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대한지역사회영양학회지 24(2): 152~162, 2019 https://doi.org/10.5720/kjcn.2019.24.2.152 ISSN 1226-0983 (print) / 2287-1624 (on-line) RESEARCH ARTICLE 폐경후여성의골다공증및심혈관계질환위험도에따른영양소및식품섭취상태 : 제 5 기국민건강영양조사 (2010-2011) 자료를이용하여 김효빈 1) 김혜숙 2) 권오란 2) 박희정 3) 1) 이화여자대학교임상보건융합대학원임상영양학전공, 학생, 2) 이화여자대학교식품영양학과, 교수, 3) 유한대학교식품영양학과, 교수 Food and Nutrient Intake Level by the Risk of Osteoporosis and Cardiovascular Disease in Postmenopausal Women: The use of the 5th Korean National Health and Nutrition Examination Surveys (2010-2011) Hyobin Kim 1), Heysook Kim 2), Oran Kwon 2), Heejung Park 3) 1) The Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul 03760, Korea, Student 2) Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 03760, Korea, Professor 3) Department of Foods & Nutrition, Yuhan University, Seoul 14780, Korea, Professor Corresponding author Park, Heejung Department of Foods & Nutrition, Yuhan University, 590, Gyeongin-ro, Bucheon-si, Gyeonggi-do 14780, Korea Tel: (02) 2610-0809 Fax: (02) 2610-0806 E-mail: hjpark@yuhan.ac.kr Received: April 10, 2019 Revised: April 22, 2019 Accepted: April 23, 2019 ABSTRACT Objectives: The purpose of this study was to investigate the food, nutrient intake, and diet quality of postmenopausal women at high risk of osteoporosis (OP) and cardiovascular disease (CVD) compared with those of control subjects. Methods: A total of 1,131 post-menopausal women aged over 45 years, who took the 2010-2011 Korean National Health and Nutrition Examination Survey (KNHANES), were included for analysis. These participants were classified into the following groups: the OP group, with a risk of OP (n=135); the CVD group, with a risk of CVD (n=373); the OP+CVD group, with a risk of OP and CVD concurrently (n=218); and the control group (n=405) according to bone mineral density (BMD) and CVD risk. Anthropometric measurements, blood profiles, dietary intake, and dietary quality indices were measured and compared among the four groups. Results: Waist circumference, total body fat percentage, blood pressure, fasting plasma glucose, total cholesterol, triglyceride, and LDL-cholesterol were higher, and HDL-cholesterol and BMD were lower in the OP+CVD group than in the control group. In the food frequency questionnaire, the OP+CVD group had significantly higher frequencies of grain (except for multi-grain) and lower frequencies of fruit and dairy product. The frequency of consumption of red meat, processed meat, and carbonated beverages was higher in OP+CVD group. In nutrient density analysis, proteins and vitamin B 2 levels were significantly lower in the OP+CVD group than in the control group. The nutritional quality index (INQ) values of calcium were in the order of 0.63, 0.58, 0.56, and 0.55 in each group, and it was urgent to improve the dietary intake for calcium in postmenopausal women. In addition, vitamin B 2 was inadequately