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318 Eun Kyung Roh and Hyun Yoon. Metabolic Syndrome and Vitamin D ORIGINAL ARTICLE Korean J Clin Lab Sci. 2015, 47(4):318-323 http://dx.doi.org/10.15324/kjcls.2015.47.4.318 pissn 1738-3544 eissn 2288-1662 The Association of Metabolic Syndrome and Vitamin D in Korean Menopausal Women: Korea National Health and Nutrition Survey, 2010 2012 Eun Kyung Roh 1 and Hyun Yoon 2 1 Department of Hospital Administration, Dong Kang University, Gwangju 61200, Korea 2 Department of Biomedical Laboratory Science, Hanlyo University, Gwangyang 57764, Korea 한국폐경기여성에서대사증후군과비타민 D 의관련성 : 2010 2012 국민건강영양조사에근거하여 노은경 1, 윤현 2 1 동강대학교보건행정학과, 2 한려대학교임상병리학과 The aim of this study was to assess the association of metabolic syndrome and Vitamin D in Korean adults. The study subjects were Korean menopausal woman (n=4,340) who participated in the Korea National Health and Nutrition Examination Survey 2010 2012. After adjusting for factors such as age, body mass index, total cholesterol, smoking, and regular exercise, the mean 25(OH)D levels (M±SE) decreased with increasing metabolic syndrome score (MSS) (MSS 0, 18.18±0.29 ng/ml; MSS 1, 18.09±0.21 ng/ml; MSS 2, 18.07±0.19 ng/ml; MSS 3, 18.04±0.21 ng/ml; MSS 4, 17.27±0.23 ng/ml), and the mean 25(OH)D level (M±SE) for metabolic syndrome (17.66±0.16 ng/ml) decreased in comparison to non-metabolic syndrome (18.11±0.14 ng/ml). In conclusion, our results suggest that an increase in metabolic syndrome score or metabolic syndrome are inversely associated with the vitamin D levels. Keywords: Metabolic syndrome, Metabolic syndrome score, Vitamin D, Postmenopausal women Corresponding author: Hyun Yoon Department of Biomedical Laboratory Science, Hanlyo University, Gwangyang 57764, Korea Tel: 82-61-760-1150 E-mail: yh9074@yahoo.co.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2015 The Korean Society for Clinical Laboratory Science. All rights reserved. Received: October 27, 2015 Revised 1 st : November 5, 2015 Revised 2 nd : November 6, 2015 Revised 3 rd : November 6, 2015 Accepted: November 6, 2015 서론대사증후군은복부비만과고혈압, 지질대사이상및공복혈당장애를포함한대사이상을동반하는질환으로예전에는 Syndrome X라고불렸으며, 인슐린에대한저항성을나타낸다 (Reaven 등, 1998). 대사증후군의발생은심혈관계질환과뇌혈관질환및제 2 형당뇨병의발생률을증가시키고, 총사망률과관련이높다고알려져있다 (Isomaa 등, 2001; McNeill 등, 2005). 미국에서폐경기여성의대사증후군유병률은약 40% 이며 (Ford 등, 2002), 우리나 라에서는약 54% 의대사증후군유병률은보이고있다 (Shin, 2014). 폐경기여성은폐경전여성에비하여고밀도콜레스테롤이감소하지만중성지방, 총콜레스테롤및저밀도콜레스테롤은증가하는것으로알려져있다 (Carr, 2003; Kim 등, 2007). 폐경기여성은이와같은지질이상으로인하여혈중 glucose 및인슐린증가와같은대사및내분비적변화가동반되고 (Lee 등, 2005), 심혈관및뇌혈관질환과대사증후군발생률도폐경이전보다현저한증가를보인다 (Moon 등, 2003; Kim 등, 2007). 비타민 D는호르몬전구체로서 vitamin D2는버섯등의일부식

