대한내과학회지 : 제 83 권제 2 호 2012 http://dx.doi.org/10.3904/kjm.2012.83.2.210 당뇨캠프가제 2 형당뇨병환자에미치는영향 충남대학교의과대학내과학교실 김태균 강예은 김지민 홍우정 김군순 김현진 김영건 구본정 Effects of Diabetic Camp in Type 2 Diabetic Patients Tae Kyun Kim, Yea Eun Kang, Ji Min Kim, Woo Jeong Hong, Koon Soon Kim, Hyun Jin Kim, Young Kun Kim, and Bon Jeong Ku Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea Background/Aims: When a patient is diagnosed with diabetes mellitus, it is important to help both the patient and their family members gain knowledge and confidence with regard to self-management. A diabetes camp is an excellent way to recognize the benefits of education. This study was conducted to evaluate the effects of diabetes camp on patients with type 2 diabetes. Methods: This study comprised 30 patients with diabetes who had participated in a diabetes camp from August 2005 through August 2011. The effectiveness of the diabetes camp was examined retrospectively via clinical parameters, compliance behavior, and a self-esteem questionnaire. Results: Glycated hemoglobin (HbA1c; p = 0.004) was significantly decreased, while measures of self-esteem (p = 0.000) and compliance (p = 0.001) were significantly increased after attending the camp. No significant differences were observed in other clinical parameters, such as weight, body mass index (BMI), and lipid profiles, before and after camp attendance. Conclusions: Diabetes camp may be an effective way to control diabetes mellitus. (Korean J Med 2012;83:210-215) Keywords: Camping; Diabetes mellitus; Glycated hemoglobin 서론사회의현대화에따른운동량및활동량의감소, 스트레스증가및서구화된식사로인한영양불균형등으로비만, 당뇨병, 고지혈증과같은성인병의발병이폭발적으로증가하고있다 [1]. 대표적성인병인당뇨병은췌장의인슐린의절대적또는 상대적결핍으로발생되는대사질환으로서아직까지현대의학으로완치가어려운난치성만성질환이다 [2]. 그러므로당뇨병발병이후의치료는혈당을정상인에가깝도록유지하고평생동안치료와자기관리를통해서, 당뇨병의합병증발생및진행을억제하고예방하는데있다 [3]. 하지만당뇨병의치료, 관리측면에서고려해야할요인과변수는많으 Received: 2012. 2. 9 Revised: 2012. 3. 30 Accepted: 2012. 5. 25 Correspondence to Bon Jeong Ku, M.D., Ph.D. Department of Internal Medicine, Chungnam National University School of Medicine, 266, Munhwa-ro, Jung-gu, Daejeon 301-747, Korea Tel: +82-42-280-7149, Fax: +82-42-280-7995, E-mail: bonjeong@cnu.ac.kr - 210 -