consumed by all groups. Conclusions: These results suggest that it is necessary to increase the intake of vitamin B 2 and calcium and decrease the frequency of intake of red meat, processed meat, and carbonated beverages in postmenopausal women with the risk of OP and CVD. Korean J Community Nutr 24(2): 152~162, 2019 KEY WORDS KNHANES, postmenopausal women, osteoporosis, cardiovascular disease, nutritional status This is an Open-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. 152

폐경후여성의골다공증및심혈관계질환위험에따른식품및영양섭취상태 153 서 폐경후여성은여성호르몬감소로인해발열, 안면홍조등의생리적증상에서골다공증, 심혈관계질환, 유방암등의만성질환까지다양한신체적, 정신적증상을경험하게된다 [1]. 특히폐경후에는여성호르몬의골흡수억제기능이저하되면서골흡수가증가하고소장에서의칼슘흡수가저하되어골밀도가현저하게감소한다 [2]. 골감소는골다공증으로직결되고, 골다공증으로인한골절은일상생활의불편감및노인의사망률과밀접한관련이있다 [3]. Sang 등 [4] 은골감소유병률은폐경전 24.5% 에비해폐경후 61.8% 까지증가하는것으로보고하고, 65세이상에서는골감소증이골다공증으로연결되면서질환의증세가심해짐을보고하였다. 폐경후에는여성호르몬의혈관보호효과가감소하면서혈중지질이상승하고증가된혈중지질은동맥경화를야기하여심혈관계질환위험을증가시킨다 [5-7]. So 등 [6] 은심혈관계질환의위험인자인총콜레스테롤, 저밀도지단백콜레스테롤, 중성지방의수치가폐경후 10-20% 증가하고고밀도지단백콜레스테롤수치는폐경후 10% 감소하였음을보고하였으며, Cho 등 [7] 의결과에서는관상동맥석회침착정도가폐경전 43.8% 수준인것이폐경후 60.0% 수준으로증가되는것으로나타났다. 최근폐경후여성에서골다공증과심혈관계질환이동반되어나타나면서두질환사이에공통적인병태생리학적기전및위험요인을가지면서한개의질환이다른질환의발생에영향을미쳐폐경후여성에게서이두질환이동반되어나타나는것으로보고되고있다 [8-14]. 골밀도저하상태에서심혈관계질환발생률과이로인한사망률이증가하였고 [11-12], Lian 등 [9] 은심혈관계질환위험요소인혈중호모시스테인수준과저밀도지단백콜레스테롤의수준이유의적으로높고, 여성, 고혈압, 이상지혈증등의특성이골다공증질환군에서유의적으로높은빈도로나타남을보고하였다. 심혈관계질환자에서도골밀도저하와골절의위험도가증가됨이다수의연구들에서보고되었으며 [13-14], Collins 등 [13] 은말초혈관질환을가진남성의경우정상남성에비해골밀도저하로인한골절의위험도가 1.5배높다고보고하였다. 두질환의상관성은폐경으로인한에스트로겐결핍과노화를주요원인으로판단되고있지만, 최근골대사경로중 bone morphogenetic protein(bmp), alkaline phosphatase(alp), osteopontin(opn) 와 matrix GLA protein(mgp) 등의골대사단백질이혈관내 론 무기질화를촉진하여심혈관계질환의위험도를직접적으로높이는것으로보고되고있다 [14-17]. 골다공증과심혈관계질환은식이요인에영향을받는대표적인질환이다. 골다공증은단백질, 인, 나트륨, 비타민D, 비타민 K 등의영양소와상관관계가높고, 심혈관계질환은트랜스지방, 포화지방, 단순탄수화물, 당첨가음료, 과일, 채소, 잡곡등의식이요인과밀접한관계가있음이전통적으로잘알려져있다. 더불어, 공통적인병태생리학적기전이있을것으로판단되는두가지복합질환자에관한식이요인에관한결과가일부보고되고있다. Bhupathiraju 등 [18] 은 American Heart Association에서주기적으로발표되는심혈관계질환자를위한식이가이드라인을사용하여시행한중재시험결과골다공증환자의골밀도지수가유의하게증가하는것을보고하여심혈관계질환의위험도를감소시키는식이요인은뼈건강과도유의한상관성이있음을예측하였다. 폐경기여성을대상으로한 Beulens 등 [19] 의연구에서는식이중메나퀴논이혈관평활근의무기질화를저해하는인자로작용하기때문에식이를통한적절한메나퀴논의섭취가심혈관계질환을예방하는데중요하다라고보고하였다. 그러나, 국내에서는심혈관계질환과골다공증과의복합질환여부를조사한연구가미비하고, 식이가이드라인에대한제시가미흡한실정이다. 식사가이드라인제시를위해서는개인의식생활에대한식사의질적평가방법이사용될수있으며, 영양소의섭취를평가하는영양소적정섭취비 (Nutrient Adequacy Ratio, NAR), 평균영양소적정섭취비 (Mean Adequacy Ratio, MAR), 영양소밀도 (Nutrient Density, ND), 영양의질적지수 (Index of Nutritional Quality, INQ) 등의다양한식사의질적평가방법이연구과정에서사용되고있다. 국내에서폐경후여성, 골다공증질환자, 혹은심혈관계질환자를대상으로식사의질을평가하는연구 [20-21] 가이루어지고있으나폐경후여성에게서이두질환이동반되어나타난다는점을반영하여분석한연구는미흡한실정이다. 골다공증과심혈관계질환의효과적인예방및조절을위해서는식생활관리가매우중요하다. 복합질환의예방관리를위해서는생화학적요인및식이요인에따른복합질환의특성을분석하고고위험군에있는있는대상자에게적절한식이가이드라인을제시하는것이중요하다. 이에따라본연구는한국인의전반적인건강및영양상태를반영한제5기 (2010, 2011년 ) 국민건강영양조사자료를이용하여폐경후여성에서골다공증과심혈관계질환의유무에따라신체및생화학적수준을파악하고, 군간식품및영양소섭취량과식사의질을평가하고자하였다. 이연구를통해폐경후

