Exercise Science Vol.27, No.2, May 2018: 134-139 ISSN(Online) 2384-0544 ORIGINAL ARTICLE 여성노인의골다공증위험과사회경제적지위및악력의관계분석 김동현, 조진경, 강현식 성균관대학교스포츠과학과 The Association between Socioeconomic Status, Handgrip Strength, and Osteoporotic Status in Elderly Women Dong-Hyun Kim, Jin-Kyung Cho, Hyunsik Kang College of Sport Science, Sungkyunkwan University, Suwon, Korea PURPOSE: The purpose of the study was to investigate the relationship of socioeconomic status (SES) and hand grip strength (HGS) with osteoporotic status in elderly women. METHODS: A total of 378 elderly women (aged 73.8±6.6 years) voluntarily participated in this cross-sectional study. Body mass index (BMI), percent body fat, bone mineral density (BMD) were measured with a dual-energy X-ray absorptiometry (DXA). HGS was measured with a hand grip dynamometer. Osteoporotic status was determined on the basis of the standardized score (T-score) of femur BMD. A questionnaire was used to assess socio-demographics, alcohol consumption, and cardiovascular risk factors. Logistic regression analysis was used to determine odds ratio (OR) and 95% confidence interval (CI) of a combination of low SES and low HGS for osteoporotic status before and after adjustments for age and BMI. Statistical significance was tested at p=.05 using SPSS-PC (version 23.0). RESULTS: One-way ANOVA showed significant group differences in age (p<.001), BMI (p=.029), femur total BMD t-score (p<.001), and BMD total t-score (p=.002) among SES+HGS-based groups. Logistic regression analysis showed that high SES+low HGS (OR=2.608, 95% CI=1.155-5.892, p=.021), low SES+high HGS (OR=2.213, 95% CI=1.124-4.358, p=.022), and low SES+low HGS group (OR=2.624, 95% CI=1.303-5.288, p=.007) had a significantly higher estimated risk of osteoporotic status even after adjustments for age and BMI, as compared with high SES+high HGS group (OR=1). CONCLUSIONS: The findings of the study suggest that both low HGS and low SES are important determinants of osteoporotic status in elderly women. Key words: Bone mineral density, Grip strength, Socio-economic status, Elderly women 서론 현대사회는보건의료기술의발달로인해노인수명의연장과출산율저하로인한생산연령인구의감소에따라전세계적으로고령화현상이빠르게진행되고있다. 통계청조사에따르면우리나라의경우현재전체인구의 12.7% 가노인인구로파악되고있고, 이와같은추세로 고령화가가속화된다면 2030년에는 24.3% 까지증가해초고령사회로진입할것으로전망했다 [1]. 인구의고령화는다양한노년기질환에대한유병률을증가시키는데특히여성의경우연령증가에따라골다공증유병률이급속하게증가하는것으로알려진다 [2]. 골다공증은골강도의감소로인해골절의위험성을증가시키는대표적인노인성근골격계질환으로우리나라 50세이상여성의 1/3 이상 Corresponding author: Hyunsik Kang Tel +82-31-299-6923 Fax +82-31-299-6942 E-mail hkang@skku.edu * 본연구는 2017 년도한국연구재단이공계중견연구지원사업 (NRF-2017S1A5B5A02023628) 지원비를받아수행되었음. Keywords 골밀도, 악력, 사회적지위, 여성노인 Received 23 Feb 2018 Revised 5 Mar 2018 Accepted 9 Apr 2018 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. 134 Copyright 2018 Korean Society of Exercise Physiology