Korean J Clin Lab Sci. Vol. 47, No. 4, Dec. 2015 319 물과고등어와같은기름진생선등에도존재하지만대부분자외선으로합성된다. 비타민 D의혈중농도는비활성형인 25-hydroxyvitamin D [25(OH)D] 를측정하여체내총비타민 D 상태를추정하는데, 그이유는활성형인 1,25-dihydroxyvitamin D보다반감기가 2 3 주로길기때문이다 (Hollis와 Horst, 2007; Prentice 등, 2008). 비타민 D의기능은골다공증과당뇨의발병을억제하고 (Shin과 Om, 2009), 면역계의정상기능유지와유방암, 전립선암을예방하고류마티즘에효과가있다고알려져있고 (Misr 등, 2008), 비타민의결핍은연골무기질화장애와연골성장판의비정상적인기질화 (organization) 로발생하는구루병과인지기능장애, 우울증의중요한기여요인이된다 (Kim, 2007). 최근, 비타민 D과관련된연구는대사증후군의구성요인인동시에혈관질환의위험요인에해당하는고혈압, 비만, 고지혈증, 당뇨등과의관련성에대한연구가많이진행되고있지만 (Brandenburg 등, 2012; Cozzolino 등, 2012; Muscogiuri 등, 2012; Park과 Lee, 2012), 대사증후군의위험인자인고밀도콜레스테롤이감소하고중성지방, 총콜레스테롤및저밀도콜레스테롤이증가하는것으로알려져있는폐경기여성을대상으로실시한연구는드물다. 따라서본연구는대한민국도심혈관계질환과대사증후군이증가하고있고, 대한민국성인의비타민 D 결핍이특히심하다고알려져있는상황에서제 5기국민건강영양조사자료를이용하여한국폐경기여성을대상으로혈중비타민 D와대사증후군의관련성에대하여알아보고자하였다. 재료및방법 1. 연구대상본연구는제 5기국민건강영양조사의자료 (2010 2012년) 를이용하였다. 조사참여자수는 25,499명이었고, 이중폐경기여성은 5,108명이었다. 5,108명중건강설문에서불충분한응답과혈압및혈액검사및비타민 D 등의검사결과가누락이되어있는대상자 768명을제외한총 4,340명을최종분석대상자로하였다. 제 5 기국민건강영양조사자료는질병관리본부연구윤리심의위원회의심의및승인을받았다 ( 승인번호 ; 2010-02CON-21-C, 2011-02CON-06-C, 2012-01EXP-01-2C). 2. 자료수집본연구는 2010년도부터 2012년도까지 3년동안시행된제 5 기국민건강영양조사자료를이용하였다. 조사항목으로는대상자들의연령, 허리둘레 (waist measurement, WM), 체질량지수 (body mass index, BMI), 안정시혈압, 아침공복시의혈액검사등 이었다. 3. 대상자의특성 1) 일반적특성및혈액화학검사대상자중연령은 50세미만군, 50 59세군, 60 69세군, 70세이상군으로구분하였다. 신체계측은체질량지수, 허리둘레, 최종수축기혈압 (systolic blood pressure, SBP), 최종이완기혈압 (diastolic blood pressure, DBP) 의측정값을사용하였고, 혈액화학검사는총콜레스테롤 (Total cholesterol, TC), 중성지방 (Triglyceride, TG), 저밀도콜레스테롤 (HDL-cholesterol, HDL-C), 공복시혈당 (Fasting blood glucose, FBG) 및 25(OH)D 등의측정값을사용하였다. 2) 대사증후군및비타민 D 대사증후군의진단기준은 Revised NCEP-ATP III의기준 (Revised NCEP-ATP III, 2001) 에의하여높은중성지방혈증은 TG 150 mg/dl으로정의하였고, 낮은고밀도콜레스테롤혈증은 HDL-C <50 mg/dl미만으로정의하였다. 높은혈당은 FBG 100 mg/dl으로정의하였고, 높은혈압은 SBP 130 mmhg이거나, DBP 85 mmhg일때로정의하였다. 복부비만은허리둘레를 APC (Asia-pacific criteria) 의기준에따라 WM 80 cm 으로정의하였다 (WHO, 2000). 이들 5개항목중정상치보다높거나낮은항목이 3개이상존재할때를대사증후군으로분류하였다. metabolic syndrome score (MSS) 는대사증후군의 5가지위험요인인높은혈압, 높은혈당, 복부비만, 높은중성지방혈증, 낮은고밀도콜레스테롤혈증등을 score로분류한것으로대사증후군의 5가지중위험요인을가지고있지않는경우를 MSS 0, 위험요인중 1개를가지고있는경우를 MSS 1, 위험요인중 2개를가지고있는경우를 MSS 2, 위험요인중 3개를가지고있는경우를 MSS 3, 위험요인중 4개이상가지고있는경우를 MSS 4 로분류하였다 (Yoon 등, 2015). 4. 자료처리및분석자료의통계처리는 SPSS WIN version 18.0 (SPSS Inc., Chicago, IL, USA) 통계프로그램을이용하였다. 대상자의특성에대한분포는빈도와백분율로나타내었고연속형자료는평균과표준편차로표시하였다. 대상자의특성에따른 25(OH)D는 independent t-test와 ANOVA test를이용하여분석하였다. 25(OH)D 에대한공분산분석을시행하여 25(OH)D에영향을주는다른요인을보정한후대사증후군과 MSS에따른 25(OH)D의평균값을비교하였다. 모든통계량의유의수준은 p<0.05 로판정하였다.

