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대한지역사회영양학회지 18(4) : 402~412, 2013 Korean J Community Nutr 18(4) : 402~412, 2013 http://dx.doi.org/10.5720/kjcn.2013.18.4.402 혈액투석환자대상영양교육과상담이짠맛미각, 영양지식및식태도변화에미치는효과 이영미 이연경 1) 경북대학교교육대학원영양교육전공, 1) 경북대학교식품영양학과 Effectiveness of Nutrition Education and Counseling on the Salty Taste Assessment, Nutrition Knowledge and Dietary Attitude of Hemodialysis Patients Young-Mi Lee, Yeon-Kyung Lee 1) Nutrition Education Major, Graduate School of Education, Kyungpook National University, Daegu, Korea 1) Department of Food Science and Nutrition. Kyungpook National University, Daegu, Korea Abstract The purpose of this study was to evaluate the effectiveness of nutrition education and counseling on the salty taste assessment, nutrition knowledge and dietary attitude of 21 hemodialysis patients. Five times of the nutrition education and three times of nutrition counseling were performed for a period of 5 months. Biochemical analysis revealed that creatinine was significantly high (p < 0.001), blood urea nitrogen and serum albumin were significantly low (p < 0.05, p < 0.01) and Na, K, Cl, K, P and uric acid were not significantly different. The distribution rate of unsalty taste preference were significantly high and the distribution rate of salty taste preference were significantly low after nutrition education and counseling (p < 0.001). Nutrition knowledge significantly improved following 5th month of education and counseling (p < 0.01). Particularly, the scores for questions related to sodium were improved. The dietary attitude was significantly improved during the counseling period (p < 0.05). There were improvements in responses to use food exchange list on diet and habitually add salt or soy sauce before the meal. According to these results, salty taste assessment, nutrition knowledge and dietary attitude were significantly improved by the hemodialysis diet therapy practices of hemodialysis patients. Therefore, we conclude that there was a need for lowsalt diet education and nutrition counseling to help them recognize the taste of low-salt foods and strive towards a preference for less salty tasting foods and the consumption of a low-salt diet. (Korean J Community Nutr 18(4) : 402~412, 2013) KEY WRDS : hemodialysis nutrition education salty taste assessment nutrition knowledge dietary attitude 접수일 : 2013 년 7 월 31 일접수수정일 : 2013 년 8 월 20 일수정채택일 : 2013 년 8 월 26 일채택 *This research was supported by Kyungpook National University Research Fund, 2010 Corresponding author: Yeon-Kyung Lee, Department of Food Science and Nutrition, Kyungpook National University, 1370 Sankyuk Dong, Buk-ku, Daegu 702-201, Korea Tel: (053) 950-6234, Fax: (053) 950-6229 E-mail: yklee@knu.ac.kr This is an pen-access article distributed under the terms of the Creative Commons Attribution Non-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. 서 신장의기능이정상기능의 10% 미만이되면수분과전해질의조절이잘이루어지지않게되고, 호르몬분비등의작용도장애를받아빈혈과뼈에이상이나타나게되면서요독증이나타나기시작한다 (Lee 2004). 말기신부전증이되면신장기능대체수단으로신장이식, 혈액투석및복막투석중한가지를선택하여야한다 (Han 1989). 투석치료는만성신부전환자의생명을연장하고정상에가까운일상생활을유지할수있도록삶의질에도움을주고있다. 그럼에도불구하고장기적으로혈액투석을하게되면에너지섭취와단백질부족으로영양결핍이생길수있으며 론 402