- Tae Kyun Kim, et al. Effects of diabetic camp - 며, 이를일일이적용하기에는현실적으로제약과한계에부딪히게된다 [4]. 여러질병상태에서낮은치료순응도와지속성은일반적으로나타나지만증상이없는만성질환에서특히나심하고, 당뇨병과같은만성질환을가진환자과반수는낮은치료순응도때문에의학적인최대효과를내지못하고있으며, 생활습관변화와약물치료의불순응은가장큰건강문제이다 [5]. 그러므로의사의치료지시에환자가어느정도잘순응하냐가당뇨병의치료에가장중요하며, 순응도를높이기위한가장효과적인방법이당뇨병자기관리교육이다 [6]. 하지만강의식교육은지식증가에는도움을주지만실제생활에서의실천으로연결기가어려운것으로알려져있다 [7]. 따라서환자의행위변화를전략으로하는교육의필요성이요구되었고, 이러한교육을위해당뇨병환자들을개인별로상담, 실습을시킬수있을뿐만아니라자조집단형성을도와줄수있는당뇨캠프의중요성이대두되었다. 우리나라에서는 1981년전남화순지역에서처음으로소아당뇨캠프가개최된후전국적으로확산되어, 현재는매년여러지역및병원단위의캠프가개최되고있다 [8]. Tessier 등 [9] 은당뇨병에서환자교육을받은군이교육을받지않은군보다합병증위험이낮았고, 혈당조절의향상을가져왔다고보고하였다. 그외에도당뇨병교육이체중감소, 자아존중감향상등당뇨병치료에효과가있음이여러연구를통해알려져있다 [10,11]. 하지만이러한당뇨병교육에관한연구는대부분선별된교육자와의료진에의한외래와강연을통한교육이었고, 당뇨캠프에서의교육은해당되지않았다. 이에본연구는당뇨캠프를통한당뇨병교육이환자의순응도및자아존중감의변화와혈당조절에미치는효과를알아보고자본연구를수행하였다. 대상및방법연구대상 2005년부터 2011년까지대한당뇨병학회충청지회에서주최한당뇨캠프참여한제2형당뇨병환자 30명 ( 남성 12명, 여성 18명 ) 을대상으로하였다. 30명의환자들모두캠프에 1회만참여하였고, 의무기록을검토를통해당뇨캠프참여전후의진찰소견, 혈액검사, 자아존중감및순응도를비교하여분석하였다. 당뇨캠프의프로그램과구성 2005년부터 2011년까지당뇨캠프는환자들의교육과만남을기본으로하여 2박 3일의일정으로구성되었다. 프로그램의구성은식이및운동요법의교육이전체시간의 60% 로가장많은시간이편성되었고, 혈당측정방법, 당뇨병의합병증교육등이있었다. 캠프에서의식이요법교육의경우영양소의복잡성과숫자들을쉽게이해시키기위해실제그림모형과음식물조리, 밥푸기코너등을이용하여교육효과를높이고있고, 운동요법의경우에는조별운동과게임을통해조원들과의시간을보내도록구성되었다. 당뇨캠프전후의체질량지수및혈액검사당뇨캠프전후의체질량지수는체중 (kg)/ 신장 (m) 2 의공식을이용하여산출하였다. 혈액검사는당화혈색소, 총콜레스테롤, 중성지방, 저밀도지질단백콜레스테롤, 고밀도지질단백콜레스테롤을측정하였다. 당화혈색소는 VARIANT II 분석기로측정하였으며, 총콜레스테롤, 중성지방, 고밀도지질단백콜레스테롤은자동혈액화학분석기 (Hitachi-7600 110, Japan) 를사용하여측정하였다. 저밀도지질단백콜레스테롤은 Friedwald 식에의해계산하였다. 모든검사치는캠프시행전후 6 ± 3개월사이의자료를이용하였다. 자아존중감 (Self-esteem) 및순응도 (Compliance) 캠프가환자에게주는자아존중감의변화를보기위하여 Rosenberg 의자아존중감측정도구를이용하였다 [12,13]. Rosenberg 자아존중감척도는총 10문항으로구성되어있으며, 1점 ( 전혀아니다 ) 에서 4점 ( 매우그렇다 ) 까지되어있다. 부정적문항은역으로환산하며범위는총 10점에서 40점까지를보이고, 점수가높을수록자아존중감이높은것을나타낸다. 환자의순응도를비교하기위해약물처방비율 (Medication Possession Ratio) 를이용하였다 [14,15]. 캠프전후 6개월간약물을처방받은기간을 180일로나누어비를측정하였다. 통계처리및분석모든측정값은평균 ± 표준편차로표시하였고, 남녀간평균값의비교분석은 Mann-Whitney U test를통하여분석하였다. 캠프전후의체질량지수와혈액검사, 약물처방비율, Rosenberg 자아존중감측정도구결과는 Wilcoxon signed rank test를시행하였다. Rosenberg 자아존중감측정도구의신뢰도 - 211 -
- 대한내과학회지 : 제 83 권제 2 호통권제 624 호 2012 - 는크론바흐알파계수 (Cronbach Alpha Coefficient) 를이용하였다. 모든통계분석은 SPSS (Version 18.0) 를사용하였으며, p 값이 0.05 미만인경우를통계적으로유의한것으로평가하였다. 결과대상집단의분포및특성대상환자 30명중남성은 12명, 여성은 18명이었으며, 이들의평균연령은 59.8 ± 9.0세이었다 (Table 1). 당뇨캠프에참여한환자들의평균당뇨병유병기간은 5.5 ± 2.7년이었다. 3명의환자는인슐린으로치료하였고, 나머지 27명은경 구혈당강하제병용요법을사용하였다. 메트포민과설폰요소제병용요법이 15명으로가장많았고, 나머지환자는메트포민, 설폰요소제단독요법이거나알파-글루코시데이즈억제제 (α-glucosidase inhibitor) 를함께사용하였다. 체질량지수는 24.8 ± 4.0 kg/m 2 이었고, 성별에따른차이는없었다. 당화혈색소는 8.2 ± 1.6% 이었고, 남녀간의차이는키이외에는유의한차이가없었다. 당뇨캠프의혈당조절효과당화혈색소는당뇨캠프전이 8.2 ± 1.6%, 캠프후가 7.5 ± 1.5% 로통계적으로유의하게감소하였다 (p = 0.004). 