320 Eun Kyung Roh and Hyun Yoon. Metabolic Syndrome and Vitamin D 결과 1. 연구대상자의일반적특성 연구대상자의일반적특성은 Table 1과같다. 대상자들의평균연령은 45.75 (±10.71) 세로조사되었고, BMI 평균값은 23.70± 3.20 kg/m 2 이었다. 대상자들의혈액검사중 TC, TG, HDL-C 평균값은각각 191.10±38.34 mg/dl, 128.14±97.08 mg/dl, 51.46±12.14 mg/dl이었고, FBG 평균값은 95.68±17.09 mg/dl이었다. 대상자들의혈압에대한수치중 SBP와 DBP 평균값은각각 123.32±12.37 mmhg, 75.50±9.56 mmhg 이었다. 대상자들중비타민 D결핍 (25(OH)D<15) 에해당하는대상자는 Table 1. General characteristics of research subjects N (%), M±SD, (N=4,340) Variables N (%) M±SD Age (year) 63.55±9.32 <50 167 (3.8) 50 59 1,473 (34.0) 60 69 1,428 (32.9) 70 1,272 (29.3) Smoking Non-smoker 4,031 (92.9) Ex-smoker 138 (3.2) Current smoker 171 (3.9) Alcohol drinking Non-drinker 2,229 (54.4) Drinker 2,111 (48.6) Regular exercise No 3,940 (90.8) Yes 398 (9.2) Metabolic syndrome score (MSS) 2.12±1.29 0 539 (12.4) 1 947 (21.8) 2 1,106 (25.5) 3 941 (21.7) 4 807 (18.6) Metabolic syndrome MSS<3 2,592 (59.7) MSS 3 1,748 (40.3) 25(OH)D (ng/ml) 17.94±6.29 <15 1,535 (35.4) 15 2,805 (64.6) BMI (kg/m 2 ) 24.29±3.28 WM (cm) 82.21±9.22 TC (mg/dl) 201.61±37.73 TG (mg/dl) 135.73±84.84 HDL-C (mg/dl) 52.53±12.38 FBG (mg/dl) 100.64±22.83 SBP (mmhg) 127.22±17.89 DBP (mmhg) 76.47±9.94 Abbreviation: 25(OH)D, 25-hydroxyvitamin D; BMI, body mass index; WM, waist measurement; TC, total cholesterol; TG, triglyceride; HDL-C, HDL-cholesterol; FBG, fasting blood glucose, SBP, systolic blood pressure; DBP, diastolic blood pressure. 1,535명 (35.4%) 이었고, 대사증후군 (MSS 3) 에해당하는대상자는 1,748명 (40.3%) 이었다. 2. 대상자의특성에따른 25(OH)D 의평균값비교 대상자의특성에따른 25(OH)D의평균값은 Table 2와같다. 대상자의특성중 25(OH)D에서평균차이를보이는변수는연령 (p=0.001), 흡연습관 (p=0.045), 중등도신체활동 (p=0.035), BMI (p<0.001) 등이었다. 대사증후군구성요소중에서는복부비만 Table 2. Serum 25(OH)D levels by subject characteristics M±SD, (N=4,340) Variables 25(OH)D (ng/ml) p-value Age (years) 0.001 <50 16.76±5.37 50 59 17.56±5.83 60 69 18.20±6.43 70 18.23±6.70 Smoking 0.045 Non-smoker 18.00±6.34 Ex-smoker 17.18±5.52 Current smoker 17.00±5.65 Alcohol drinking 0.357 Non-drinker 17.85±6.41 Drinker 18.03±6.16 Regular exercise 0.035 No 17.87±6.28 Yes 18.59±6.39 Body mass index (kg/m 2 ) <0.001 <25 18.19±6.47 25 17.52±5.96 Total cholesterol (mg/dl) 0.099 <200 18.10±6.51 200 17.78±6.06 Waist measurement (cm) 0.042 Normal* 18.17±6.47 Abdominal obesity 17.77±6.16 Triglycerides (mg/dl) 0.003 Normal 18.13±6.30 Elevated triglycerides 17.52±6.26 HDL-cholesterol (mg/dl) 0.036 Normal 18.11±6.32 Reduced HDL-C 17.71±6.24 Fasting blood glucose (mg/dl) 0.892 Normal** 17.93±6.17 Elevated FBG 17.95±6.50 Blood pressure (mm/hg) 0.029 Normal 18.13±6.23 Elevated blood pressure 17.71±6.35 *Normal is defined as WM <80 cm; Abdominal obesity is defined as WM 80 cm; Normal is defined as TG <150 mg/dl; Elevated triglyceride is defined as TG 150 mg/dl; Normal is defined as HDL-C 50 mg/dl; Reduced HDL-C is defined as HDL-C <50 mg/dl; **Normal is defined as FBG <100 mg/dl; Elevated FBG is defined as FBG 100 mg/dl; Normal is defined as SBP <130 mmhg or DBP <85 mmhg Elevated blood pressure is defined as SBP 130 mmhg or DBP 85 mmhg.