이영미 이연경 403 (Thunberg 등 1981; Walser 1983; Kopple 1988) 탄수화물, 지방, 단백질대사에이상이나타나고체액전해질조성에이상이올수있다 (Kopple 등 1978; Kopple 1978; Schoenfeld 등 1983; Walser 1983; Guthrie & Crocetti 1985). 투석을받는말기신부전환자의영양실조유병율은 18~56% 정도로보고되고있고 (Young 등 1991; Kopple 1997) 영양실조가투석환자의이환율과사망률의위험인자로작용하여환자의예후에직접적인영향을미치기때문에 (Young 등 1989) 병의진행을완화시키기위해서식사요법이중요하다 (Jeon 등 1993). 만성신부전식사요법은임상증상, 생화학적분석치, 영양상태에따라달라질수있기때문에실제로식사요법에대한개개인의이해력이없으면식사요법의실천은기대할수없다. 또한식품에함유된영양소의차이를정확하게파악하여권장식품과제한식품에대한분명한이해가따라야한다 (Kim 등 2001). 식사요법으로열량과단백질을적절한양으로섭취하도록하고, 칼륨, 나트륨, 인의제한과체액의균형을유지하여남아있는신기능의손실을최소화하고, 요독증을예방할수있도록한다 (Jang 등 2006). 혈액투석환자는소변량이적거나없어나트륨섭취를엄격히제한하며고혈압과부종을조절하기위하여보통 40~120 meq(1,000~2,760 mg) 가권장되며나트륨을제한하면갈증을예방하여과량의수분섭취와체중증가를막을수있다 (The Korean Dietetic Association 2008). 과다한염분과수분섭취는폐기관지에많은수분을고이게하여폐울혈증, 폐부종, 기침, 맑은객담, 수면시호흡곤란등의증상이생긴다 (Lee 2004). 우리국민의나트륨섭취는 2010년 4,877.46 mg으로나트륨의충분섭취량 (1,500 mg) 대비 325.1% 로다른영양소에비해과잉섭취하는것으로조사되었다 (Korea Health Industry Development Institute 2012). 나트륨의섭취는식품속에들어있는나트륨, 조리시들어가는나트륨과식탁소금을통해이루어진다. 2010년국민건강영양조사에따르면나트륨섭취에가장크게기여하는식품은소금으로전체섭취량의 19.31% 를공급하는수준이었고, 소금, 배추김치, 간장, 된장이전체나트륨섭취량의 50% 이상을차지하는것으로나타났다. 그다음으로라면, 고추장, 총각김치, 백미, 국수, 쌈장이나트륨주요급원식품 10 위안에포함되었으며이들 10가지식품이전체섭취량의 69% 를공급하는것으로나타났다. 또한나트륨섭취에가장크게기여하는음식은배추김치였고, 그다음으로라면, 총각김치, 된장국, 김치찌개, 미역국, 된장찌개, 양파장아찌, 쌈장, 고추장등으로나타났다 (KHIDI 2012). 혈액투석환자의치료지시이행정도를측정한결과저염식이행정도가다른식사요법에비해낮으며 (Min & Lee 2006), 미각감소로인한영양상태불량을개선하고자신맛, 짠맛, 단맛, 쓴맛에대한미각역치를조사한결과투석후짠맛, 신맛, 단맛이유의하게미각인지역치가낮아졌으나쓴맛과미각감소와연관이있는것으로알려진혈청아연농도는유의한차이가없었다 (Cho 등 1999). 식염인지도에관한연구 (Yu 등 2000) 에서는정제염을첨가한 0.10%, 0.25%, 0.50%, 0.75%, 1.00% 인쌀미음을만들어맛보도록한결과, 전체적으로 0.50%, 남자는 0.50%, 여자는 0.25% 농도를선호하였고, 농도별선호도는 0.50, 0.25%. 0.75% 순으로환자들의식염농도의선호도는일반인과별다름이없는것으로보이고, 식사요법실천시식염의제한에중점을두었다고하였지만인식도와실천에큰차이를보여저염식에대한영양교육이이론교육보다는실천적인측면이강조되어야한다고연구의필요성을제기하였다. 혈액투석환자를대상으로영양상태를분석한연구에서단백질및에너지섭취가전반적으로감소되어있어 (Kim 등 2000a; Lee 등 2000; Youn 등 2002) 영양상태개선이필요함을강조하였다. 투석환자의영양교육에대한연구는많지않으나영양교육의효과가유의하게높아환자들의영양상태개선뿐만아니라합병증예방및높은사망률과이환률의감소를위해서지속적인영양교육의필요성을제시하였다 (Kang 2003; Yang 등 2003). 또한 Lee 등 (2004) 은혈액투석환자들의영양소섭취상태가불량한것에비해영양지식정도는다소높은것으로관찰되어영양지식이식사섭취량에반영되지않아단순한영양지식의전달이아니라실제로환자들이실천할수있도록환자의식생활에대한지속적인관찰과환자개인에맞는세심한영양교육이지속적으로이루어지는것이필요하다고제언하였다. 더구나대부분종합병원과건강검진센터에서는영양교육을실시하고있으나 (Cho & Kim 1998) 개인병원에서혈액투석환자대상영양교육은많이부족한실정이다. 또한혈액투석환자의식염섭취실태, 저염식에관한연구도많지않으며, 짠맛미각판정에관한연구는전무한상황이다. 따라서본연구에서는개인의원에내원하는혈액투석환자를대상으로나트륨섭취줄이기에중점을두고교육을하였으며, 짠입맛의변화정도를비교하기위하여영양교육및상담전후짠맛미각판정을실시하였다. 또한신체계측, 혈액생화학적분석을통해영양상태를평가하고교육전 후로영양지식과짜게먹는식태도변화를측정함으로써영양교육및영양상담의효과를분석하였다.

404 혈액투석환자대상영양교육과상담이짠맛미각, 영양지식및식태도변화에미치는효과 연구대상및방법 1. 연구대상 대구시소재개인내과의원에서혈액투석을받고있는환자 21명 ( 남자 14명, 여자 7명 ) 을대상으로 2010년 11월초에서 2011년 4월초까지약 5개월동안 2주에 1회개별영양교육및영양상담을실시하였다. 2. 신체계측 체지방측정기 (ioi757, JW medical, Korea) 를이용하여투석직후에신장, 체중, 체지방량, 제지방량, 근육량, 허리엉덩이둘레비 (Waist-Hip circumference Ratio) 를측정하였고, 혈압은투석전 후에측정하였다. 3. 혈액생화학검사 투석전혈액을채취하여총단백질 (T-P), 알부민 (Alb), 총콜레스테롤 (CH), 중성지방 (T-G), 혈중요소질소 (BUN), 크레아티닌 (Crea), 칼슘 (Ca), 나트륨 (Na), 칼륨 (K), 염소 (Cl), 인 (P), 요산 (Uric acid) 은자동화학분석기 (Photometer 5010, Robert Riele GmbH, Germany) 를이용하였고, 헤모글로빈 (Hb) 과헤마토크리트 (Hct) 는자동혈구계측기 (mek-5208k, Nicon Korea) 를이용하여측정하였다. 4. 영양지식및식태도 영양지식은혈액투석관련 20문항으로구성하였으며이중 4문항은나트륨에관한지식을포함하였고, 문항형태는 10문항은 4지선다형 (multiple-choice) 이었고나머지 10 문항은진위형 (true-false type) 이었으며, 맞으면 1점, 틀리면 0점으로처리하여총점을 20점으로하였다. 식태도조사는 15문항으로하였으며이중 8문항은짜게먹는식태도에관련된것이었고, 5점 Likert 척도로조사하였다. 5. 짠맛에대한미각판정 짠맛에대한미각판정은영양교육및상담전, 영양교육 3 개월후, 영양교육 5개월후 ( 상담 3회후 ) 의총 3회에걸쳐측정하였다. 미각판정의정확성을위해대부분투석후에실시하였고, 몇명환자는투석후의심한혈압차이로인한어지러움과두통때문에투석후에측정할수없어투석 2시간뒤에실시하였다. 미각판정은미각판정도구 (Shin 등 2008a) 를이용하여실시하였다. 미각측정용시료 5단계시료를입에넣고서잠시머금고있다가뱉어내게한다음, 용 액의농도별로싱겁다, 약간싱겁다, 적당하다, 약간짜다, 짜다로짠맛의강도를테스트하였다. 그농도의선호도에대해서는싫다, 약간싫다, 보통이다, 약간좋다, 좋다로답하도록하였다. 강도와선호도체크결과로짜게먹는편, 약간짜게먹는편, 보통으로먹는편, 약간싱겁게먹는편, 싱겁게먹는편의 5단계로판정하였다. 6. 영양교육및영양상담효과평가계획 1) 영양교육및영양상담계획영양교육및영양상담계획은 Table 1과같다. 영양교육및상담은영양교육을전공하고있는영양사에의해실시되었으며, 영양교육을시작하기전일반사항, 의무기록사항및생화학검사, 신체계측, 영양지식및식태도조사, 짠맛미각판정을실시하였다. 그결과를바탕으로하여 2주에 1회개별영양교육을 5회실시하였고, 영양상담은개별영양교육후총 3회에걸쳐실시하였다. 영양교육및영양상담의효과를비교하기위해영양지식은영양교육및상담실시전과영양교육 5개월후 ( 영양상담 3회후 ) 에동일한조사를실시하였고, 식태도는영양교육및상담실시전, 영양교육 3개월후, 영양교육 5개월후 ( 상담 3회후 ) 의 3회에걸쳐조사하였다. 2) 영양교육및상담내용개인별영양교육은혈액투석환자를위한팜플렛을제작하여제공하고 2주에 1회, 회당 10~15 분정도개인면담으로 5회실시하였다. 1차시는혈액투석의식사요법목적및지침, 2차시혈액투석의영양관리, 3차시혈액투석의식사관리 ( 신장질환을위한식품교환표 ), 4차시영양표시읽는법, 5차시혈액투석합병증에대한식사요법에관한내용으로실시하였다. 3회에걸친영양상담은개인별영양목표를세우고그에따른실천방법을환자들과함께생각하여실생활에적용할수있도록상담하였다. 7. 통계처리모든결과는 SPSS(Statistical Package Social Science) Win 17.0 프로그램을이용하여통계처리하였으며모든분석에대한유의수준은 p < 0.05로하였다. 개별영양교육및상담의효과평가는영양교육및상담전, 영양교육 3개월및영양교육 5개월후 ( 영양상담 3회후 ) 의결과를비교하였으며, 대상자수가적어비모수통계분석을실시하였고근사유의확률을제시하였다. 신체계측치의남녀간비교에는 Mamm-Whitney 검정을실시하였고, 혈액생화학치비교는 Friedman test, 미각판정치비교는카이제곱,