154 김효빈 김혜숙 권오란 박희정 여성에서함께발생하는골다공증및심혈관계질환의효과적인예방및관리를위한식생활지침을계발하는데기초자료를제시하고나아가폐경후여성의삶의질향상과건강증진에기여하고자한다. 연구대상및방법 1. 연구대상 본연구의대상자는제 5기 1차년도 (2010) 와 2차년도 (2011) 국민건강영양조사 (Korean National Health And Nutrition Examination Survey, KNHANES) 의응답자 17,476명중에서설문조사, 검진조사, 영양조사에참여하고, 45세이상폐경후여성대상자이면서열량섭취가 500~5,000 kcal 인총 1,131명을선정하여분석을실시하였다. 연구대상자를골다공증유병유무와심혈관계질환위험도에따라대조군 (Control, n=405), 골다공증군 (OP, n=135), 심혈관계질환군 (CVD, n=373), 복합질환군 (OP+CVD, n=218) 으로구분하여식사의질을평가하였다. 대조군은골다공증이없고심혈관계질환위험도가낮은집단, 골다공증군은골다공증이있고심혈관계질환위험도가낮은집단, 심혈관계질환군은골다공증이없고심혈관계질환위험도가높은집단, 그리고복합질환군은골다공증이있고심혈관계질환위험도가높은집단으로분류하였다. 2. 연구내용 1) 골다공증분류기준 골밀도는대상자의요추 (Lumbar spine, L1-L4), 대퇴골 (Femoral total), 대퇴골경부 (Femoral neck) 부위를이중에너지방사선흡수법 (Dual Energy X-ray Absorptiometry, DXA) 을이용한 X선측정기 (DISCOVERY-W fan-beam densitometer, Hologic INC., Bedford, MA, USA) 를사용하여골밀도를측정하였다. 골절위험도를알아보기위한세계보건기구 (WHO) 의기준에따라 T- score -1.1 미만은정상, -1.1~-2.4는골감소증, -2.5 이하는골다공증으로분류된다. 그러나본연구에서는총대상자를이분법적으로나누기위해골다공증이없는군 (Tscore -2.5 미만 ) 과골다공증이있는군 (T-score -2.5 이상 ) 으로분류하였다. 2) 심혈관계질환위험도분류기준심혈관계질환위험도는심혈관계질환의위험요인과 10년후에심혈관계질환이발생할위험도를측정함으로써산출하였다. 심혈관계질환의위험요인은 2008년미국심장협회에서제시한심혈관계질환위험도계산기준 [22] 에따라연령, 총콜레스테롤, 고밀도지단백, 수축기혈압, 흡연, 당뇨병유무등의지표를이용하여산정하였다. 여성의 10년후심혈관계질환의발생위험도점수는알고리즘을근거로지표의각항목의가중치를부여하여계산한후총점수에따라 10년이후에심혈관계질환이발병할위험도를확률 (%) 로도출하였다. Framingham 평가기준에따라 10년후심혈관계질환발생위험도 10% 미만은저위험군, 10-20% 는중정도위험군, 20% 이상은고위험군으로분류되지만, 본연구에서는 Oguoma 등 [23] 의분류기준을참조하여심혈관계질환위험이낮은군 (10% 미만 ) 과심혈관계질환위험이높은군 (10% 이상 ) 으로분류하였다. 3) 신체계측및혈액검사조사대상자의신체계측수치는국민건강영양조사의검진조사를통해수집된자료를이용하였으며, 신장, 체중, 허리둘레를조사하고신장과체중수치를이용하여체질량지수 (body mass index, BMI) 를산출하였다. 총체지방량 (%) 및총근육량 (kg) 수치를이용하였다. 수축기혈압 (systolic blood pressure, SBP) 및이완기혈압 (diastolic blood pressure, DBP) 은검진조사자료의최종혈압수치를이용하였다. 총콜레스테롤 (total cholesterol, TC), 중성지방 (triglyceride, TG), HDL- 콜레스테롤 (high density lipoprotein cholesterol, HDL-C), LDL-콜레스테롤 (low denstity lipoprotein Table 1. Group classification by OP and CVD risk criteria Osteoporosis (T-score) Cardiovascular disease (risk) Normal & Osteopenia (T-score < 2.5) Low risk (Risk < 10%) Osteoporosis (T-score 2.5) Low risk (Risk < 10%) Normal & Osteopenia (T-score < 2.5 ) High risk (Risk 10%) Osteoporosis (T-score 2.5) High risk (Risk 10% )

폐경후여성의골다공증및심혈관계질환위험에따른식품및영양섭취상태 155 cholesterol, LDL-C) 은효소법 (Hitachi Automatic Analyzer 7600, Hitachi, Japan) 을이용하여측정한수치이며, 비타민D와부갑상선호르몬은각각 Radioimmunoassay(1470 WIZARD gamma-counter, Perkin- Elmer, Finland), Chemiluminescence Immunoassay (LIAISON, Diasorin, U.S.A) 을이용하여분석한값을사용하였다. 4) 식이섭취조사및식품섭취량평가골다공증유병유무와심혈관계질환위험도에따른대상자들의집단사이에식품섭취빈도차이를비교하기위해서에너지와영양소의주요급원식품으로이루어진식품섭취빈도조사표를이용하여식품군에따른섭취빈도를조사하였다. 식품군은기존의 15개의식품군 ( 곡류, 서류, 두류, 육류 & 난류, 생선류, 채소류, 해조류, 과일류, 유제품류, 음료류, 주류, 패스트푸드 ) 과잡곡을제외한곡류, 잡곡, 적색육류와가공육류, 탄산음료를추가하여분석하였다. 섭취빈도는거의안먹음, 1년에 6-11회, 한달 1회, 한달 2-3회, 1주 1회, 1주 2-3회, 1주 4-6회, 하루 1회, 하루 2회, 하루 3 회로되어있는것을주당환산계수를곱하여산출하였다. 식품섭취량은 24시간회상법을이용하여 1일평균영양소섭취량을산출하였고총열량중탄수화물, 단백질, 지방의섭취비율을평가하기위해열량구성비 (Carbohydrate Protein Fat ratio, CPF ratio) 를계산하였다. 5) 식사의질평가한국인영양소섭취기준 (The Korean Nutrition Society 2015) 중권장섭취량이제시되어있는 9개의영양소를대상으로영양소섭취적절도를평가하였다. 