Korean J Clin Lab Sci. Vol. 47, No. 4, Dec. 2015 321 Table 3. Comparisons of serum 25(OH)D levels for metabolic syndrome and MSS (N=4,340) Variables 25(OH)D (ng/ml) Non-adjusted (M±SD) p-value 25(OH)D (ng/ml) Adjusted* (M±SE) p-value MSS 0.004 0.041 0 18.24±6.40 18.18±0.29 1 18.16±6.24 18.09±0.21 2 18.09±6.33 18.07±0.19 3 18.02±6.06 18.04±0.21 4 17.17±6.44 17.27±0.23 Non-MetS 18.15±6.31 0.007 18.11±0.14 0.042 MetS 17.62±6.25 17.66±0.16 Abbreviation: MSS, metabolic syndrome score; MetS, metabolic syndrome. *Adjusted for age, BMI, TC, smoking, and regular exercise. (p=0.042), 높은중성지방 (p=0.003), 낮은 HDL-C (p=0.036), 높은혈압 (p=0.029) 등이었고, 높은혈당 (p=0.892) 은 25(OH)D의평균값에서유의한차이가없었다. 3. 대사증후군과 MSS 에따른 25(OH)D 의평균비교 대사증후군과 MSS에따른 25(OH)D의평균비교는 Table 3과같다. 연령, BMI, TC, 흡연습관, 중등도신체활동등을보정한후 MSS에따른 25(OH)D의평균값 (M±SE) 은 MSS 0이 18.18±0.29 ng/dl 이었고, MSS 1이 18.09±0.21 ng/dl, MSS 2가 18.07± 0.19 ng/dl, MSS 3이 18.04±0.21 ng/dl, MSS 4가 17.27±0.23 ng/dl 로 MSS가증가할수록 25(OH)D의평균값이감소하였고 (p=0.041), 연령, BMI, TC, 흡연습관, 중등도신체활동등을보정한후, 대사증후군에따른 25(OH)D의평균값 (M±SE) 에서도비대사증후군 (18.11±0.14 ng/dl) 에비하여대사증후군 (17.66± 0.16 ng/dl) 의 25(OH)D의평균값 (M±SE) 이유의하게감소하였다 (p=0.042). 고찰 본연구는국민건강영양조사자료 (2010 2012) 를이용하여폐경기여성에서대사증후군과비타민 D의관련성에대한연구이다. 본연구의주요결과는비타민 D에대한관련변수를보정한후에도비대사증후군에비하여대사증후군의 25(OH)D 의평균값 (M±SE) 이유의하게낮았고, 대사증후군구성요소의증가에따라 25(OH)D 의평균값 (M±SE) 이유의하게감소하였다는결과이다 (Table 3). 비타민 D는심 뇌혈관질환과고혈압, 당뇨및골다공증을예방한다고알려져있는데 (Shin 과 Om, 2009), 비타민 D의결핍은당뇨와고혈압의발생률을증가시키고동맥경화증과심혈관의석회 화를가속화시킨다 (Hollis 등, 2007). 또한각각의대사증후군구성요소는관상동맥의위험요소이며, 이들이군집적으로나타나는대사증후군은심혈관계질환과뇌혈관질환및제 2형당뇨병의발생률을증가시킨다 (Meigs, 2000; Grundy, 2007). 비타민 D와대사증후군에대한연구에서, Lu 등 (2009) 은 50 70세의베이징과상하이노인을대상으로실시한연구에서비타민 D 정상군 (24.4%) 에비하여비타민 D 결핍군 (69.2%) 의대사증후군발생률 (p-trend=0.0002) 이높았다. 또한 Park 등 (2012) 은 60 세이상의한국노인을대상으로실시한연구에서 25(OH)D는 TG (p=0.023), SBP (p=0.002), DBP (p<0.001) 의증가와관련이있었고, 대사증후군의발생률 [Odds Ratio (OR): 1.73, 95% Confidence interval (CI): 1.13-2.66] 의증가와관련이있었다. 반대로, Kahder 등 (2011) 은 18세이상의요르단성인을대상으로실시한연구에서 25(OH)D는대사증후군및대사증후군구성요소모두와연관성이없었다. 이와같이비타민 D와대사증후군에대한연구결과는나라와인종, 연령층과질병의유무에따라다르게나타나기때문이다. 본연구결과에서대사증후군구성요소중높은혈압은 25(OH)D와관련이없었지만, 대사증후군의구성요소가증가함에따라 25(OH)D가감소하였고 (p=0.041), 비대사증후군에비하여대사증후군의 25(OH)D가감소하였다 (p=0.042). 대사증후군에서비타민 D가감소하는이유는첫째, 본연구는대한민국의대표적지표인제 5기국민건강영양조사자료 (2010 2012) 를이용한연구로대상자는폐경기여성이다. 여성은폐경으로인하여에스트로겐분비의감소로체지방분포에서변화가나타난다. 이로인하여내장지방의증가에의한복부비만의증가로대사증후군의발생위험도가증가한다 (Lee 등, 2005). 비만과복부비만은대사증후군의강력한위험인자이며, 비타민 D의감소와관계가있다. Lee 등 (2013) 은한국청소년 1,660명을대상으로실시한 serum 25(OH)D와비만및대사증후군에대한연구에서비만청소년에서비타민 D가유의하게감소한다고하였고 (p<0.001), Lagunova 등 (2011) 은비만에서비타민 D가감소하는이유를비만인사람은비타민 D가신장에서 1,25(OH)D2로전환되는과정에서문제가있을것으로추측하고있다. 