이영미 이연경 405 Table 1. Flow chart of nutrition education and counseling First Evaluation 1st~3rd 1st Nutrition education 4th~5th 2nd Nutrition education 6th~7th 3rd Nutrition education 8th~9th 4th Nutrition education 10th~11th 5th Nutrition education 12th~13th Medical record & Biochemical data Anthropometry Nutrition knowledge Dietary attitude Salty taste assessment Nutrition education Lesson 1 Lesson 2 Lesson 3 Lesson 4 Lesson 5 Mid-term Evaluation 1st Nutrition counseling 2nd Nutrition counseling 3th Nutrition counseling Final Evaluation 14th 15th~16th 17th~18th 19th~20th 21st~22nd Medical record & Biochemical data Anthropometry Nutrition knowledge Dietary attitude Salty taste assessment Nutrition counseling Personal follow-up 1 Personal follow-up 2 Personal follow-up 3 Kruskal-Wallis test, Friedman test, 영양지식의영양교육및상담전과영양교육 5개월 (3회상담후 ) 후결과비교는 Mcnemar test와 Wilcoxon test, 영양교육및상담전, 영양교육 3개월, 영양교육 5개월후의식태도비교는 Friedman test로그유의성을검증하였다. 결 1. 일반사항및신체계측치 대상자의평균연령과신체계측결과는 Table 2와같다. 남자는평균 48세, 여자는평균 49세였고, 투석기간은남자는 9.85년, 여자는평균 11.4 년이었다. 신체계측결과남녀모두체질량지수 (BMI), 이상체중백분율 (PIBW), 체지방률 (%), 허리둘레, 허리엉덩이둘레비율 (WHR) 은모두정상범위에속하였다. 제지방, 근육량, 허리둘레, WHR, 투석전수축기혈압과이완기혈압이남자가여자보다유의하게높았고 (p < 0.001, p < 0.001, p < 0.01, p < 0.05, p < 0.05, p < 0.05) 체지방률은여자가남자보다유의하게높았다 (p < 0.01). 과 2. 영양교육및상담전후혈액생화학치변화 혈액생화학적검사결과는 Table 3과같다. 전체대상자의헤모글로빈 (Hb) 은상담전 10.94 ± 1.00 g/dl, 상담 3 개월 11.37 ± 1.01 g/dl, 상담 5개월 11.24 ± 1.21 g/d 로약간증가하였으나유의하지않았으며, 헤마토크리트치도상담전 33.11 ± 3.00(%), 상담 3개월 35.02 ± 3.50(%), 상담 5개월 35.14 ± 3.32(%) 로유의하지않았다. 알부민은상담전 4.14 ± 0.40 g/dl, 상담 3개월 3.99 ± 0.34 g/dl, 상담 5개월 3.86 ± 0.29 g/dl로상담 5개월후에유의하게낮아졌다 (p < 0.01). 혈중요소질소는상담전 74.62 ± 15.20 mg/dl, 상담 3개월 71.52 ± 12.79 mg/dl, 상담 5개월 62.14 ± 14.15 mg/dl로유의하게낮아졌다 (p < 0.05). 크레아티닌은상담전 9.10 ± 2.23 mg/dl, 상담 3개월 10.85 ± 2.78 mg/dl, 상담 5개월 9.62 ± 2.81 mg/dl로유의하게증가를하였다 (p < 0.001). 나트륨, 칼륨, 염소, 칼슘, 인, 요산은유의한변화가없었다. 3. 영양교육및상담전후짠맛에대한미각판정치변화 1) 영양교육및상담전후미각판정치변화혈액투석환자의상담전후에따른미각판정결과는 Table 4와같다. 전체적으로상담기간에따른미각판정결과에서유의한차이가있었다 (p < 0.001). 싱겁게먹는편 과 약간싱겁게먹는편 의비율을합하여싱겁게먹는비율로볼때영양교육및상담전 33.3%, 영양교육 3개월후 33.3%, 영양교육 5개월후 ( 상담 3회후 ) 47.6% 로전반적으로싱겁

406 혈액투석환자대상영양교육과상담이짠맛미각, 영양지식및식태도변화에미치는효과 Table 2. Anthropometric measurements of the subjects Items Male (n = 14) Female (n = 7) Z 1) Age (yrs) 48.36 ± 12.18 2) 49.29 ± 12.34 0.037 Duration (yrs) 9.85 ± 96.44 11.36 ± 97.02 0.562 Height (cm) 165.27 ± 98.16 154.56 ± 98.24 2.276* Weight (kg) 57.57 ± 11.34 50.29 ± 95.31 1.978* BMI (kg/m²) 20.99 ± 93.13 19.80 ± 91.50 0.970 PIBW 95.39 ± 14.17 94.32 ± 97.19 0.075 LBM (kg) 47.15 ± 96.46 35.20 ± 94.32 3.368*** BFM (kg) 11.30 ± 96.42 12.30 ± 92.62 0.952 Body Fat (%) 18.45 ± 97.20 25.69 ± 92.60 2.575** Muscle mass (kg) 43.78 ± 95.90 32.49 ± 94.02 3.368*** Waist circumference (cm) 80.43 ± 99.15 70.34 ± 93.11 2.893** WHR 0.87 ± 90.89 0.78 ± 90.05 2.356* Pre-HD SBP (mmhg) 163.21 ± 23.17 120.71 ± 37.69 2.498* Pre-HD DBP (mmhg) 86.79 ± 10.30 74.17 ± 98.01 2.240* Post-HD SBP (mmhg) 131.79 ± 30.42 102.86 ± 27.52 1.800 Post-HD DBP (mmhg) 75.77 ± 12.72 65.00 ± 10.49 1.736 Reduced body weight (kg) 2.87 ± 91.15 2.62 ± 90.68 1.196 1) Z-value by Mann-Whitney Test 2) Mean ± SD BMI: Body Mass Index [weight (kg)/height (m²)], PIBW: Percent Ideal Body