증가되어있음을발견하였다. 사상체질중태음인은고혈압 18, 당뇨 19, 인슐린저항성 20, 고지혈증 21, 대사증후군 22, 복부비만 41 의독립적인위험인자이며, 소양인또한대사증후군 22 에서소음인에비해높은위험도를 가지고있다. 이들질환은심혈관계질환의위험을높이며 systemic inflammation과깊은관련성이있다 42. 특히, 강등 43 은로지스틱회귀분석을통해태음인과소양인이소음인에비해 high-sensitivity CRP 증가의빈도가높음을발견하였다. 이는태음인과소양인이소음인에비해 systemic inflammation의위험도가높다는것을의미한다. 따라서태음인과소양인에서폐기능장애의위험이높은이유가 systemic inflammation과관련있을것으로추측할수있다. 둘째로, 사상체질간에나타나는체형적차이이다. 여등 44 의연구에따르면정상체중군 (18.5 BMI<23) 에서소음인은체간이빈약하고골반부위가약간큰정도이며, 소양인은골반부위가사상체질중가장빈약하며, 태음인은체간이발달하여가슴 ~ 윗배 ~ 허리가다른체질보다크다. 비만체형군 (23 BMI) 에서도소음인은상반신 ~ 허리가빈약하며, 소양인은골반이빈약하고, 태음인은허리 ~ 곡골부위가크다. 특히정상체중군에서소음인과태음인의체형특징을판별하는데가슴 ~ 윗배 ~ 허리의체간부둘레와너비가유용한척도이며, 비만체형군에서는허리둘레가유용한척도임이보고되었다. 그리고장등 41 은연령과 BMI를보정한후에도태음인이소음인에비해복부비만의위험도가남성에서 1.77배 (p<0.045), 여성에서 1.65배 (p<0.01) 높음을보고하였다. 즉, 태음인은 BMI 정상군과비만군모두에서소음인보다허리를포함한체간부가발달함을알수있다. 또한, 비만은폐기능감소와밀접한관계가있으며특히체지방의분포가폐기능에큰영향을미치는데, 체간형비만은물리적으로흉벽의탄성, 호흡근의근력및기능, 폐용적및말초기관지의크기를감소시키며복부지방은흉곽과횡격막에영향을미쳐폐의확산을제한한다 45. 그리고한단면연구 46 에서는정상체중, 과체중, 비만군에서모두허리둘레가폐기능 (FVC, FEV 1) 과역의상관관계가있음을밝혔다. 이로볼때중심성비만은 BMI와상관없이폐기능의감소와관련있으며, 소음인에비해중심형비만으로발전하기쉬운태음인이여러물리적기전에의해폐기능감소의위험이높은것으로추측할

190 Impaired Lung Function and Sasang Constitution 수있다. 이전연구 13-16 결과와유사하게성별, 연령, 흡연력, 음주력, 운동력, BMI의혼란요인을보정한후에도대사증후군이폐기능장애및제한성환기와유의한관계가있음을확인하였다. 그러나대사증후군구성요소별분석결과는이전연구와달랐다. 박등 13 은대사증후군구성요소중고중성지방과저HDL-콜레스테롤을합쳐네그룹으로만들어비교하였는데, FVC에서는모든요소가관련이있으나 FEV 1 에서는혈압상승이폐기능장애와관련이없으며, 두측정치에서모두복부비만이다른요소보다 OR이높음을확인하였다. Leone 등 14 은 Factor analysis 를통해 Lipids, Glucose-blood pressure, Abdominal obesity의세그룹으로묶어폐기능과의관계를분석하였는데, 세그룹모두유의한관계가있으며특히 Abdominal obesity가폐기능장애와현저하게관련있음을발견하였다. Lin 등 15 이발표한연구결과에서는다섯구성요소에서모두유의한관계가있었으나복부비만이다른요소에비해두드러지지않았다. 현연구에서는 FVC에서이상지질혈증군 (TG and HDL-C), 공복혈당상승군이유의하게관계있었고, FEV 1 에서복부비만군, 이상지질혈증군이유의하게관계있었다. 이번연구에서는이전연구 13,14,47 와달리복부비만과폐기능장애의관계가다른요소보다명확하지않았다. 이유를추측하면다음과같다. 첫째, 폐기능검사결과의분석방법에서차이가있다. 같은한국인집단을대상으로한박등 13 의연구에서는이번연구와동일한폐기능예측식 34 을사용하여 FVC%pred, FEV 1%pred를구하였으나, 이들값을 quartile로나눈후가장높은 quartile를기준으로가장낮은 quartile과비교하였다. 따라서정상하한치 (LLN) 를사용하여폐기능의장애유무를구분한이번연구와달리복부비만과폐기능의관계가더명확하게나타난것으로볼수있다. 둘째로, 아시아인의복부비만기준이서양인기준보다낮다는점이다. 미국의 National Cholesterol Education Program Adult Treatment Panel III(NCEP ATP III) 48 에서는복부비만의기준을남성 102cm, 여 성 88cm 이상으로정의하고있으며, AHA/NHLBI 36 에서도같은기준을사용하고있다. 그러나 WHO Western-Pacific Region 의보고서 49 에서는아시아태평양지역사람의복부비만기준을남성 90cm, 여성 80cm로할것을권고하였고, 이번연구에서인용한대한내분비학회와대한비만학회비만진료지침 37 은한국인복부비만기준을남성 90cm, 여성 85cm 이상으로정의하고있다. 폐기능과복부비만의의미있는관계를보고한이전의연구들 14,46 은서양인의기준을사용하였다. Lin 등 15 은대만사람을대상으로복부비만의기준을둘로나누어각각폐기능장애와비교하였는데, 남성 90cm, 여성 80cm로정의한복부비만군이남성 102cm, 여성 88cm로정의한복부비만군에비해상대적으로연관성이낮음을보여주었다 [OR adj(95%ci): 1.12 (1.02-1.24) vs 1.35 (1.13-1.63)]. 이로볼때아시아태평양지역의복부비만기준으로정의할경우복부비만과폐기능장애의관련성이상대적으로명확하지않은것으로생각되며, 향후아시아인을대상으로복부비만과폐기능의관계를확인하는대집단연구가더필요할것으로보인다. 이번연구에서또다른특이한점은성별, 연령, 흡연력, 음주력, 운동력, BMI 의혼란요인을보정한후태음인과소음인에서는대사증후군과폐기능장애의관계가유의하나소양인에서는그렇지않다는것이다. 그러나소음인의경우 FVC의폐기능장애에서대사증후군과의관련성이나타났으나, 대사증후군대상자부족 (n=7) 으로표준오차가커서결과를신뢰하기에한계가있다. 이전연구 22 에따르면사상체질중태음인에서대사증후군의유병율이가장높으며, 태음인이다른체질에비해대사증후군의위험도가높다. 또한, 대사증후군과폐기능장애모두심혈관계질환의위험을증가시킨다 2-5,50,51. 따라서심혈관계질환의관리를위해태음인에서선별적인폐기능검사를동반한대사증후군의관리및예방이필요할것으로사료된다. 또한대사증후군구성요소와폐기능장애의관계를분석하였을때, 태음인에서이상지질혈증군이 FVC,