이골건강이상으로인해골절을경험할정도로발생률이높은질환이다 [2]. 여성의경우폐경후에스트로겐의감소와더불어골밀도감소가급격히일어나기때문에적합한예방활동을통해골밀도의감소속도를늦추는것이골다공증을예방및관리에중요하다 [3]. 골밀도는연령, 성, 가족력과같은유전적요인과더불어음주, 흡연, 식이, 운동과같은생활습관요인도중요하게작용하는것으로보고된다 [4,5]. 이에미국골다공증학회에서는골다공증을예방하고치료하기위해규칙적인근육강화운동을권고하고있다. 최근연구에의하면근수축을통한근력향상은근육에서분비하는마이오카인 (myokine) 이골획득 (acquisition) 과유지 (maintenance) 및향상에긍정적인영향을미쳐근육과뼈대사의상호작용의기전적측면을보고하였다 [6]. 악력은근력을단순하고쉽고비침습적인방법으로측정하여노인의영양상태, 사망및기능체력을예측할수있어최근많은연구자들에게이용되고있다 [7]. 이와관련된선행연구에의하면낮은악력수준은심혈관계질환 [8], 당뇨병 [9], 대사질환 [10] 과연관성이있는것으로나타났고, 그뿐만아니라노인의사망을예측하는것으로보고했다 [11]. 최근연구에의하면낮은수준의악력은폐경기여성의척추 (spinal), 대퇴 (femur neck), 고관절 (hip) 의골절위험률증가와상관관계가있다고보고하였다 [12]. 한편, 교육수준, 직업, 소득수준을예측인자로한사회경제적지위 (socioeconomic status, SES) 에따라건강불평등에영향을미친다고하였고특히노년기집단에서건강격차가가장크게나타난다고보고하여노인집단의사회경제적지위와노년기질환에대한관심이증대되고있다 [13]. 선행연구에따르면낮은사회경제적지위는당뇨, 심혈관질환, 대사증후군과같은만성질환에대한위험률을증가시키는것뿐만아니라골다공증과도상관관계가있는것으로알려진다 [14-16]. 그예로중년미국인을대상으로실시한횡단적연구결과에따르면낮은수준의사회경제적지위를갖고있을수록골전환 (bone turnover) 이증가되는것으로나타나골절의위험이더증가되는것을확인하였다 [16]. 또한, Zingmond et al. [17] 의연구에의하면낮은수준의사회경제적지위와고관절골절위험률증가와상관관계가있는것으로보고하였다. 그러나국내노인을대상으로사회경제적지위와골다공증유병률과의관계에대한연구결과는남녀에따라상이한차이가있는것으로관찰되었고어떤사회경제적지표를사용하는지에따라결과가다르게나타나는것으로확인되었다 [18]. 선행연구들의결과를종합해보면여성노인의골다공증은사회경제적지위와근력과연관성이있을것으로판단되지만현재까지국외연구에비해국내선행연구는미흡한실정이다. 따라서본연구에서는여성노인을대상으로사회경제적지위를대변하는교육수준과체력지표를대변하는악력이골다공증과연관성을갖는지검증하는것을본연구의목적으로하였다. 연구방법 1. 연구대상 본연구는경기도 S 시지역의특별한의학적질환이없고정상적인 생활이가능한 60 세이상여성노인 378 명을연구대상자로하였다. 참 여한피험자의특성은 Table 1 에제시된것과같다. 모든피험자는연구 의목적및진행방법에대한사항을문서와구두로자세히설명들었으 며실험참여동의서를작성한후실험에참여하였다. 본연구는 S 대학 교생명윤리위원회의승인 (SKKU-IRB-2014-01-002) 을받아진행되었다. 2. 인구사회학적지표및건강관련요인 인구사회학적요인은성별, 만나이, 학력을조사하였으며학력의경 우총교육년수를조사하였다. 건강관련요인으로는폐경나이, 음주 빈도, 심혈관질환위험요소 ( 나이, 가족력, 흡연, 좌식생활, 비만, 고혈 압, 고지혈증 ) 개수를조사하였다. 3. 신체구성지표및골밀도 신장은자동측정기 (DS-102, Jenix, Korea) 를이용하여측정하였고, 이중에너지 X 선흡수계측 (Dual-energy X-ray Absorptiometry, DEXA) 원리를사용한 Lunar DPX Pro (GE medical systems Lunar, USA) 를이 용하여체중, 근육량및골밀도를측정하였다. 체질량지수 (body mass index, BMI) 는체중 (kg)/ 신장 (m 2 ) 공식을통해산출하였고, 사지근육 량 (appendicular skeletal muscle mass index, ASM index) 은사지근육 량 (kg)/ 신장 (m 2 ) 공식을이용하여산출하였다. 