영양소적정섭취비 (Nutrient Adequacy Ratio, NAR) 와평균영양소적정섭취비 (Mean Adequacy Ratio, MAR), 영양밀도 (Nutrient Density, ND) 와영양질적지수 (Index of Nutritional Quality, INQ) 를이용하여전체적인식사의질을평가하였다. NAR = 특정영양소섭취량 / 특정영양소권장섭취량 MAR = N개의영양소에대한 NAR의합 / N개의영양소 ND = 식사 1,000kcal당특정영양소섭취량 INQ = 식사 1,000kcal당특정영양소섭취량 / 1,000 kcal당특정영양소권장섭취량 Table 2. Anthropometric characteristics of the subjects Variables Total (N=1,131) Age (yr)*** 57.70 ± 0.38 62.16 ± 0.84 66.07 ± 0.52 70.95 ± 0.72 64.22 ± 0.35 Waist circumference (cm) 80.7 ± 0.55 6) 78.06 ± 0.97 87.75 ± 0.53 82.93 ± 0.74 82.36 ± 0.37 <0.001 Body mass index (kg/cm 2 ) 23.57 ± 0.20 22.84 ± 0.30 26.06 ± 0.21 24.05 ± 0.31 24.13 ± 0.12 <0.001 Total body fat (%) 35.10 ± 0.42 34.65 ± 0.63 38.72 ± 0.35 36.47 ± 0.57 36.23 ± 0.31 <0.001 Total body muscle mass (kg) 32.77 ± 0.22 31.57 ± 0.33 34.58 ± 0.30 32.18 ± 0.39 32.78 ± 0.17 <0.001 Systolic blood pressure (mmhg) 118.41 ± 0.93 118.81 ± 1.35 140.03 ± 1.14 139.76 ± 1.34 129.25 ± 0.65 <0.001 Diastolic blood pressure (mmhg) 72.90 ± 0.64 73.84 ± 0.88 82.20 ± 0.72 82.11 ± 0.72 77.76 ± 0.37 <0.001 Fasting plasma glucose (mg/dl) 96.74 ± 1.29 94.98 ± 0.97 105.42 ± 1.55 106.46 ± 2.68 100.90 ± 0.83 <0.001 Total cholesterol (mg/dl) 197.43 ± 2.33 196.32 ± 3.22 206.90 ± 2.46 215.25 ± 3.10 203.97 ± 1.53 <0.001 Triglyceride (mg/dl) 119.08 ± 6.13 129.33 ± 7.79 161.95 ± 6.26 162.56 ± 7.48 143.23 ± 3.30 <0.001 HDL-cholesterol (mg/dl) 56.36 ± 0.84 53.90 ± 1.03 49.62 ± 0.95 48.85 ± 1.01 52.18 ± 0.45 <0.001 LDL-cholesterol (mg/dl) 117.26 ± 2.32 116.55 ± 2.65 124.89 ± 2.22 133.89 ± 2.52 123.15 ± 1.21 <0.001 Vitamin D (ng/ml) 18.31 ± 0.56 17.77 ± 0.65 17.50 ± 0.54 17.27 ± 0.84 17.71 ± 0.38 0.334 Parathyroid hormone (pg/ml) 66.40 ± 2.02 78.73 ± 4.67 69.80 ± 1.94 69.32 ± 2.21 71.06 ± 1.55 0.047 Total femur BMD (g/cm 2 ) 0.79 ± 0.01 0.70 ± 0.01 0.78 ± 0.01 0.72 ± 0.01 0.75 ± 0.00 <0.001 Femur neck BMD (g/cm 2 ) 0.64 ± 0.01 0.56 ± 0.01 0.64 ± 0.01 0.58 ± 0.01 0.61 ± 0.00 <0.001 Lumbar spine BMD (g/cm 2 ) 0.86 ± 0.01 0.65 ± 0.01 0.85 ± 0.01 0.67 ± 0.01 0.76 ± 0.00 <0.001 ***: Significantly different among the groups at p<0.001 P 5)

156 김효빈 김혜숙 권오란 박희정 3. 자료분석및통계처리 본연구에서수집된자료는 SPSS 19.0 통계프로그램 (SPSS Inc., Chicago, IL, USA) 을이용하여분석하였고, p<0.05 수준에서통계적유의성을검증하였다. 복합표본추출디자인을고려하여층화, 추출단위, 가중치를적용한복합표본분석방법을사용하였다. 각군간차이분석은군간유의한차이가나타난연령변수를보정한모델을사용하여복합표본일반선형모형분석 (General linear model: GLM) 을이용하였다. 결 1. 골다공증유병유무및심혈관계질환위험도에따른일반적인특성 폐경후여성의골다공증유무및심혈관계질환위험도에따른평균연령및생화학적요인에대한결과는 <Table 2> 에제시하였다. 연구대상자의평균연령은대조군이 57.7 세, 복합질환군이 70.95 세로유의적인차이 (p<0.001) 가 과 있었으므로, 신체및혈액수준은연령을보정한후결과값을제시하였다. 신체계측및혈액수치분석결과, 심혈관계질환군에서는허리둘레 (p<0.05), BMI(p<0.001), 체지방량 (p<0.001), 근육량 (p<0.001) 이가장높았다. 심혈관계질환군과복합질환군에서는수축기혈압 (p<0.001), 이완기혈압 (p<0.001), 공복혈당 (p<0.001), 중성지방 (p<0.001) 이가장높았으며, 골다공증군과복합질환군에서대퇴골골밀도 (p<0.001), 대퇴골경부골밀도 (p<0.001), 요추골밀도 (p<0.001) 가낮게나타났다. 복합질환군에서는총콜레스테롤 (p<0.001), LDL- 콜레스테롤 (p<0.001) 은유의적으로높게나타났고, HDL-콜레스테롤 (p<0.001) 은유의적으로낮게나타났다. 2. 