YS Pak et al. 191 FEV 1 의폐기능장애와유의한관계가있으며, 소양인에서공복혈당상승군이 FVC의폐기능장애와유의한관계가있음을발견하였다. 이와같은결과는전체대상자의분석결과에서도발견된다. 눈여겨볼점은체질별분석결과의 OR이전체대상자분석결과의 OR보다증가된것이다. 이상지질혈증과공복혈당상승이폐기능장애와관계가있다는점은이전연구 8,10,13,15 에서밝혀졌다. 그러나사상체질과이들질환의생물학적기전을규명한연구는지금까지부족하며, 이에관한추가연구가필요할것으로보인다. 이번연구의제한점은다음과같다. 첫째, 일개건강검진센터를대상으로하였기때문에연구집단을일반화하기에한계가있다. 대상자들의다수가수도권에거주하기에사회경제적수준이다른지역사회에비해높은편이나흡연력음주력운동력등사회력을혼란변수로써보정하였기때문에사회활동과관련된 selection bias는감소했을것으로보인다. 둘째, 40~64 세의중년성인을대상으로하였기때문에연령에따른 selection bias가존재한다. 이번연구데이터에서 65세이상의노인은타연령에비해단순흉부방사선촬영상이상폐조직의빈도가높았다. 따라서잠재적폐질환의가능성때문에노인군은연구에서배제하였다. 그리고 40세이상의중년성인은 20-30대에비해대사증후군과같은심혈관계위험질환의유병율이뚜렷하게높으며 52. 폐기능은 20대중반에최대에도달하여서서히감소한다 53. 따라서대사적요소와폐기능감소의관계를명확하게평가하기위해서 40세미만의성인은대상자에서제외되었다. 셋째, 소음인에서대사증후군의빈도가낮은까닭으로대사증후군과폐기능장애의관계를명확하게평가하지못하였다. 넷째, 태양인의빈도가희소하여 (n=1) 분석에서제외되었다. 이번연구는사상체질과폐기능장애의관계에대한첫연구로, 향후다른인구집단을대상으로한대집단연구가필요하며, 체질과대사적요소, 그리고폐기능장애간의기전을규명하기위한연구가필요할것으로보인다. 요약하면, 사상체질중태음인과소양인은소음인에비해연령, 성별, 흡연력, 음주력, 운동력, BMI의혼란요인과상관없이폐기능장애의독립적인위험인자로작용한다. 또한태음인에서는대사증후군이폐기능장애의독립적인위험인자로작용하며, 특히이상지질혈증과관련이깊다. V. 參考文獻 1. Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26:948-968 2. Hole D, Watt G, Davey-Smith G, Hart C, Gillis C, Hawthorne V. Impaired lung function and mortality risk in men and women: Findings from the renfrew and paisley prospective population study. BMJ. 1996;313:711-715 3. Ryan G, Knuiman MW, Divitini ML, James A, Musk AW, Bartholomew HC. Decline in lung function and mortality: The busselton health study. Journal of epidemiology and community health. 1999;53:230-234 4. Schunemann HJ, Dorn J, Grant BJ, Winkelstein W, Trevisan M. Pulmonary function is a long-term predictor of mortality in the general population29-year follow-up of the buffalo health study. CHEST Journal. 2000;118:656-664 5. Sin DD, Wu L, Man SFP. The relationship between reduced lung function and cardiovascular mortality*: A population-based study and a systematic review of the literature. CHEST Journal. 2005;127:1952-1959 6. Margretardottir OB, Thorleifsson SJ, Gudmundsson G, Olafsson I, Benediktsdottir B, Janson C et al. Hypertension, systemic inflammation and body weight in relation to lung function impairment-an epidemiological study. Copd. 2009;6:250-255 7. Selby JV, Friedman GD, Quesenberry CP, Jr. Precursors of essential hypertension: Pulmonary function, heart

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