골감소증 / 골다공증은 대퇴골밀도의 T-score 에근거하였으며 T-score -1.0 의경우정상집단 으로 -2.5 <T-score <-1.0 의집단의경우골감소증집단, T-score -2.5 의 경우골다공증집단으로구분하였다 [19]. Table 1. Characteristics of study participants Variables Total (n=378) Age (year) 73.8±6.6 BMI (kg/m 2 ) 27.4 ± 3.2 Percent body fat (%) 36.5±6.2 Age of menopause (year) 49.5±5.4 Cardiovascular risk factors, n (%) 0-2 3-4 5 and over Weekly alcohol consumption, n (%) 0-1 2 and over 184 (48.7) 158 (41.8) 36 (9.5) 370 (97.9) 8 (2.1) Femur total BMD T-score -1.428±1.016 Education (year) 6.4±4.0 Grip strength (kg) 18.6±5.0 BMI, body mass index; BMD, bone mineral density. 김동현외 골다공증과사회경제적지위및악력의관계 135
Vol.27, No.2, May 2018: 134-139 4. 악력측정악력 (kg) 은악력계 (TANITA No. 6103, Tokyo, Japan) 를이용하여 kg 단위로측정하였다. 모든참여자는팔을 15도정도벌리고자연스럽게선자세에서악력계를힘있게쥐도록한후눈금을읽었으며좌우각각악력측정을두번씩수행하였고측정된값중최대수치를사용하였다 [20]. 5. 자료처리방법본연구의연속형변수는평균과표준편차 (mean ± SD) 로표기하였고, 범주형변수의경우빈도와퍼센트로표기하였다. 집단별연속형변수에대한차이검증은일원변량분석 (One-way ANOVA) 을하였고유의한결과에대한사후검증으로 LSD를사용하였다. 또한집단별범주형변수에대한차이검증은교차분석 (Chi-square) 을이용하였다. 참여자들의집단은사회경제학적지표를대변하는학력과체력지표를대표하는악력을이용하여세분화하였다. 교육년수가 7년이상인집단을 high SES (H_SES), 6년이하인집단을 low SES (L_SES) 로정의하였다. 악력의경우중위값을사용하여상위 50퍼센트집단을 high hand grip strength (H_HGS), 하위 50퍼센트집단을 low hand grip strength (L_HGS) 로정의하였다. 따라서참여자의집단은사회경제학적지표와체력지표를이용하여 4집단 (H_SES+H_HGS, L_SES+H_ HGS, H_SES+L_HGS, L_SES+L_HGS) 으로세분화한뒤로지스틱회귀분석을통해골감소증의상대적위험도 (odds ratio, OR) 와 95% 신뢰구간을산출하였다. 가설검정을위한유의수준은 α =.05로설정하였 으며모든자료의통계분석은 SPSS-PC (version 18.0) 를이용하였다. 연구결과 1. 사회경제적지표와체력지표에따른신체구성및인구사회학적특성비교 Table 2는사회경제학적지표와체력지표에따른집단간신체구성, 인구사회학적특성및건강관련요인을나타낸것이다. 그결과, 나이 (p <.001), BMI (p =.029), 대퇴골밀도 t-score (p <.001), 전신골밀도 t- score (p =.002) 에서집단간통계학적인유의한차이가있는것으로나타났다. 집단간차이가있는변인에대해사후분석을실시한결과, 나이는 H_SES+H_HGS 집단이 L_SES+H_HGS (p <.001), H_SES+L_ HGS (p <.001), L_SES+L_HGS (p <.001) 집단에비해유의하게많은것으로나타났고, L_SES+H_HGS와 H_SES+L_HGS 집단간에는 (p =.775) 유의한차이가나지않는것으로나타났다. BMI는 L_SES+ H_HGS 집단이 H_SES+H_HGS (p =.003), H_SES+L_HGS (p =.016), L_SES+L_HGS (p =.038) 집단에비해통계학적으로유의하게높은것으로나타났고나머지세집단에서는통계학적유의한차이가나타나지않았다. 대퇴골밀도 t-score의경우 H_SES+H_HGS 집단이 L_ SES+H_HGS (p =.009), H_SES+L_HGS (p =.013), L_SES+L_HGS (p <.001) 집단에비해통계학적으로유의하게높은것으로나타났고 L_SES+H_HGS와 H_SES+L_HGS 집단간 (p =.807) 에는유의한차이가나지않았다. 