골다공증유병유무및심혈관계질환위험도에따른영양소섭취상태폐경후여성의골다공증유무및심혈관계질환위험도에따른영양소섭취상태는 <Table 3> 과같다. 대조군은다른질환군에비해총열량중탄수화물의섭취비율 (p<0.05) Table 3. Daily nutrient intakes of the subjects Variables Total (N=1,131) Energy (kcal) 1,566.94 ± 839.98 6) 1,685.83 ± 898.21 1,559.16 ± 838.63 1,658.96 ± 848.62 1,617.72 ±8 36.11 0.230 Carbohydrate (g) 290.86 ± 882.83 307.10 ± 887.10 301.87 ± 882.64 300.64 ± 883.89 300.12 ± 882.56 0.111 Protein (g) 55.50 ± 880.95 50.37 ± 882.13 50.62 ± 880.74 50.72 ± 881.38 51.80 ± 880.76 0.090 Fat (g) 24.62 ± 880.79 21.41 ± 881.55 21.93 ± 880.74 22.38 ± 881.03 22.58 ± 880.59 0.259 Carbohydrate (%) 73.60 ± 880.66 76.52 ± 881.05 76.10 ± 880.62 75.92 ± 880.86 75.54 ± 880.47 0.027 Protein (%) 13.72 ± 880.24 12.85 ± 880.38 12.56 ± 880.18 12.69 ± 880.29 12.96 ± 880.15 0.001 Fat (%) 13.31 ± 880.44 12.00 ± 880.68 11.97 ± 880.42* 12.03 ± 880.56 12.33 ± 880.29 0.128 C:P:F ratio 74:14:13 77:13:12 76:13:12 76:13:12 76:13:12 Fiber (g) 6.96 ± 880.26 7.57 ± 880.56 6.87 ± 880.27 6.98 ± 880.33 7.10 ± 880.20 0.425 Vitamin A (μgre) 749.54 ± 882.00 691.00 ± 890.00 621.11 ± 841.82 636.58 ± 858.38 674.56 ± 837.42 0.255 Carotene (μg) 4,037.63 ± 487.48 3,639.96 ± 462.05 3,372.95 ± 246.50 3,367.60 ± 350.47 3,604.53 ± 213.12 0.434 Retinol (μg) 66.41 ± 887.39 85.16 ± 835.03 54.60 ± 886.43 40.34 ± 886.07 61.63 ± 889.64 0.005 Vitamin B 1 (mg) 1.01 ± 880.02 1.02 ± 880.04 0.99 ± 880.02 1.01 ± 880.03 1.00 ± 8v0.02 0.307 Vitamin B 2 (mg) 0.98 ± 880.02 0.86 ±88 0.05 0.85 ± 880.02 0.83 ± 880.04 0.88 ± 880.02 0.017 Niacin (mg) 13.20 ± 880.25 12.24 ± 880.26 12.59 ± 880.22 11.95 ± 880.26 12.49 ± 880.19 0.652 Vitamin C (mg) 99.08 ± 884.70 92.56 ± 887.66 92.77 ± 885.19 93.39 ± 886.57 94.45 ± 883.31 0.776 K (mg) 2,628.78 ± 856.29 2,580.14 ± 110.28 2,479.51 ± 854.54 2,505.01 ± 103.24 2,548.36 ±8 44.24 0.308 Ca (mg) 476.18 ±8 19.27 404.38 ± 825.22 422.89 ± 818.85 400.95 ± 823.12 426.10 ± 889.99 0.371 P (mg) 996.30 ± 815.39 947.45 ± 827.36 930.39 ± 812.57 930.44 ± 816.65 951.14 ± 889.12 0.149 Fe (mg) 12.95 ± 880.46 13.68 ± 880.86 14.19 ± 881.11 14.47 ± 881.72 13.82 ± 880.54 0.400 Na (mg) 3,923.66 ± 153.59 4,085.60 ± 280.37 3,568.66 ± 133.95 4,161.56 ± 189.47 3,934.87 ± 894.60 0.004 P 5)

폐경후여성의골다공증및심혈관계질환위험에따른식품및영양섭취상태 157 이유의적으로낮았으며, 총열량중단백질의섭취비율 (p<0.01) 과비타민 B 2 (p<0.05) 섭취량이유의적으로높았다. 심혈관계질환군에서는나트륨의섭취량이가장낮았으며 (p<0.01) 복합질환군에서단백질섭취비율과레티놀 (p<0.01), 비타민 B 2 (p<0.05) 섭취량이가장낮았으며, 나트륨의섭취량은가장높았다 (p<0.01). 3. 골다공증유병유무및심혈관계질환위험도에따른식품섭취빈도폐경후여성의골다공증유무및심혈관계질환위험도에따른식품섭취빈도결과는 <Table 4> 에제시하였다. 식품섭취빈도조사결과에서대조군은유제품 (p<0.05) 의섭취량과과일류 (p<0.01) 의섭취량이가장높았으며, 골다공증군은적색육류와가공육섭취빈도와채소섭취빈도, 유제품섭취빈도, 탄산음료섭취빈도가모두가장낮았다. 복합질환군은잡곡을제외한곡류 (p<0.01) 와채소류 (p<0.05) 의섭취빈도가유의적으로높았으며, 적색육류와가공육섭취의경우복합질환군에서섭취빈도가높았다 (p<0.05). 반면, 복합질환군에서의과일류 (p<0.01) 와유제품류 (p<0.05) 의섭취빈도가가장낮게나타났으며, 탄산음료 (p<0.05) 의섭취빈도는유의적으로높게나타났다. 4. 골다공증유병유무및심혈관계질환위험도에따른식사의질평가폐경후여성의영양소섭취정도를평가하기위해영양소적정섭취비 (NAR), 평균영양소적정섭취비 (MAR), 영양밀도 (ND), 영양의질적지수 (INQ) 에대한분석을실시하였다. 영양소적정섭취정도는군별평균값의유의적인차이는없지만, 인과철분을제외한대부분의영양소들의섭취량이권장섭취량보다매우부족한것으로나타났다 (Table 5). 