또한 30 명의대상환자중 5명의환자에서경구혈당강하제및인슐 Table 1. Baseline characteristics of the study population Total Male Female p value a Number 30 12 18 - Age, yr 59.8 ± 9.0 60.6 ± 7.4 59.2 ± 10.1 0.51 Height, cm 161.2 ± 7.0 167.8 ± 5.1 156.8 ± 3.8 0.001 Weight, kg 64.6 ± 12.4 69.4 ± 16.2 61.4 ± 8.2 0.075 BMI, kg/m 2 24.8 ± 4.0 24.4 ± 4.6 25.0 ± 3.6 0.511 HbA1c, % 8.2 ± 1.6 8.5 ± 1.3 8.0 ± 1.7 0.299 T-C, mg/dl 181.5 ± 49.3 173.8 ± 43.7 186.7 ± 53.3 0.687 LDL-C, mg/dl 101.9 ± 35.4 107.3 ± 38.8 98.3 ± 33.5 0.459 HDL-C, mg/dl 46.7 ± 12.4 43.4 ± 8.6 49.0 ± 14.2 0.27 TG, mg/dl 159.0 ± 152.5 134.8 ± 55.6 175.1 ± 192.3 0.832 BMI, body mass index; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; T-C, total cholesterol. a Comparisons were performed using the Mann-Whitney U test. Table 2. Comparison of clinical and laboratory parameters before and after camp attendance Before camp After camp p value a Weight, kg 64.6 ± 12.4 63.9 ± 11.0 0.380 BMI, kg/m 2 24.8 ± 4.0 24.6 ± 3.7 0.517 HbA1c, % 8.2 ± 1.6 7.5 ± 1.5 0.004 T-Chol, mg/dl 181.5 ± 49.3 172.0 ± 55.5 0.262 LDL-C, mg/dl 101.9 ± 35.4 97.4 ± 38.7 0.845 HDL-C, mg/dl 46.7 ± 12.4 45.7 ± 9.1 0.284 TG, mg/dl 159.0 ± 152.5 150.5 ± 133.3 0.453 BMI, body mass index; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; T-Chol, total cholesterol. a Comparisons were performed using the Wilcoxon signed rank test. - 212 -
- 김태균외 7 인. 당뇨캠프의영향 - Table 3. Comparison of the Rosenberg self-esteem scale items before and after camp attendance Question Before camp After camp 1. On the whole, I am satisfied with myself. 2.7 ± 0.5 2.7 ± 0.5 2. At times, I think I am no good at all. 2.3 ± 0.5 2.7 ± 0.5 3. I feel that I have a number of good qualities. 3.2 ± 0.7 3.2 ± 0.6 4. I am able to do things as well as most other people. 3.0 ± 0.3 3.2 ± 0.4 5. I feel I do not have much to be proud of. 2.8 ± 0.8 3.1 ± 0.6 6. I certainly feel useless at times. 2.7 ± 0.6 3.0 ± 0.5 7. I feel that I am a person of worth, at least on an equal plane with others. 2.4 ± 0.6 2.9 ± 0.5 8. I wish I could have more respect for myself. 2.1 ± 0.4 2.8 ± 0.6 9. All in all, I am inclined to feel that I am a failure. 2.5 ± 1.0 2.9 ± 0.8 10. I take a positive attitude toward myself. 2.5 ± 1.0 2.8 ± 0.8 Positively worded items = Items 1, 2, 4, 6, and 7; negatively worded items = Items 3, 5, 8, 9, and 10. The scale is a 10-item Likert scale with items answered on a 4-point scale (from strongly agree to strongly disagree). Table 4. Comparison of the Rosenberg self-esteem scale and medication possession ratio before and after camp attendance Before camp After camp p value a Self-esteem scale 26.2 ± 4.6 29.3 ± 4.0 0.000 Medication possession ratio 0.92 ± 0.07 0.96 ± 0.05 0.001 The scores for the 10 items were summed. The higher the score, the higher the self-esteem. a Comparisons were performed using the Wilcoxon signed rank test. 