Weight, LBM: Lean Body Mass, BFM: Body Fat Mass, %BF: Percent Body Fat, WHR: Waist-Hip circumference Ratio, Pre-HD : Pre-hemodialysis, Post-HD : Post-hemodialysis, SBP : Systolic Blood Pressure, DBP : Diastolic Blood Pressure *: p < 0.05, **: p < 0.01, ***: p < 0.001 by Mann-Whitney Test Table 3. Changes in the biochemical data of the subjects after the intervention Variables Baseline (n = 21) 3rd month (n = 21) 5th month (n = 21) χ 21) Hb (g/dl) 10.94 ± 91.00 2) 11.37 ± 91.01 11.24 ± 91.21 91.525 Hct (%) 33.11 ± 93.00 35.02 ± 93.50 35.14 ± 93.32 94.554*** T-P (g/dl) 7.07 ± 90.55 7.08 ± 90.41 7.08 ± 90.43 90.494 Alb (g/dl) 4.14 ± 90.40 3.99 ± 90.34 3.86 ± 90.29 11.878** CH (mg/dl) 154.62 ± 32.36 158.62 ± 35.77 151.90 ± 32.01 93.244 T-G (mg/dl) 102.05 ± 58.87 99.57 ± 44.53 105.86 ± 79.80 91.268 BUN (mg/dl) 74.62 ± 15.20 71.52 ± 12.79 62.14 ± 14.15 98.617* Crea (mg/dl) 9.10 ± 92.23 10.85 ± 92.78 9.62 ± 92.81 15.205*** Na (mmol/dl) 136.37 ± 92.84 135.12 ± 92.96 135.36 ± 93.30 94.025 K (mmol/dl) 6.00 ± 91.14 6.07 ± 90.79 5.81 ± 90.75 92.193 Cl (mmol/dl) 111.55 ± 93.39 110.30 ± 92.97 109.82 ± 93.18 90.667 Ca (meq/dl) 10.60 ± 91.02 10.74 ± 90.88 10.56 ± 91.22 90.220 P (mg/dl) 5.42 ± 91.46 5.49 ± 91.50 5.21 ± 91.57 90.667 Uric Acid (mg/dl) 7.15 ± 91.28 7.42 ± 91.11 6.84 ± 91.26 93.975 1) χ 2 -value by Friedman Test 2) Mean ± SD Hb: Hemoglobin, Hct: Hematocrit, T-P: protein, Alb: Albumin, CH: cholesterol, T-G: Triglyceride, BUN: Blood urea nitrogen, Crea: Creatinine *: p < 0.05, **: p < 0.01, ***: p < 0.001 by Friedman Test Table 4. Changes in salty taste assessment of the subjects before and after counseling Items Baseline (n = 21) 3rd month (n = 21) 5th month (n = 21) χ 2 Unsalty 91 (994.8) 1) 92 (999.5) Slighty unsalty 97 (933.3) 96 (928.6) 1) 98 (938.1) Neither unsalty nor salty 99 (942.9) 97 (933.3) 1) 98 (938.1) 32.159*** Slighty salty 95 (923.8) 96 (928.6) 1) 92 (999.5) Salty 91 (994.8) 1) 91 (994.8) 21 (100.0) 21 (100.0) 1) 21 (100.0) Mean ± SD 2.90 ± 0.77 3.00 ± 1.00 2.62 ± 0.97 93.574 NS 1) N (%) NS: Not Significant among 3 periods by Friedman Test ***: p < 0.001 by chi-square Test

이영미 이연경 407 게먹는비율이높아졌다. 또한 약간짜게먹는편 과 짜게먹는편 의짜게먹는비율은영양교육및상담전 23.8%, 영양교육 3개월후 33.3%, 영양교육 5개월후 ( 상담 3회후 ) 14.3% 로영양교육 3개월후짜게먹는환자가증가하였다가영양상담 3회후짜게먹는비율이감소하였다. 미각판정의평균값으로비교하면영양교육 3개월후 3.00 ± 1.00로영양교육및상담전 2.90 ± 0.77에비해약간높아졌다가영양교육 5개월후 ( 상담 3회후 ) 2.62 ± 0.97로낮아졌으나유의한차이는없었다. 2) 짠맛미각판정시료농도별강도의비교농도에따른강도차이를비교한결과는 Table 5와같다. 시료염도 0.08%, 0.16%, 0.31%, 0.63%, 1.25% 순으로염도의차이를인식하고있었다 (p < 0.001). 같은농도의시료에대해서영양교육및상담후에다르게느끼는지에대하여분석한결과유의한차이는없었다. 3) 짠맛미각판정시료농도별선호도의비교농도에따른선호도차이를비교한결과는 Table 6과같다. 염도에따른선호도에유의한차이는없었다. 각시료의평균점수로살펴보면영양교육및상담전에는 1.25% 염 도에대한선호도가낮았으나그외나머지염도의선호도는비슷하였다. 영양교육 3개월후 0.31% 를가장선호하였고, 1.25% 의선호도는가장낮았다. 영양교육 5개월후 ( 상담 3 회후 ) 0.16% 와 0.31% 농도순으로선호도가높았고 1.25%, 0.08% 농도순으로선호도가낮았다. 즉영양교육및상담전과영양교육 3개월후 0.31% 를가장선호하였으나영양교육 5개월후 ( 상담 3회후 ) 0.16% 를가장선호하였다. 4. 영양교육및상담전후영양지식변화혈액투석환자의영양지식변화정도는 Table 7과같다. 전체대상자의영양지식총점은영양교육및상담전 14.33 ± 1.89점, 영양교육 5개월후 16.24 ± 2.36점으로영양교육후유의하게영양지식이높아졌다 (p < 0.05). 남자는영양교육전 14.00 ± 2.04점, 영양교육 5개월후 16.50 ± 2.03점으로유의하게높아졌다 (p < 0.01). 여자는영양교육전 15.00 ± 1.41점, 영양교육 5개월후 15.71 ± 3.04점으로점수는높아졌으나통계적으로는유의하지않았다. 문항중에서는 조미료중에서사용량을제한하지않아도되는것은? 