또한평균영양소적정비도 0.74~0.76 수준으로나타났다. 영양밀도 (ND) 에서는질환군이대조군에비해단백질 (p<0.05), 비타민 B 2 (p<0.05), 나이아신 (p<0.05), 인 (p<0.05) 의수치가유의적으로낮게나타났다 (Table 6). 단백질의경우대조군 34.31g, 골다공증군 32.12g, 복합질환군 31.73g, 심혈관계질환군 31.40g 의순으로유의적으로낮았다. 비타민 B 2 의영양소밀도는대조군, 골다공증군, 심혈관계질환군, 복합질환군의순서로낮게나타났다. 영양질적지수 (INQ) 에서는폐경후여성의모든군에서단백질, 비타민 A, 인, 철의 INQ 값이 1보다크게나타나관련영양소섭취상태가양호하였다. 그러나칼슘의경우각군이 0.63, 0.58, 0.56, 0.55의순으로나타나폐경후여 Table 4. Consumption frequencies of foods of the subjects Variables Total P 5) Grain (n=1,127) 34.13 ± 0.67 6) 35.11 ± 1.15 34.76 ± 0.62 33.97 ± 0.78 34.49 ± 0.44 0.713 Grain(except for multigrain) (n=1,128) 20.98 ± 0.28 21.84 ± 0.47 21.06 ± 0.24 21.91 ± 0.27 21.45 ± 0.18 0.001 Multigrain (n=1,129) 13.12 ± 0.53 13.26 ± 0.90 13.71 ± 0.62 12.10 ± 0.73 13.05 ± 0.38 0.340 Potatoes (n=1,131) 1.28 ± 0.09 1.28 ± 0.13 1.35 ± 0.08 1.57 ± 0.18 1.37 ± 0.06 0.518 Bean (1,130) 11.48 ± 0.51 11.26 ± 0.95 11.54 ± 0.62 11.32 ± 0.89 11.4 ± 0.36 0.996 Meat (n=1,131) 3.50 ± 0.19 3.07 ± 0.36 3.14 ± 0.20 3.79 ± 0.25 3.37 ± 0.12 0.090 Red and processed meat (n=1,131) 1.36 ± 0.09 1.19 ± 0.15 1.19 ± 0.87 1.61 ± 0.14 1.34 ± 0.06 0.032 Fish (n=1,131) 5.99 ± 0.35 4.91 ± 0.51 5.45 ± 0.34 5.96 ± 0.35 5.58 ± 0.20 0.128 Vegetable (n=1,128) 29.01 ± 0.99 27.55 ± 1.20 29.27 ± 0.98 32.59 ± 1.38 29.60 ± 0.60 0.033 Seaweed (n=1,131) 3.82 ± 0.24 2.96 ± 0.26 3.66 ± 0.23 3.65 ± 0.31 3.52 ± 0.12 0.091 Fruit (n=1,131) 7.92 ± 0.37 6.44 ± 0.53 6.30 ± 0.33 6.31 ± 0.47 6.74 ± 0.25 0.006 Dairy product (n=1,130) 3.45 ± 0.26 2.28 ± 0.33 2.88 ± 0.22 2.28 ± 0.27 2.72 ± 0.13 0.028 Drink (n=1,130) 8.92 ± 0.52 8.33 ± 0.71 8.69 ± 0.53 10.29 ± 0.68 9.06 ± 0.31 0.150 Soft drink (n=1,131) 0.27 ± 0.05 0.14 ± 0.04 0.41 ± 0.10 0.37 ± 0.10 0.30 ± 0.03 0.027 Alcohol (n=1,130) 0.63 ± 0.12 0.36 ± 0.09 0.47 ± 0.09 0.59 ± 0.13 0.51 ± 0.06 0.266 Fast food (n=1,131) 0.28 ± 0.03 0.24 ± 0.05 0.25 ± 0.04 0.30 ± 0.04 0.27 ± 0.02 0.568

158 김효빈 김혜숙 권오란 박희정 Table 5. Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) of the subjects NAR&MAR Total (N=1,131) Protein 0.87 ± 0.01 6) 0.85 ± 0.01 0.85 ± 0.01 0.85 ± 0.01 0.86 ± 0.01 0.473 Vitamin A 0.70 ± 0.02 0.67 ± 0.04 0.69 ± 0.02 0.70 ± 0.03 0.69 ± 0.01 0.922 VitaminB 1 0.76 ± 0.01 0.73 ± 0.02 0.75 ± 0.01 0.78 ± 0.01 0.76 ± 0.01 0.126 VitaminB 2 0.67 ± 0.01 0.62 ± 0.02 0.64 ± 0.01 0.63 ± 0.02 0.64 ± 0.01 0.673 Niacin 0.78 ± 0.01 0.73 ± 0.02 0.77 ± 0.01 0.76 ± 0.01 0.76 ± 0.01 0.920 Vitamin C 0.68 ± 0.02 0.69 ± 0.03 0.64 ± 0.02 0.67 ± 0.03 0.67 ± 0.01 0.190 Ca 0.52 ± 0.01 0.49 ± 0.02 0.48 ± 0.01 0.48 ± 0.02 0.49 ± 0.01 0.312 P 0.95 ± 0.01 0.93 ± 0.02 0.93 ± 0.01 0.94 ± 0.01 0.93 ± 0.01 0.620 Fe 0.91 ± 0.01 0.88 ± 0.02 0.89 ± 0.01 0.89 ± 0.02 0.89 ± 0.01 0.457 MAR 0.76 ± 0.01 0.73 ± 0.02 0.74 ± 0.01 0.74 ± 0.01 0.74 ± 0.01 0.552 P 5) Table 6. Nutrient Density (ND) of the subjects ND Total (N=1,131) Protein 34.31 ± 80.59 6) 32.12 ± 80.95 31.40 ± 80.49 31.73 ±8 0.73 32.40 ± 80.38 0.001 