린의용량이감소하였고, 나머지 25명은약물처방에서차이가없었다. 체중, 체질량지수및혈청지질농도는당뇨캠프전후에통계적으로유의한차이가없었다 (Table 2). 당뇨캠프전후자아존중감, 순응도의변화자아존중감측정에서는 10개의문항중자신에게만족하고긍정적인태도를나타낸 7, 8번항목의평균점수가크게상승했다 (Table 3). 자아존중감척도평균점수에서는캠프전 26.2 ± 4.6 점, 캠프후 29.3 ± 4.0 점으로캠프후에자아존중감이유의하게상승하였다 (p = 0.000, Table 4). 자아존중감척도문항의신뢰도인크론바흐알파계수 (Cronbach Alpha Coefficient) 는 α = 0.89이다. 순응도의변화는약물처방비율 (Medication Possession Ratio) 을이용하였고, 캠프전약물처방비율 (Medication Possession Ratio) 은 0.92 ± 0.07, 캠프후 0.96 ± 0.05로유의한증가를보였다 (p = 0.001, Table 4). 고찰당뇨병은완치가어려운만성대사성질환으로평생생활습관교정을통해지속적인자기관리가필요하다. 하지만제 2형당뇨병의경우대부분행동양상이이미확립된시기인성인기에발생하므로새로운습관을배운다거나생활습관을변화시켜자기관리를실천하는것은매우어려운일이다. 당뇨병환자의자기관리실천율은경구약물복용이나발관리에대한것은높으나, 식사와운동요법의실천율은낮은것으로보고되고있다 [16]. 이는당뇨병과같이어느정도진행되어야증상이나타나는환자들에게현재식습관에대한교정의필요성을못느낄뿐만아니라오히려입맛이떨어져먹는즐거움에제약을준다는생각이지배적이었기때문이다 [17,18]. 즉환자의굳어진사고의인식전환이이루어지기어려웠다. 당뇨병교육시당뇨병에관련해서환자의잘못된식이요법의개념에덧붙여, 영양학적인문제의복잡성과그러한숫자로만들어진영양소, 식사지침의이해와실천의 - 213 -
- The Korean Journal of Medicine: Vol. 83, No. 2, 2012 - 어려움이있었다. 한편운동요법에낮은실천율은주로사회적지지 ( 운동모임, 동료, 운동장소 ) 의부재에서오는결과로알려져있다 [19]. 이러한연구결과를근거로대부분의성인당뇨캠프에서는식이및운동요법의교육에 50% 이상의시간을할애하여교육에서부족했던사회적지지부분을채워주려노력하고있다. 본연구에서는당뇨캠프전과비교하여당뇨캠프후에당화혈색소가유의하게감소함을관찰하였다. 이는당뇨캠프후에혈당측정기를이용해측정한혈당이감소했다는 Kim 등 [20] 의연구와부합한다. 또한 30명의대상환자중 5명의환자에서경구혈당강하제및인슐린의용량이감소한것으로보아당뇨캠프가혈당조절에효과적임을알수있었다. Miller 등 [21] 의소아당뇨캠프연구에서도당뇨캠프후인슐린요구량이감소했다고보고하였다. 캠프전후당화혈색소의유의한감소는캠프에서의식이요법과운동요법의효과로생각된다. 실제로캠프후시행한설문조사에서 30명의환자중 21명은식이요법의변화가가장큰도움이되었다고하였고, 나머지 9명은운동요법이라고대답하였다. 체중과 BMI, 콜레스테롤수치는통계상유의한차이가없었다. 캠프전후 BMI는키와체중으로만측정하였고, 허리둘레를측정하지못해근육량의변화에따른 BMI 차이를반영하지못하였지만, 30명의환자중운동요법을적용한환자는 9명으로근육량의차이는적을것으로생각된다. 당뇨캠프는교육외에도동일한질병을앓고있는다른환자들과의만남을통해공감대를형성하고, 평소자신만이겪고있다고생각했던어려움이나우울감, 정신적스트레스를해소할수있는장점도있는것으로알려져있다 [22]. 이러한당뇨캠프의정서적이점을확인하기위해, 저자들은 Rosenberg 측정도구를이용하여자아존중감을측정하였고, 측정결과캠프후에자아존중감이향상되었음을확인할수있었다 (Table 4). 10개의문항을항목별로분석해보면캠프전후에대부분의항목에서평가점수의상승을볼수있지만, 특히자신이다른사람들처럼존중받을수있고가치있는사람이라는생각들이큰폭으로상승되었다 (Table 3). 이는캠프에서의체험학습과같은병을가진환자들과의만남을통한정서적공유가자아존중감향상에영향일미친다는연구와일치한다 [23]. 캠프에서의자아존중감의향상과혈당조절사이에도상관관계가있음이보고되었고 [24], 본연구에서혈당조절의개선에자아존중감의상승도일부기여했 으리라생각된다. 자아존중감척도문항의신뢰도인크론바흐알파계수 (Cronbach Alpha Coefficient) 는 α = 0.89로신뢰도는높았다. 약물순응도의경우약물처방비율 (Medication Possession Ratio) 을이용하였고, 캠프전후유의한상승을나타내었다 (Table 4). 단, 처방받은약은모두복용하였다는가정하에계산되었다. 교육에의해약물처방비율이상승되었다는보고들은있었으나 [25,26], 본연구에서는다른연구와다르게연구에포함된 30명모두약물처방비율이 75% 이상으로순응군으로분류되었다. 본연구에포함된 30명모두자아존중감과약물순응도의향상을가져왔다. 이는 30명모두캠프에자발적으로참여한환자군으로치료에대한의지가높은편이고, 3차병원을방문하는환자들의특성상질환을심각하게생각하기때문인것으로생각된다. 당뇨병은평생동안관리가필요한질환으로개개인의생활습관에맞는개별화된교육방법이필요한것으로알려져있다. 또한당뇨병의관리에대한평가도단기간보다는장기간에걸쳐서이루어져야한다. 