둘째, 비타민 D는부갑상선호르몬 (parathyroid hormone, PTH) 과역상관관계가있다. Guasch 등 (2012) 은스페인여성 316명을대상으로실시한연구에서 BMI가증가할수록 PTH가증가하였고 (p<0.001), BMI의증가가부갑상선호르몬의증가와비타민 D의감소에영향을주는가장주요인자라고하였다. 또한, Lee 등 (2015) 은 2011년국민건강영양조사자료를이용한복부비만과 PTH에대한연구에서정상군에비하여복부비만군에서고 PTH군 (PTH>65ng/L) 의 OR값 (OR: 1.19, CI: 1.02-1.39) 이유의하게증가하였다. 본연구의결과에서

322 Eun Kyung Roh and Hyun Yoon. Metabolic Syndrome and Vitamin D 대사증후군및대사증후군의구성요소의증가가 25(OH)D 수준을감소시키는지, 25(OH)D 수준이대사증후군및대사증후군의구성요소를증가시키는지는알수없다. 그러나비대사증후군에비하여대사증후군의 25(OH)D 수준이낮은이유로대사증후군구성요소가증가할수록 25(OH)D 수준이감소하기때문이라고사료된다. 그러나본연구는제한점이있다. 국민건강영양조사를이용한단면연구이기때문에비타민 D와대사증후군의인과관계를설명할수가없고, 향후추적조사를통해서비타민 D와대사증후군에대한코호트연구를시행할수있다면이들의인과관계를확인하기위한더욱더정확한결과를얻을수있을것으로기대된다. 요약 본연구는국가자료인제 5기국민건강영양조사자료 (2010 2012) 를이용하여폐경기여성 (n=4,340) 에서대사증후군과비타민 D의관련성을평가하고자실시하였다. 연구결과에서연령, BMI, TC, 흡연습관및중등도신체활동을보정한후, 25(OH)D에대한평균값 (M±SE) 이 MSS 0은 18.18±0.29 ng/ml, MSS 1은 18.09±0.21 ng/ml, MSS 2는 18.07±0.19 ng/ml, MSS 3은 18.04±0.21 ng/ml, MSS 4 는 17.27±0.23 ng/ml 로 MSS가증가할수록감소하였고 (p=0.041), 비대사증후군 (18.11±0.14 ng/ml) 에비하여대사증후군 (17.66±0.16 ng/ml) 에서유의하게증가하였다 (p=0.042). 결론적으로대사증후군구성요소의증가와대사증후군은비타민 D의수준과역으로관계가있다. Acknowledgements: None Funding: None Conflict of interest: None References 1. Brandenburg VM, Vervloet MG, Marx N. The role of vitamin D in cardiovascular disease: From present evidence to future perspectives. Atherosclerosis. 2012, 225:253-263. 2. Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab. 2003, 88:2404-2411. 3. Cozzolino M, Stucchi A, Rizzo MA. Vitamin D receptor activation and prevention of arterial ageing. Nutrition, metabolism, and cardiovascular diseases. 2012, 22:547-552. 4. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA. 2002, 287:356-359. 5. Grundy SM. Metabolic syndrome: a multiplex cardiovascular risk factor. J Clin Endocrinol Metab. 2007, 92:399-404. 6. Guasch A, Bulló M, Rabassa A, Bonada A, Castillo DD, Sabench F, et al. Plasma vitamin D and parathormone are associated with obesity and atherogenic dyslipidemia: a cross-sectional study. Cardiovasc Diabetol. 2012, 11:149. 7. Hollis BW, Horst RL. The assessment of circulating 25(OH)D and 1,25(OH)2D: where we are and where we are going. J. Steroid. Biochem. Mol Biol. 2007, 103:473-476. 8. Isomaa B, Almgren P, Forsen B, Torsen B, Laht K, Nissen M, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001, 24:683-689. 9. Khader YS, Batieha A, Jaddou H, Batieha Z, El-Khateeb M, Ajlouni K. Relationship between 25-Hydroxyvitamin D and metabolic syndrome among Jordanian adults. Nutr Res Pract. 