전신골밀도 t-score의경우, H_SES+H_HGS 집단이 Table 2. Descriptive statistics of measured parameters according to SES plus HGS-based subgroups Variables H_SES + H_HGS (n = 92) L_SES + H_HGS (n = 59) H_SES + L_HGS (n = 97) L_SES + L_HGS (n = 130) Education (year) 10.3 ± 2.0 bd 4.2 ± 2.4 ac 10.5 ± 1.9 bd 3.6 ± 2.6 ac <.001 Grip strength (kg) 22.3 ± 3.7 cd 22.2 ± 4.3 cd 15.5 ± 2.6 ab 14.7 ± 2.8 ab <.001 Age (year) 70.6 ± 6.0 bcd 73.7 ± 5.3 ad 74.0 ± 5.8 ad 76.8 ± 6.1 abc <.001 Age of menopause (year) 49.8±6.00 49.3±5.3 49.6±5.1 49.4±5.6.977 BMI (kg/m 2 ) 24.3 ± 3.1 b 25.6 ± 3.2 acd 24.3 ± 3.4 b 24.7 ± 3.2 b.029 Percent body fat (%) 35.4±5.8 37.6±5.6 36.8±6.2 36.6±6.73.136 CVD risk factors, n (%) 0-2 3-4 5 and over Alcohol consumption, n (%) 0-1 2 and over 48 (55.8) 33 (38.4) 5 (5.8) 84 (97.7) 2 (2.3) 41 (42.3) 42 (43.3) 14 (14.4) 94 (96.9) 3 (3.1) 35 (59.3) 18 (30.5) 6 (10.2) 59 (100) 0 (0) 57 (43.8) 62 (47.7) 11 (8.5) 127 (97.7) 3 (2.3) Femur total BMD T-score -1.080 ± 0.700 bcd -1.405 ± 1.001 ad -1.446 ± 1.001 ad -1.735 ± 1.088 abc <.001 BMD total T-score -1.297 ± 0.857 bcd -1.669 ± 0.929 a -1.805 ± 1.069 a -1.764 ± 1.007 a.002 SES, socio-economic status; HGS, handgrip strength; H_SES, high SES; L_SES, low SES; H_HGS, high HGS; L_HGS, low HGS; BMI, body mass index; CVD, cardiovascular disease; BMD, bone mineral density. a significantly different vs. H_SES + H_HGS; b significantly different vs. L_SES + H_HGS; c significantly different vs. H_SES + L_HGS; d significantly different vs. L_ SES + L_HGS (p<.05). p.098.629 136 Dong-Hyun Kim, et al. Osteoporosis, Socioeconomic Status and Handgrip Strength
Table 3. The osteoporotic risks of exposing to low SES and low HGS in this study sample Model 1 OR (95% CI) Model 2 OR (95% CI) Model 3 OR (95% CI) H_SES + H_HGS (n=92) 1 1 1 H_SES + L_HGS (n=59) 3.233 (1.529-6.837)** 2.470 (1.127-5.413)* 2.608 (1.155-5.892)* L_SES + H_HGS (n=97) 2.414 (1.305-4.466)** 1.795 (0.937-3.442) 2.213 (1.124-4.358)* L_SES + L_HGS (n=130) 4.615 (2.423-8.455)** 2.487 (1.260-4.909)** 2.624 (1.303-5.288)** SES, socio-economic status; HGS, handgrip strength; H_SES, high SES; L_SES, low SES; H_HGS, high HGS; L_HGS, low HGS; OR, odds ratio; CI, confidence interval; Model 1, unadjusted; Model 2, adjusted for age; Model 3, adjusted for age and BMI. **p<.01; *p<.05. L_SES+H_HGS (p =.009), H_SES+L_HGS (p =.002), L_SES+L_HGS (p =.001) 집단에비해통계학적으로유의하게높은것으로나타났으며나머지세그룹간에는통계학적으로유의한차이가나지않는것으로나타났다. 2. 사회경제적지표와체력지표에따른골다공증의상대적위험도분석 Table 3은사회경제적지표와체력지표에따른골다공증의상대적위험도를산출한결과이다. 그결과 H_SES+H_HGS를기준으로하였을때 H_SES+L_HGS 집단 (OR =3.233, p =.002), L_SES+H_HGS 집단 (OR=2.414, p =.005), L_SES+L_HGS 집단 (OR= 4.615, p <.001) 의골다공증에대한상대적위험도가통계학적으로유의하게증가된것을확인하였다. 