항목의점수가유의하게증가하였다 (p < 0.01). Table 5. Comparison of the intensity 1) by salt concentration Concentration χ 2 Baseline (n = 21) 3rd month (n = 21) 5th month (n=21) 0.08% 1.52 ± 0.81 2) 1.29 ± 0.56 1.19 ± 0.60 93.842 NS 0.16% 2.05 ± 0.87 1) 2.10 ± 0.83 2.43 ± 0.68 95.216 NS 0.31% 2.90 ± 0.83 1) 2.86 ± 0.79 3.10 ± 0.62 91.265 NS 0.63% 3.95 ± 0.74 1) 3.95 ± 0.80 4.14 ± 0.57 91.755 NS 1.25% 4.76 ± 0.44 1) 4.86 ± 0.48 4.86 ± 0.48 92.545 NS χ 2 75.983*** 80.135*** 86.478*** 1) Unsalty; 1, slighty unsalty; 2, neither unsalty nor salty; 3, slighty salty; 4, salty; 5 2) Mean ± SD NS: Not Significant among 3 periods by Friedman Test ***: p < 0.001 by Kruskal-Wallis Test Table 6. Comparison of the preference 1) for salty taste during counseling Concentration χ 2 Baseline (n = 21) 3rd month (n = 21) 5th month (n9=921) 0.08% 2.05 ± 1.12 2) 1.95 ± 1.20 1.57 ± 1.24 2.632 NS 0.16% 2.67 ± 1.39 1) 2.76 ± 1.37 3.43 ± 1.40 2.853 NS 0.31% 3.00 ± 1.05 1) 3.14 ± 1.06 3.14 ± 1.10 1.418 NS 0.63% 2.33 ± 1.32 1) 2.33 ± 1.35 2.14 ± 0.85 0.269 NS 1.25% 1.38 ± 0.86 1) 1.19 ± 0.70 1.19 ± 0.68 1.900 NS χ 2 23.410*** 33.333*** 48.965*** 1) Dislike: 1 point, Like: 5 points 2) Mean ± SD NS: Not Significant among 3 periods by Friedman Test ***: p < 0.001 by Kruskal-Wallis Test

408 혈액투석환자대상영양교육과상담이짠맛미각, 영양지식및식태도변화에미치는효과 Table 7. Nutrition knowledge of the subjects before and after counseling Item Baseline (n = 14) Male Female 5th month (n = 14) p 1) Before (n = 7) 5th month (n = 7) p 1) Before (n = 21) 5 months (n = 21) 1 13 (592.9) 2) 14 (100.0) 1.000 7 (100.0) 7 (100.0) 20 (595.2) 21(100.0) 1.000 2 4 (528.6) 7 (550.0) 0.453 3 (542.9) 6 (585.7) 50.250 7 (533.3) 13 (561.9) 0.109 3 6 (542.9) 12 (585.7) 0.180 6 (585.7) 5 (571.4) 51.000 12 (557.1) 17 (581.0) 0.388 4 10 (571.4) 13 (592.9) 0.375 5 (571.4) 5 (571.4) 51.000 15 (571.4) 18 (585.7) 0.453 5 3 (521.4) 6 (542.9) 0.453 1 (514.3) 2 (528.6) 51.000 4 (519.0) 8 (538.1) 0.289 6 13 (592.9) 13 (592.9) 1.000 7 (100.0) 7 (100.0) 20 (595.2) 20 (595.2) 1.000 7 13 (592.9) 14 (100.0) 1.000 7 (100.0) 7 (100.0) 20 (595.2) 21(100.0) 1.000 8 6 (542.9) 6 (542.9) 1.000 3 (542.9) 3 (542.9) 51.000 9 (542.9) 9 (542.9) 1.000 9 8 (547.1) 13 (592.9) 0.063 5 (571.4) 7 (100.0) 50.500 13 (561.9) 20 (595.2) 0.016* 10 12 (585.7) 13 (592.9) 1.000 7 (100.0) 7 (100.0) 19 (590.5) 20 (595.2) 1.000 11 10 (571.4) 13 (592.9) 0.250 6 (585.7) 5 (571.4) 51.000 16 (576.2) 18 (585.7) 0.687 12 11 (578.6) 10 (5571.4) 1.000 5 (571.4) 4 (557.1) 16 (576.2) 14 (566.7) 1.000 13 7 (550.0) 6 (542.9) 1.000 4 (557.1) 6 (585.7) 0.625 11 (552.4) 12 (557.1) 0.125 14 14 (100.0) 14 (100.0) 7 (100.0) 7 (100.0) 21 (100.0) 21 (100.0) 15 11 (578.6) 14 (100.0) 0.250 5 (571.4) 6 (585.7) 51.000 16 (576.2) 20 (595.2) 0.125 16 12 (585.7) 12 (585.7) 1.000 6 (585.7) 7 (100.0) 51.000 18 (585.7) 19 (590.5) 1.000 17 13 (592.9) 14 (100.0) 1.000 7 (100.0) 7 (100.0) 20 (595.2) 21 (100.0) 1.000 18 13 (592.9) 13 (592.9) 1.000 4 (557.1) 4 (557.1) 51.000 17 (581.0) 17 (581.0) 1.000 19 10 (571.4) 12 (585.7) 0.687 6 (585.7) 3 (542.9) 50.250 16 (576.2) 15 (571.4) 1.000 20 7 (550.0) 13 (592.9) 0.070 4 (557.1) 3 (542.9) 51.000 11 (552.4) 16 (576.2) 0.227 score 14,00 ± 2.04 16.50 ± 2.03 2.598**3) 15.00 ± 1.41 15.71 ± 3.04 0.556 NS3) 14.33 ± 1.89 16.24 ± 2.36 2.394* 3) 1) p-value by Mcnemar Test 2) N (%) 3) χ²-value by Wilcoxon Test NS: Not Significant between groups by Wilcoxon Test *: p < 0.05, **: p < 0.01 61. f the following information, what is incorrect information for hemodialysis patients? 62. What is the correct way to supplement nutritional energy in the diets of hemodialysis patients? 63. Which high-quality protein is not good for hemodialysis patients? 64. Hemodialysis patients should limit the intake of which nutrient (s)? 65. What is the daily allowance of sodium intake for hemodialysis patients? 66. What is the daily allowance of water intake for hemodialysis patients? 67. Which food do you have to limit because of its high potassium content? 68. Which foods are rich in phosphorus and therefore, you do not need to limit their consumption? 