Vitamin A 447.55 ± 45.37 431.63 ± 45.28 365.33 ± 24.10 394.27 ± 38.26 409.70 ± 17.86 0.304 VitaminB 1 0.63 ± 80.01 0.63 ±8 0.02 0.61 ±8 0.01 0.63 ± 80.02 0.62 ± 80.01 0.504 VitaminB 2 0.59 ± 80.01 0.54 ±8 0.03 0.53 ±8 0.02 0.52 ± 80.02 0.54 ± 80.01 0.018 Niacin 8.17 ± 80.16 7.58 ± 80.28 7.83 ±8 0.14 7.52 ± 80.15 7.78 ± 80.10 0.046 Vitamin C 60.08 ± 82.61 58.89 ± 83.76 55.49 ± 82.97 59.71 ± 84.15 58.54 ± 81.77 0.651 Ca 293.86 ± 11.98 266.56 ± 16.23 259.72 ± 11.67 255.89 ± 15.40 269.01 ± 86.38 0.198 P 621.08 ± 89.00 601.43 ± 15.91 582.29 ± 88.00 585.26 ± 10.58 597.52 ± 85.69 0.028 Fe 8.04 ± 80.29 8.62 ± 80.55 8.92 ± 80.88 8.99 ± 81.09 8.65 ± 80.36 0.512 P 5) Table 7. Index of Nutritional Quality(INQ) of the subjects ND Total (N=1,131) Protein 1.23 ± 0.02 6) 1.15 ± 0.03 1.13 ± 0.02 1.14 ± 0.03 1.16 ± 0.01 0.001 Vitamin A 1.33 ± 0.13 1.28 ± 0.13 1.09 ± 0.07 1.17 ± 0.11 1.21 ± 0.05 0.317 VitaminB 1 0.99 ± 0.02 0.98 ± 0.04 0.95 ± 0.02 0.98 ± 0.03 0.98 ± 0.01 0.581 VitaminB 2 0.86 ± 0.02 0.77 ± 0.04 0.76 ± 0.02 0.75 ± 0.03 0.79 ± 0.01 0.013 Niacin 1.01 ± 0.02 0.94 ± 0.04 0.97 ± 0.02 0.93 ± 0.02 0.96 ± 0.01 0.035 Vitamin C 1.05 ± 0.04 1.02 ± 0.07 0.96 ± 0.05 1.03 ± 0.07 1.01 ± 0.03 0.656 Ca 0.63 ± 0.03 0.58 ± 0.03 0.56 ± 0.03 0.55 ± 0.03 0.58 ± 0.01 0.215 P 1.53 ± 0.02 1.48 ± 0.04 1.44 ± 0.02 1.44 ± 0.03 1.47 ± 0.01 0.032 Fe 1.76 ± 0.07 1.86 ± 0.13 1.92 ± 0.18 1.95 ± 0.25 1.87 ± 0.08 0.721 P 5)

폐경후여성의골다공증및심혈관계질환위험에따른식품및영양섭취상태 159 성에서칼슘섭취에대한식생활개선이시급한것으로나타났다. 더불어비타민 B 2 의경우에도전체군에서부적절하게섭취하고있는것으로나타났고, 대조군에비해질환군에서더욱불량한것으로나타났다. 고 우리나라의중년여성의비율이증가함에따라폐경기여성의건강관리가중요시되고있다. 특히폐경후여성에게서골다공증과심혈관계질환이동반되어나타나는현상이보고되고있으며 [8-14], 이들두만성질환은식생활과밀접한관련이있기때문에폐경기여성의건강한삶의질유지에올바른식사관리는반드시필요한요건이다. 본연구는 2010-2011년도국민건강영양조사자료를이용하여폐경후여성을대상으로골다공증및심혈관계질환위험도에따른군간의신체계측요인, 혈액학적요인, 식품및영양소섭취량, 식사의질에대한군별특성을도출하고, 복합질환예방을위한식이가이드라인의기초자료로활용하고자한다. 본연구에서는복합질환군의평균연령이대조군에비해서유의적으로높았으며, 이러한결과는기존연구에서골다공증과심혈관계질환모두고령인구에서발생하고이러한질병의유병률증가는노화와관련이있다는연구결과 [24-26] 와일관되는결과이다. 신체계측과혈액수준분석결과, 심혈관계질환군에서는허리둘레, BMI, 체지방등의수준이높았으며, 복합질환군에서는골밀도가저하되고, 체지방률이높은신체계측상의특징을가지고있었다. 폐경후여성에게서심혈관계질환위험도를감소시키기위해비만관리가요구되지만 [5] 체중감량이골다공증의위험요인으로작용하여체중감량에주의를요한다. 그러나본연구에서복합질환군의경우대조군에비해허리둘레가유의적으로높았고, 복부비만이골밀도를감소시켜골다공증을야기한다는연구결과 [27] 가있으므로복합질환군에게서복부비만을개선시키기위한관리가필요하다고할수있다. 체중을싣는유산소운동은뼈의조골작용을돕고제지방이골밀도에긍정적인영향을미쳐골다공증은물론복부비만을개선시켜심혈관계질환위험도를줄일수있으므로 [6, 28] 폐경후여성들중복합질환군에게는체중부하운동의종류를안내하고규칙적인실천이권장된다. 식품섭취빈도결과, 복합질환군은다른군에비해잡곡을제외한곡류 ( 쌀, 라면, 국수, 빵류, 떡류, 과자류 ) 와채소류, 적색육류및가공육류, 탄산음료의섭취는많은경향이있었다. 그에반해과일류, 유제품의섭취횟수는낮았다. 복합질환군에서빈번하게섭취했던당함유음료, 정제된곡류, 가 찰 공육은다양한염증지표와산화적스트레스, 이상지질혈증, 복부비만, 골다공증, 당뇨등의만성질환과도연관이있다는것은이미널리알려져있다 [5, 10, 18, 24, 29]. 또한정제된곡류와가공육위주의섭취패턴은높은총콜레스테롤, LDL 콜레스테롤을증가시키고채소와과일, 생선위주의식사패턴은 HDL 콜레스테롤을증가시킨다는연구결과 [30] 과과일및유제품을충분하게섭취하고흰빵, 가공육, 마가린, 탄산음료는적게섭취하는식사패턴은복부지방증가를예방하는데도움이된다는연구결과 [31] 를통해본연구중복합질환군의식품섭취빈도에서드러나는식이섭취특징인정제된곡류와가공육섭취빈도가높은것은두질환의공통요인인이상지질혈증및복부비만과도관련이있다고할수있다. 심혈관계질환예방을위한가장대표적인식사패턴인지중해식식사패턴은섬유소, 생선, 채소및과일을충분히섭취하고, 적색육류, 가공육류, 주류, 가공식품의섭취를줄이는것을그특징으로하며, 대표적인염증지표인혈청반응성단백질 (C-reactive protein, CRP) 과인터루킨 -6를저하시켜염증을억제하는데가장효과적인식사모델로알려져있다 [32]. 