본연구에서는혈당조절및자아존중감에대한평가가당뇨캠프전후로 6 ± 3개월사이에이루어져비교적단기간임을알수있다. 따라서전향적으로기획되고몇년의기간을두고효과를판정하는장기간의연구가필요하리라생각된다. 결론적으로, 본연구를통해당뇨캠프가혈당조절및자아존중감향상, 순응도에효과가있음을알수있었다. 요약목적 : 당뇨병은완치되지못하는만성질환이므로환자자신에의한자가관리가특히중요하다. 자가관리를위한교육으로당뇨병캠프가전국적으로실시되고있다. 이에본연구에서는당뇨캠프에참여한제2형당뇨병환자들을대상으로캠프의효과를평가하고자하였다. 방법 : 2005년 8월부터 2011년 8월까지대전충청지회당뇨캠프에참여한 30명의제2형당뇨병환자를대상으로하였다. 캠프전과캠프후의두군으로나누어신체계측치, 당화혈색소, 혈청지질값, 자아존중감, 순응도를조사하였다. 자아존중감은 Rosenberg 자아존중감척도를사용하였고, 순응도는약물처방비율 (medication possession ratio) 을이용해 - 214 -
- Tae Kyun Kim, et al. Effects of diabetic camp - 측정하였다. 결과 : 당화혈색소는당뇨캠프전 8.2 ± 1.6%, 캠프후 7.5 ± 1.5% 로유의하게감소하였다 (p = 0.004). 두군사이의자아존중감측정에서는캠프전 26.2 ± 4.6, 캠프후 29.3 ± 4.0으로캠프후에자아존중감의상승을보였고 (p = 0.000), 순응도로측정된약물처방비율은캠프전 0.92 ± 0.07에서캠프후 0.96 ± 0.05로호전되었다 (p = 0.001). 이외에임상자료에서는캠프전후차이가없었다. 결론 : 제2형당뇨병환자에서당뇨캠프를통한교육은혈당감소와자아존중감향상, 순응도에효과를나타낸다. 중심단어 : 당뇨병 ; 캠핑 ; 당화혈색소 REFERENCES 1. Lawman HG, Wilson DK. A review of family and environmental correlates of health behaviors in high-risk youth. Obesity (Silver Spring) 2012;20:1142-1157. 2. Tahrani AA, Bailey CJ, Del Prato S, Barnett AH. Management of type 2 diabetes: new and future developments in treatment. Lancet 2011;378:182-197. 3. Song MS, Song KH, Ko SH, et al. The long-term effect of a structured diabetes education program for uncontrolled type 2 diabetes mellitus patients-a 4-year follow-up. J Korean Diabetes Assoc 2005;29:140-150. 4. Kim GY, Park JY, Kim BW. Short-term glycemic control and the related factors in association with compliance in diabetic patients. Korean J Prev Med 2000;33:349-363. 5. Gold DT, McClung B. Approaches to patient education: emphasizing the long-term value of compliance and persistence. Am J Med 2006;119(4 Suppl 1):S32-S37. 6. Kim EJ. Aims of diabetes treatment and importance of diabetes education. Diabetes Metab J 1985;9:1-3. 7. Miller NH. Compliance with treatment regimens in chronic asymptomatic diseases. Am J Med 1997;17:43-49. 8. Song OK, Park HK, Yoo HJ, Yoon YG. Analysis of group diabetes education in Korea. J Korean Diabet Assoc 1988; 12:201-206. 9. Tessier DM, Lassman-Vague VJ. Diabetes and education in the elderly. Diabetes Metab 2007;33(Suppl 1):S75-S78. 10. Gravely SS, Hensley BK, Hagood-Thompson C. Comparison of three types of diabetic foot ulcer education plans to determine patient recall of education. J Vasc Nurs 2011;29: 113-119. 11. Tan MY, Magarey JM, Chee SS, Lee LF, Tan MH. A brief structured education programme enhances self-care practices and improves glycaemic control in Malaysians with poorly controlled diabetes. Health Educ Res 2011;26:896-907. 