69. What seasoning does not require limited usage? 10. What problems occur when eating out? 11. It is recommended to eat frozen or chilled fruits between meals because it is a good way to relieve thirst. () 12. Put water in a large container so that water is available for you to drink when you are thirsty and need to drink water. () 13. When cooking vegetables, use stems rather than leaves or hearts. ( ) 14. If you eat raw vegetables, eat them only after they have been chopped and then, rinsed several times in water. () 15. It is better to use the water used for blanching vegetables when you cook. ( ) 16. Hemodialysis patients do not need to restrict their calorie or protein intake. ( ) 17. Eat several raw vegetables such as seaweed and spinach for dietary fiber. ( ) 18. Sodium, as a component of salt, is 40% of salt. () 19. Salt can help balance moisture content in our bodies. () 20. Food additives in manufactured foods such as baking powder, raising agent, and sodium bicarbonate are harmful to human health. However, food additives do not contain sodium. ( ) p 1) 5. 영양교육및상담전후식태도변화 영양교육및상담전후의식태도변화정도는 Table 8과같다. 식태도총점은영양교육및상담기간동안유의한변 화가있었다 (p < 0.01). 식품교환표를식생활에이용한다. 는문항의점수가영양교육및상담전 1.52 ± 0.98, 영양교육 3개월후

이영미 이연경 409 Table 8. Comparison of dietary attitude score before and after counseling Item number Baseline (n = 21) 3rd month (n = 21) 5th month (n = 21) χ 21) 1 3.24 ± 91.55 2) 3.14 ± 1.31 3.57 ± 0.93 92.533 2 1.52 ± 90.98 2.38 ± 1.47 2.48 ± 0.81 11.281** 3 3.38 ± 91.43 3.24 ± 1.22 3.57 ± 1.40 90.824 4 3.20 ± 91.32 3.30 ± 1.30 3.40 ± 1.43 91.477 5 3.52 ± 91.63 3.62 ± 1.28 3.86 ± 1.20 90.444 6 3.86 ± 91.28 3.86 ± 0.96 4.14 ± 1.06 90.862 7 2.10 ± 91.45 2.52 ± 1.66 2.67 ± 1.40 98.359* 8 2.14 ± 91.60 2.57 ± 1.69 2.86 ± 1.42 96.542* 9 3.95 ± 91.16 4.00 ± 0.95 4.38 ± 0.86 92.302 10 4.14 ± 91.50 4.95 ± 0.22 4.71 ± 0.64 97.583* 11 4.05 ± 91.11 4.62 ± 0.92 4.57 ± 0.93 98.930* 12 4.48 ± 90.98 4.81 ± 0.51 4.43 ± 1.08 93.250 13 3.52 ± 91.60 3.71 ± 1.27 4.14 ± 1.06 93.957 14 3.71 ± 90.96 4.10 ± 0.70 4.14 ± 0.80 93.857 15 2.81 ± 91.89 3.00 ± 1.73 3.33 ± 1.43 90.894 score 3) 49.48 ± 11.10 53.81 ± 8.35 56.33 ± 9.64 13.125** 1) χ 2 -value by Friedman Test 2) Mean ± SD 3) score = 75 point, Quite agree: 5 points, Not agree at all: 1 point *: p < 0.05, **: p < 0.01 by Friedman Test 51. I try to apply nutrition knowledge to my daily diet. 52. I apply the food exchange list to my daily diet. 53. When I prepare and/or eat a meal, I am interested in the food ingredients. 54. When I prepare and/or eat a meal, I consider nutritional balance. 55. When I eat out, I am careful of sodium, phosphorus and potassium intake. 56. I try not to overeat on holidays or when eating out. 57. When I buy processed foods, I carefully read the nutrition facts. 58. When I buy processed foods, I check the amount of sodium on nutrition labels. 59. When I cook, I try to reduce salty flavor. 10. I have the habit of adding salt or soy sauce before I eat certain foods. 11. When the food is not salty, I add more salt or soy sauce. 12. When I eat bread, I spread plenty of margarine or butter on it. 13. When I eat soup or stew, I eat a lot of soup broth. 14. I eat a lot of kimchi at every meal. 15. When I eat out, I ask them to prepare my food with less/no salt 2.38 ± 1.47, 영양교육 5개월후 ( 상담 3회후 ) 2.48 ± 0.81 로유의하게높아졌다 (p < 0.01). 가공식품구입할때영양표시를자세히읽어본다 의문항은 2.10 ± 1.45, 영양교육 3개월후 2.52 ± 1.66, 영양교육 5개월후 ( 상담3 회후 ) 2.67 ± 1.40으로유의하게높아졌다 (p < 0.05). 가공식품구입시영양표시의나트륨량을확인한다 문항이영양교육및상담전 2.14 ± 1.60, 영양교육 3개월후 2.57 ± 1.69, 영양교육 5개월후 ( 상담 3회후 ) 2.86 ± 1.42로유의하게높아졌다 (p < 0.05). 식사전에습관적으로소금이나간장을뿌린다. 는문항은영양교육및상담전 4.14 ± 1.50, 영양교육 3개월후 4.95 ± 0.22, 영양교육 5개월후 ( 상담 3회후 ) 4.71 ± 0.64 로유의하게개선되었다 (p < 0.05). 음식이나국이싱 거우면간장을더넣는다 문항도영양교육및상담전 4.05 ± 1.11, 영양교육 3개월후 4.62 ± 0.92, 상담 5개월 4.57 ± 0.93 으로유의하게향상되었다 (p < 0.05). 고 대한신장학회등록위원회 (The Korean Society Nephrology 2009) 보고에따르면전국혈액투석환자의평균연령은 57.9세, 5년이상투석한경우가 43%, BMI 21.8, 평균혈압 102/63.4 mmhg였다. 본연구대상자들의평균연령은 48.67세로전국평균보다낮은편이었고, BMI도 20.59 로전국평균 21.8보다낮았고 Yang 등 (2003) 의연구대 찰