2011, 5:132-139. 10. Kim HM, Park J, Ryu SY, Kim J. The effect of menopause on the metabolic syndrome among Korean women: the Korean National Health and Nutrition Examination Survey, 2001. Diabetes Care. 2007, 30:701-706. 11. Kim YE. The association between vitamin D deficiency and frailty syndrome. J Korean life Insur Med Assoc. 2007, 26:3-12. 12. Lagunova Z, Porojnicu AC, Vieth R. Serum 25-hydroxyvitamin D is a predictor of serum 1,25-dihydroxyvitamin D in overweight and obese patients. Pediatric diabetes. 2011, 141: 112-117. 13. Lee HJ, Kwon HS, Park YM, Chun HN, Choi YH, Ko SH, et al. Waist circumference as a risk factor for metabolic syndrome in Korean adult evaluation from 5 different criteria of metabolic syndrome. J Korean Diabetes Assoc. 2005, 29:48-56. 14. Lee KS, Yoon YS, Yoon H. The association of abdominal obesity, obesity and parathyroid hormone in Korean adults (aged 50 years): The Korea National Health and Nutrition Survey, 2011. J Korea Acad Industr Coop Soc. 2015, 16:3882-3888. 15. Lee SH, Kim SM, H. S. Park HS. Serum 25-hydroxyvitamin D levels, obesity and the metabolic syndrome among Korean children. Nutr Metab Ccardiovas. 2013, 23:785-791. 16. Lu L, Yu Z, Pan A, Hu FB, Franco OH, Li H, et al. Plasma 25-Hydroxyvitamin D concentration and metabolic syndrome among middle-aged and elderly Chinese individuals. Diabetes Care. 2009, 32:1278-1283. 17. McNeill AM, Rosamond WD, Girman CK, Golden SH, Schmidt ML, East HE, et al. The metabolic syndrome and 11-year risk of incident cardiovascular disease in the Atherosclerosis Risk in Communities Study. Diabetes Care. 2005, 28:385-390. 18. Meigs JB. Invited commentary: insulin resistance syndrome syndrome X multiple metabolic syndrome a syndrome at all factor analysis reveals patterns in the fabric of correlated metabolic risk factors. Am J Epidemiol. 2000, 152:908-911. 19. Misr M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008, 122:398-417. 20. Moon HK, Kim YD, Yang DG, Kim SG, Cha KS, Kim MH, et al. Age and Gender Distribution of Patients with Acute Myocardial Infarction Admitted to University Hospitals during the Period of 1990-1999. Korean Circ J. 2003, 33:92-96. 21. Muscogiuri G, Sorice GP, Ajjan R. Can vitamin D deficiency cause diabetes and cardiovascular diseases: Present evidence and future perspectives. Nutr Metab Ccardiovas. 2012, 22:

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