또한, 나이와 BMI를보정한후에도 H_SES+L_HGS 집단 (OR =2.608, p =.021), L_SES+H_HGS 집단 (OR =2.213, p =.022), L_ SES+L_HGS 집단 (OR =2.624, p =.007) 의골다공증에대한상대적위험도가통계학적으로유의하게증가된것을확인하였다. 논의 본연구는 60세이상여성노인 378명을대상으로사회경제학적지표및악력에따른골밀도를비교하고, 두가지변인이골다공증에독립적인예측인자로작용하는지검증하는것을연구의주요목적으로하였다. 그결과낮은사회경제학적지표와낮은악력을가진집단에서골다공증에걸릴상대적위험도가가장높은것으로나타났고, 낮은사회경제학적지표를가지고있더라도악력이높은집단이골다공증에걸릴상대적위험률이낮은것으로나타났다. 최근연구에의하면사회경제적지표는노인의건강불평등과연관성이있는것으로나타났고특히골다공증과도연관성이있다고보고되고있는가운데, 본연구에서도사회경제적지표와골다공증의연관성은선행연구와일치하는것으로나타났다. Wang et al. [21] 의연구에의하면 2,905명의폐경기여성을대상으로흑인, 백인, 히스패닉인으로집단을세분화한뒤, 사회경제적지표인교육, 월수입그리고교 육과월수입을조합해서고관절골밀도와상관관계를보았을때, 흑인과백인폐경기여성에서만사회경제적지표와고관절골밀도는양의상관관계를갖는것으로나타났다. Pearson et al. [22] 의연구에따르면 1,187명의여성노인을대상으로사회경제적박탈지수 (Jarman score) 를근거로하여 4개의집단으로세분화한뒤발뒤꿈치골밀도와의상관관계를보았을때사회경제적박탈지수가높을수록골밀도가낮아지는것을확인하였고, 로지스틱회귀분석결과사회경제적박탈지수와더불어체질량지수, 나이, 척추측만증, 시각적문제가골다공증의위험인자인것으로나타났다. 또한 Kim et al. [18] 의연구에의하면 8,221명의 50세이상국내남녀골다공증환자를대상으로남성과여성으로집단을세분화한뒤사회경제적지표와골다공증유병률과의관계에대해횡단적연구를실시한결과여성의경우교육수준과골다공증의유병률이음의상관관계를갖는것으로나타났고남성의경우월수입과골다공증의유병률이음의상관관계에있는것으로나타났다. 본연구에서도낮은교육수준은골다공증에대한상대적인위험도를유의하게증가시키는것으로나타났으나낮은교육수준을가지더라도높은악력을가진집단에서골다공증에대한상대적인위험도가떨어지는것을확인하였다. 인체의골격근과뼈는서로상호보완적인관계에있다는선행연구들이보고되고있다. 예를들어근감소증 (sarcopenia) 과같은골격근의위축 (muscle atrophy) 은뼈에가해지는부하감소로인해뼈의손실을유도한다고보고하였으며근육의무게 (muscle weight) 는기계적인부하를통해뼈의질량을조절한다고보고하였다 [23,24]. 이때근육의무게는근력으로도간주될수있는데근력은골밀도와연관성이있다고보고했다. Kim et al. [25] 연구에따르면악력은근력을대변할수있는측정요소라보고하였고이때연령이악력을결정하는데중요한요인이라고하였다 [26]. 또한폐경기여성의근력감소는나이가증가됨에따라발생하는근육량의감소와연관성있는것으로나타났고, 근력과고관절의골밀도는양의상관관계가있는것으로보고하였다 [27]. 종합하면, 악력측정은노인의골밀도뿐만아니라골절, 하지근육의기능및운동능력을평가할수있는측정변인으로사료된다. 최근연구에의하면낮은수준의악력은폐경기여성의골다공증에 김동현외 골다공증과사회경제적지위및악력의관계 137
Vol.27, No.2, May 2018: 134-139 강력한위험인자인것으로보고하였다 [28]. Tachiki et al. [29] 은 680명의골다공증에걸린일본폐경기여성을대상으로하여악력을 3분위로나누어대퇴, 요추, 그리고전신의골밀도와상관관계를살펴본결과, 악력이클수록요추와대퇴의골밀도가높아지는양의선경향이있는것으로나타났고이는사지근육량과나이를보정하고도통계학적유의성이있는것으로확인되었다. 또한 Ma et al. [30] 은중국남녀노인 1,234명을대상으로악력을체중으로나눈후사분위수로집단을세분화하여골다공증에걸릴상대적인위험도를로지스틱회귀분석으로분석해본결과악력이낮은집단이높은집단에비해다양한공변량으로보정하고도골다공증에대한상대적인위험도가통계학적으로유의하게증가된것을확인하였다. 운동은기계적인부하를뼈에가하여골형성을촉진시키는역할을하는것으로알려진다. 선행연구에따르면운동은뼈의질량과기능적측면을효과적으로향상시킨다고하였다. 그예로젊은성인남성 1,068명을대상으로신체활동의증가가최대골량 (peak bone mass) 형성을증가시키는지에대해 5년간추적관찰을한결과, 신체활동의증가는젊은성인의최대골량형성을증가시키는것으로나타났다 [31]. Al-Shreef et al. [32] 은인슐린을투여하지않는당뇨환자를대상으로 6개월간운동중재를실시한후운동전과운동후에각각악력, 혈액의칼슘농도및부갑상샘호르몬의농도를측정한결과운동중재후악력과칼슘농도는증가하였고부갑상샘호르몬수치는감소한것을확인할수있었다. 즉, 운동을통한악력증가는뼈의대사를조절하여골밀도를증가시킬수있을것으로사료된다. 본연구에서도선행연구의결과와유사하게비슷한수준의사회경제적지표를가지고있을경우악력이높은집단에서골다공증에대한상대적위험도가감소하는것을확인하였다. 특히, 낮은수준의사회경제적지표를가지더라도악력이높을경우높은수준의사회경제적지표와더불어낮은악력수준을갖는것보다골다공증에대한상대적위험도가감소하는것을확인하였다. 