410 혈액투석환자대상영양교육과상담이짠맛미각, 영양지식및식태도변화에미치는효과 상자의 BMI가 21.9 가전국평균값에근접하였다. 투석기간은평균 10.35년으로전국평균보다투석기간이긴것으로나타났다. 본연구대상자들의제지방량은 42.97 kg으로 Yang 등 (2003) 의연구대상자 42.7 kg, Kim 등 (2006) 의연구대상자 45.7 kg, Lee 등 (2002) 의연구대상자 43.3 kg 과비슷한수준이었다. 생화학검사항목중본연구대상자의상담전헤모글로빈 (10.94 ± 1.00 g/dl) 과헤마토크리트치 (33.11 ± 3.00%) 는대부분정상범위에속하였고우리나라혈액투석환자의평균헤모글로빈 10.34 g/dl, 헤마토크리트치는 31.5%(The Korean Society Nephrology 2009) 와비슷하였다. 알부민도다른연구와비교할때비슷한결과를가지나본연구에서상담기간동안알부민의수치가유의하게감소하였는데 (p < 0.01) 이는알부민은단백질및칼로리섭취량과도밀접하게관련되어있으나급성반응물질로써염증상태를나타내는 CRP(C-reactive protein), 페리틴과는음의상관관계를보이며염증상태동반시식사섭취량과무관하게감소한다 (Kim 등 2000b; Lee 등 2002). 본연구대상자의알부민감소원인을찾아보면만성신부전환자의입원원인중에서 1/4정도가혈관접근합병증에관련된다. 혈관접근의혈전과폐쇄가가장많으며 fistulogram 을시행하여협착, 혹은혈전이발견되면풍선확장술, 혈전제거술혹은혈관복구술, 우회술등을시행하는데혈관접근에감염이흔히발생된다 (Kim 등 2006). 상담기간중몇명의환자들이혈관확장수술을받은결과수술중출혈과수술부위의상처가있어알부민수치가감소하였을것으로사료된다. 개인에따른건체중변화와신장손상정도에따라이미고혈압이있는경우나트륨섭취감소가혈압에별영향을미치지못하고정상혈압에가깝게유지하고있는환자의경우수축기혈압이다소떨어지는것을연구기간동안관찰할수있었다. 특히투석일사이에수분섭취과다가있으면급격한혈압차이로인한증상을방지하기위해이론적계산으로나온체중을감소시키지않아나트륨과혈압관계를연구하기에는통제해야하는요소가있어혈액투석환자의나트륨섭취감소와혈압과의관계를설명하기에부족한점이있다. 짠맛에대한미각판정결과는상담전에전체 2.90 ± 0.77, 남자 3.00 ± 0.68, 여자 2.71 ± 0.95였으며대구시직장인을대상으로한 Shin 등 (2008a) 의연구결과에서는전체 3.33 ± 1.00, 남자 3.33 ± 0.96, 여자 3.31 ± 1.07로나타나본연구대상자들이대구시직장인보다더싱겁게먹고있는것으로나타났다. 영양교육및상담전전체대상자들의 42.9% 가보통으로먹는편, 남자는 57.1% 가보통으로먹는편, 여자는 57.1% 가약간싱겁게먹는편의비율이가장높았는데 Shin 등 (2008a) 의연구는전체 35.4% 가보통으로먹는편, 남자 33.6% 가약간짜게먹는편, 여자 37.2% 가보통으로먹는편비율이가장높아본연구결과를일반인결과와비교하면싱겁게먹는편의비율과보통으로먹는편의비율이높고짜게먹는편의비율은낮았다. 본연구에서사용한동일한시료를사용하여당뇨병환자를대상으로짠맛에대한미각판정을한연구 (Jung 2011) 에서는교육전후간에유의한차이가없었고단지교육전남자와여자간에유의한차이가있었다 (p < 0.01). 교육전환자전체의 45.2% 가약간짜게먹는비율이가장높았으나교육후 54.8% 가보통으로먹는비율이가장높게나타났었다. 본연구에서영양교육전영양지식이 14.33 점에서교육후 16.24점으로유의하게증가하였다 (p < 0.05). 조미료중에서사용량을제한하지않아도되는것은? 항목의점수가유의하게증가하였는데 (p < 0.01), 이는나트륨함량이높은조미료를알고있음을의미한다. 본연구와동일한미각판정시료를사용하였고영양교육을실시한 Shin 등 (2008b) 의연구에서싱겁게먹기와관련된영양지식 10개문항이교육전 7.10 ± 1.86, 교육후 8.80 ± 1.33으로평균점수가향상되어 (p < 0.001) 영양교육의효과가유의하게나타났다. 본연구에서도영양교육자료로활용한대구광역시싱겁게먹기센터팜플렛과직접제작한혈액투석식사요법팜플렛이효과적이었음을알수있으며, 또한혈액검사결과를참고하여영양목표를세우고, 특히칼륨과인의제한이유와함유식품에대하여신장질환을위한식품교환표를이용하여개별교육을실시하였기때문에지식이향상된것으로사료된다. 식태도는식품교환표이용과짜게먹지않는식태도에긍정적인변화 (p < 0.01) 가있었다. 특히 식사전에습관적으로소금이나간장을뿌린다 와 음식이나국이싱거우면간장을더넣는다 는항목이개선되어싱겁게먹기위한식태도의변화가일어난것이다. 혈액투석환자의식태도에관한연구가거의없어동일한문항은아니지만 Kim 등 (2001) 의식습관 ( 식사요법의실천 6문항, 일상식사에서의바람직한식품섭취 2문항, 하루 3끼식사의규칙성 2문항 ) 은 20점만점에평균 10.44점을나타내었다. 연구수행의어려운점으로영양상담도중환자의거부, 중도포기, 상담하는당일의환자상태에따라대상자수가불규칙하여당초 30명에서시작하여 5개월간영양교육및상담을모두받은환자는 21명뿐이었다. 또한오랜투석생활로인해체득한경험으로환자스스로주관적으로관리하는

이영미 이연경 411 부분도없지않았고제한하는식품을많이먹더라도투석으로제거되기때문에별문제가생기지않는다고인식하고있었다. 요약및결론 내과의원에내원하는혈액투석환자를대상으로식사요법의실천에도움을주고자영양교육및상담을실시하였고그효과를평가하였으며, 그결과를요약하면다음과같다. 1. 영양교육및상담후생화학분석결과남녀혈액투석환자모두크레아티닌이유의하게높아졌고 (p < 0.001), 혈중알부민과혈중요소질소는유의하게낮아졌으며 (p < 0.01, p < 0.05), 나트륨, 칼륨, 염소, 칼슘, 인, 요산은유의한변화가없었다. 2. 영양교육및상담기간에따른짠맛미각판정결과싱겁게먹는비율이영양교육및상담전 33.3%, 상담 3개월째 33.3%, 상담 5개월째 47.6% 로점차높아졌고, 짜게먹는비율은상담전 23.8%, 상담 3개월째 33.3%, 상담 5개월째 14.3% 로유의하게낮아졌다 (p < 0.001). 3. 