또한혈청 CRP 수치가높은경우골다공증발생위험이 1.54 배더높다는연구결과 [33] 를종합적으로볼때, 골다공증과심혈관계질환에대한위험을복합적으로가지고있는폐경기여성에게충분한잡곡, 채소류, 과일, 유제품, 생선을섭취하고적색육류및가공육, 탄산음료의섭취는줄이는식사패턴을실천하도록하는것이중요하다고사료된다. 본연구에서각군간주요영양소섭취를살펴본결과, 복합질환군에서는총열량중탄수화물의섭취비율이높고, 총열량중단백질섭취비율이낮게나타나, 상대적으로탄수화물위주의식사로주로구성된식이패턴을가졌다고할수있다. Kim 등 [34] 은 40-64세까지의여성의탄수화물섭취량은총섭취열량및 BMI를보정한후에도허리둘레와유의적인상관관계가있었으며, 여성의경우, 총열량섭취량에대한탄수화물섭취가 75.7% 를초과할때당뇨및내당능장애, 당뇨병의발생할위험이유의성있게증가한다고보고하였기때문에폐경기여성에서두질환의예방및관리를위해적정량의단백질과질좋은종류의지방섭취를통해탄수화물을과잉섭취하지않도록주의가필요하다. 또한미량영양소섭취결과, 복합질환군은레티놀, 비타민 B 2, 나이아신, 인의섭취량이가장낮았고, 나트륨의섭취량은가장높았다. 레티놀, 비타민 B 2 와나이아신의섭취부족은이들영양소의주요급원식품인단백질식품과유제품섭취부족으로인한결과로사료된다. 나트륨섭취량은나트륨섭취가증가할수록소변을통한칼슘배설이증가 [35] 하고또한

160 김효빈 김혜숙 권오란 박희정 나트륨의과잉섭취는고혈압을초래하여심혈관계질환위험률을증가 [7] 시키는것으로보고되어있다. 본연구중복합질환군에서나트륨섭취가가장높은것으로나타났으므로, 폐경기여성중복합질환군에서나트륨섭취에매우주의를기울여야할것으로사료된다. 영양소섭취에서일부 3대영양소와미량영양소의부적절한섭취현상이관찰되어균형된영양소섭취를평가할수있는 NAR과 MAR을통해대상자의식사의질을분석하였지만각군간의 NAR과 MAR의유의적인차이는없었다. 열량 1,000 kcal 당각영양소섭취량을나타내어식사의질을나타내는영양밀도 (ND) 와영양질적지수 (INQ) 를분석한결과, 복합질환군의단백질, 비타민B 2, 나이아신, 인의영양밀도와영양질적지수가유의적으로낮게나타났다. 따라서폐경후뼈건강과심혈관건강을위해비타민B 2, 나이아신의급원식품을식사에보충하여섭취하는것이바람직하다. 더불어, 칼슘의 INQ 값은 0.55~0.68 수준을값을나타내어우리나라폐경기여성의칼슘의영양질적지수가매우낮아폐경후여성에서칼슘섭취에대한식생활교육이시급한것으로나타났다. 칼슘섭취량의경우골다공증과도역의상관관계가있지만, 칼슘섭취량이낮을경우심혈관계질환의위험도가증가한다는 Kong 등 [36] 의보고가있으므로폐경기여성에서복합질환예방을위해칼슘섭취의강조가매우필요하다. 본연구는단면연구인국민건강영양조사자료를이용하였으므로골다공증및심혈관계질환과본연구에서나타난관련요인사이의인과관계를주장하기에는일차적인한계가있고, 대상자들이심혈관계질환및골다공증외에서다른질환이식생활에영향을미쳤을가능성을배제할수없으므로본연구에서나타난모든식생활요인이질환과관련성이있다고결론짓기에는부족함이있을수있다. 또한국민건강영양조사자료에제공되지않는두질환과관련이있는지표와영양소의섭취에대해서는평가가불가능하였으며, 식품이나식품군섭취를기초로한식사의질평가가이루어지지않았다는점등은본연구의제한점이라할수있다. 그러나, 본연구는폐경기여성에서골다공증과심혈관계질환이동반되어나타난다는특징을고려하여군을분류하고군에따른영양소및식품섭취상태를평가하고복합질환예방을위한식이가이드라인의기초자료로활용할수있는것에의미가있을것으로판단된다. 향후후속연구에서는폐경후골다공증및심혈관계질환의발병률을증가시키는식생활위험요인과두질환의영향을미치는식사패턴에대한전향적연구가필요할것으로사료된다. 요약및결론 본연구는폐경후여성중골다공증과심혈관계질환위험도가높은복합질환자의식품및영양소섭취상태를조사하기위해수행되었다. 이를위해제5기국민건강영양조사자료를이용하여폐경후여성을골다공증유병유무와심혈관계질환위험도에따라대조군, 골다공증군 (OP 군 ), 심혈관계질환군 (CVD군), 골다공증 + 심혈관계질환군 ( 복합질환군 ) 으로분류하였으며, 각군별신체및혈액학적특성을파악하고, 식품섭취상태와식사의질을비교분석하였다. 1) 전체대상자 1,131명중대조군은 405 명 (35.8%), 골다공증유병자인 OP군은 135 명 (11.9%), 심혈관계질환위험도가높은 CVD 군은 373 명 (33%), 복합질환군은 218 명 (19.3% 으로조사되었다. 2) 복합질환군은골밀도가가장낮았으며, 허리둘레와체지방량이높았다. 혈압및중성지방, 공복시혈당, LDLcholesterol 은높았으며, HDL-cholesterol 은낮았다. 3) 복합질환군에서는총열량중탄수화물섭취비율이높고, 단백질섭취비율이낮았다. 채소류섭취는많았으나, 잡곡류를제외한곡류의섭취빈도가높았고, 과일류와유제품류의섭취는적었다. 더불어적색육및가공육과탄산음료의섭취빈도가높았다. 4) 모든폐경기여성에서인과철을제외한대부분의영양소들의섭취량이권장섭취량보다부족한것으로나타났다. 특히칼슘과비타민 B 2 의섭취가부족한것으로나타났다. 복합질환군에서는대조군보다비타민B 2, 나이아신이부족해서복합질환군의식사의질이대조군에비하여좋지않음을알수있었다. 영양밀도분석시단백질의경우대조군에비해질환군에서모두유의적으로낮았으며, 비타민 B 2 의경우에도대조군에비해질환군의수준이낮았다. 5) 영양질적지수 (INQ) 에서는폐경후여성의모든군에서단백질, 비타민 A, 인, 철의 INQ 값이 1보다크게나타나관련영양소섭취상태가양호하였다. 그러나칼슘의경우각군이 0.63, 0.58, 0.56, 0.55의순으로나타나폐경후여성에서칼슘섭취에대한식생활개선이시급한것으로나타났다. 더불어비타민 B 2 의경우에도전체군에서부적절하게섭취하고있는것으로나타났다. 이상으로보아폐경후여성에게빈번하게발생하는만성질환인골다공증과심혈관계질환이복합적으로동반될경우폐경후여성들에게복부지방개선과골밀도증진을위해체중부하운동의종류를안내하고규칙적인실천이권장된다. 영양관리를위해서는잡곡류에대한비중을높여비타민

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