이는운동을통한체력혹은근력증진은골다공증에대한위험도를감소시켜줄수있는수정가능한생활습관인자인것으로판단된다. 그러나본연구는연구대상을여성노인에국한했다는점, 사회경제학적지표로교육만을사용했다는점, 근력을악력으로만측정했다는점에연구의제한점이있다. 또한횡단적연구설계를바탕으로하였기에생활습관수정을통한체력및근력개선이노년기골다공증에미치는영향에대한인과관계를증명할수없어추후본연구의제한점들이보완된중재연구가필요할것으로사료된다. 결론 본연구에서여성노인의낮은수준의사회경제적지표와낮은수준의악력은나이와체질량지수를보정하고도골다공증을결정하는독 립적인위험인자로작용하는것으로나타났다. 또한낮은수준의사회경제적지표를가지고있더라도악력이높은경우, 골다공증에대한상대적위험률이감소하는것으로나타났다. 따라서본연구의결과는골다공증을예방하는데높은수준의사회경제적지표와더불어생활습관수정을통해개선가능한체력및근력유지의중요성을의미하는것으로판단된다. REFERENCES 1. Statistics Korea. Future population projection. [on line] Search date 2018. 01.19. http://kosis.nso.go.kr 2. Park EJ, Joo IW, Jang MJ, Kim YT, Oh KW, et al. Prevalence of osteoporosis in the Korean population based on Korea National Health and Nutrition Examination Survey (KNHANES) 2008-2011. Yonsei Med J. 2014;55(4):1049-57. 3. Cauley JA. Estrogen and bone health in men and women. Steroids. 2015;99:11-5. 4. Lee I, Cho J, Jin Y, Ha C, Kim T, et al. Body fat and physical activity modulate the association between sarcopenia and osteoporosis in elderly Korean women. J Sports Sci Med. 2016;15(3):477-82. 5. Shan PF, Wu XP, Zhang H, Cao XZ, Gu W, et al. Bone mineral density and its relationship with body mass index in postmenopausal women with type 2 diabetes mellitus in mainland China. J Bone Mine Metab. 2009;27(2):190-7. 6. Colaianni G, Cuscito C, Mongelli T, Pignataro P, Buccoliero C, et al. The myokine irisin increases cortical bone mass. Proc Natl Acad Sci U S A. 2015;112(42):12157-62. 7. Norman K, Stobäus N, Gonzalez MC, Schulzke JD, Pirlich M. Hand grip strength: outcome predictor and marker of nutritional status. Clin Nutr. 2011;30(2):135-42. 8. Gubelmann C, Vollenweider P, Marques-Vidal P. Association of grip strength with cardiovascular risk markers. Eur J Prev Cardiol. 2017;24(5):514-21. 9. Kimbro LB, Mangione CM, Steers WN, Duru OK, McEwen L, et al. Depression and all-cause mortality in persons with diabetes mellitus: are older adults at higher risk? Results from the Translating Research Into Action for Diabetes Study. J Am Geriatr Soc. 2014;62(6):1017-22. 10. Kawamoto R, Ninomiya D, Kasai Y, Kusunoki T, Ohtsuka N, et al. Handgrip strength is associated with metabolic syndrome among middle-aged and elderly community-dwelling persons. Clin Exp Hypertens. 2016;38(2):245-51. 138 Dong-Hyun Kim, et al. Osteoporosis, Socioeconomic Status and Handgrip Strength
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