12. Rosenberg, M. Society and Adolescent Self-Image. Princeton: Princeton University Press, 1965. 13. Lee JY, Nam SK, Lee MK, Lee JH, Lee SM. Rosenberg self-esteem scale: analysis of item-level validity. The Korean Journal of Counseling and Psychotherapy 2009;21:173-189. 14. Ahn J. A study on the relationship between non-pharmacological treatments and adherence to antidepressant pharmacotherapies in Korea. J Korean Med Assoc 2011;54: 381-385. 15. Hong JS, Kang HC. Oral antihyperglycemic medication adherence and its associated factors among ambulatory care with adult type 2 diabetes patients in Korea. Korean J Health Policy Adm 2010;20:128-143. 16. Pham DT, Fortin F, Thibaudeau MF. The role of the Health Belief Model in amputees' self-evaluation of adherence to diabetes self-care behaviors. Diabetes Educ 1996;22:126-132. 17. Lee YM, Jin KN, Lee DW, et al. Effectiveness of dietary education for the diabetes treatment. Korean Clin Diabetes 2002;3:87-96. 18. Vickery CE, Hodges PA. Counseling strategies for dietary management: expanded possibilities for effecting behavior change. J Am Diet Assoc 1986;86:924-928. 19. Ye HS, Jun JD, Park HS. Knowledge & practice about diet & exercise in NIDDM patients. J Korean Acad Fam Med 1996;17:223-231. 20. Kim HS, Shim KH. Effect of a diabetic camp program on the fasting blood sugar level in type 2 diabetic patients. J Korean Acad Adult Nurs 1999;11:477-485. 21. Miller AR, Nebesio TD, DiMeglio LA. Insulin dose changes in children attending a residential diabetes camp. Diabet Med 2011;28:480-486. 22. Yoo JH, Han KJ, Choe MA, An HY. Change of Dpression, self-efficacy and self-esteem in diabetic children and adolesce after diabetic camp participation. The Seoul Journal of Nursing 1999;13:72-87. 23. Békési A, Török S, Kökönyei G, Bokrétás I, Szentes A, Telepóczki G. Health-related quality of life changes of children and adolescents with chronic disease after participation in therapeutic recreation camping program. Health Qual Life Outcomes 2011;9:43. 24. Gu MO, Yoo JW, Eum DC. A survey on self regulation behavior of diabetic patients performing SMBG. J Korean Diabet Assoc 1994;18:235-241. 25. Kim KS, Kim MJ, Park SH, et al. Medication adherence: evaluation and impact on glycemic control in type 2 diabetes mellitus. JKSHP 2009;26:148-153. 26. Joo HK, Choi JS. A study on patient compliance in hypertension and diabetes. J Korean Acad Fam Med 1994;15: 446-464. - 215 -