영양지식은상담전에비해상담 5개월째에유의하게향상되었으며 (p < 0.05), 짜게먹는식태도는상담기간동안바람직한방향으로개선되었다 (p < 0.01) 이상의결과에서혈액투석환자대상식사요법교육과상담이이들의영양지식향상과바람직한식태도변화에유의하게영향을미치는것으로나타났고나트륨저감화실천을위한짠맛미각교육과상담이혈액투석환자들에게싱겁게먹고자하는동기부여와실천으로이끄는데도움이된것으로사료된다. References Cho YH, Yoon JB, Kim SR (1999): Effect of hemodialysis on taste acuity in patient with end-stage renal disease. Korean J Nephrol 18(2): 307-312 Cho YW, Kim GB (1998): The present status of nutrition education in medical area - centered on the status of Korea. Proceedings of 1989 fall conference of the Korean Nutrition Society, pp.52-56 Guthrie HA, Crocetti AF (1985): Variability of nutrition intake over a 3-day peroid. J Am Diet Assoc 85(3): 325-327 Han DS (1989): Dietetic theraphy of chronic renal failure. Korean J Intern Med 37(1): 1-10 Jang YG, Byeon GW, Lee BG, Lee JH, Lee HM, Jo YY (2006): Medical nutrition therapy, Hyoil, Seoul, pp.341-355 Jeon SY, Kang GY, YU MH (1993): Diet therapy. Gwanmungak, Seoul, pp. 235-256 Jung HJ (2011): Effect of nutrition education and counseling on dietary therapy action in type diabetes patients. MS thesis, Kyungpook National University, p.42, pp.61-62 Kang SS (2003): Effect of pre-dialysis nutrition education on nutritional status of hemodialysis patients. MS thesis, Ewha womens University Kim HH, Shin EK, Lee HJ, Lee NH, Chun BY, Ahn MY, Lee YK (2009): Evaluation of the effectiveness of a salt reduction program for employees. Korean J Nutr 42(4): 350-357 Kim HJ, Kim SA, Sohn CM (2006): Association of the nutritional status and essential amino acids intake in hemodialysis patients. Korean J Nutr 39(7): 617-623 Kim JY, Kwon KH, Choi HY, Kim KS, Yang YK (2000a): Comparison of nutritional status according to serum C-reactive protein concentration in hemodialysis patients. Korean J Nephrol 19(3): 461-467 Kim SM, Lee YS, Cho DK (2000b): Nutritional assessment of the hemodialysis patients. Korean J Nutr 33(2): 179-185 Kim, YH, Seo HJ, Kim SR (2001): A study of the nutritional status, nutritional knowledge, and dietary habits of the hemodialysis patients. Korean J Nutr 34(8): 920-928 Kopple JD (1978): Abnormal amino acid and protein metabolism in uremia. Kidney Int 14(4): 340-348 Kopple JD (1988): Nutrition, Diet and the Kidney. 7th Ed, Philadelphia, pp.1230-1286 Kopple JD (1997): Protein-energy malnutrition in maintenance dialysis patients. Am J Clin Nutr 65(5): 1544-1577 Kopple JD, Jones M, Fukuda S, Swendseid ME (1978): Amino acid and protein metabolism in renal failure. Am J Clin Nutr 31(9): 1532-1540 Korea Health Industry Development Institute (2012): National food & nutrition statistics: based on 2010 Korea National Health and Nutrition Examination Survey. Lee HT, Cho S, Lee SH, Kim SR, Kim YH, Seo HJ (2002): Influence of routine calorie and protein intake on nutritional status in stable chronic hemodialysis patients : A 18 months follow-up study. Korean J Nephrol 21(1): 129-136 Lee HW (2004): Healthy living dialysis. Jungmyeong, Seoul Lee JH, Ahn SH, Song JH (2000): Factors influencing malnutrition in maintenance hemodialysis patients. Korean J Nephrol 19(5): 778-783 Lee NY, Jang YG, Park HC (2004): The research on the nutritional status of hemodialysis patients and nutrition knowledge. Proceedings of 2004 fall Conference of the Korean Society of Community Nutrition (Poster Presentation), p. 423 Min HS, Lee EJ (2006): A study of relationship between compliance with therapeutic regimens and physiological parameters of hemodialysis patients. J Korean Acad Nurs 36(1): 64-73 Schoenfeld PY, Henry RR, Laird NM, Roxe DM (1983): Assessment of nutritional status of the national cooperative dailysis study population. Kidney Int Apr(13): 80-88 Shin EK, Lee HJ, Ahn MY, Lee YK (2008a): Study on the development and evaluation of validity of salty taste assessment tool. Korean J Nutr 41(2): 184-191 Shin EK, Lee HJ, Jun SY, Park EJ, Jung YY, Ahn MY, Lee YK (2008b): Development and evaluation of nutrition education program for sodium reduction in foodservice operation. Korean J

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