대한한방소아과학회지제 30 권제 3 호 (2016 년 8 월 ) J Pediatr Korean Med. August, 2016;30(3):108-120 ISSN 1226-8038(Print), 2287-9463(Online), http://dx.doi.org/10.7778/jpkm.2016.30.3.108 소아비만의치료에대한국내임상연구동향 김경리 한재경 김윤희 대전대학교한의과대학소아과학교실 Abstract Review of Korean Clinical Studies on Treatment for Childhood Obesity Kim Kyoung Ri Han Jae Kyoung Kim Yun Hee Department of Pediatrics, College of Korean Medicine, Daejeon University Objectives The purpose of this study is to investigate Korean clinical studies on treatment of childhood obesity and to propose for better treatment options for childhood obesity. Methods Based on RISS, KISS, OASIS, KMbase with the keyword childhood obesity, child obesity, obese child, overweight child, total of 21 randomized controlled trials (RCTs), 11 single clinical studies, 3 chart reviews and 3 case reports have been found, and were analyzed. Results and Conclusion 1. Some study subjects were classified based on their sex - only men or women in a group or sometimes both. Another way of classify the study subjects were based on their age - preschooler, primary school students, middle school students, and high school students. The diagnostic criteria of the subjects were BMI (body mass index), Body fat percentage, Obesity index, Weight and unknown criteria. 2. The treatments used in 38 studies were exercise alone, education alone, both exercise and education or herbal therapy. The 7 studies that used herbal therapy as part of their study intervention had a study group with herbal intervention only and the other 2 study group with herbal treatment in addition to exercise and education. 3. 9 studies included herb medicines, electroacupuncture, auricular acupuncture, cupping, aroma massage, infrared light, and abdomen pad. Herb medications used in 5 studies included Chegameuiin-tang 2 kinds, Sobieum, Biman-tnag, and I-razin. 4. The methods of assessment used in 38 studies were classified by 7 categories and anthropometry parameters which is the basic methods are used in all studies 5. Almost studies (29 studies in all 38 studies) were using anthropometric parameters results on significantly effectiveness of childhood obesity. 6. More studies are needed to prove true effectives from various treatments, especially herbal therapy for childhood obesity. Key words : Childhood obesity, Child obesity, Obesity treatment Received: July 22, 2016 Revised: August 16, 2016 Accepted: August 18, 2016 Corresponding Author: Han Jae Kyung Department of Pediatrics, Daejeon University Cheonan Oriental Medicine Hospital, 4 Notaesan-ro, Seobuk-gu, Cheonan, Chungcheongnam-do 331-958, Republic of Korea Tel: +82-41-521-7570, Fax: +82-41-521-7557 E-mail: philia1@hanmail.net c The Association of Pediatrics of Korean Medicine. All rights reserved. This is an open-access article distributed under the tenus 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.
소아비만의치료에대한국내임상연구동향 109 Ⅰ. Introduction 비만이란단순히체중의증가를의미하는것이아니라신체에체지방이과하게축적되어나타난과체중이나이로인한대사장애를동반하는질환이다. 주요원인은고지방및인스턴트식품의섭취와운동부족등으로본다 1). 비만은성인뿐만아니라소아 청소년에서도계속증가하고있으며, 국내소아 청소년의비만유병율은 1998년 8.5% 에서 2010년 10.8% 로 2000년대이후에도증가추세에있는것으로나타났다 ( 국민건강영양조사, 2010). 체내지방세포의크기는비만인성인, 아동모두에게증가된상태이나비만아동은성인비만과달리지방세포의개수도같이증가하기때문에 2) 성인보다장기적으로비만의개선이어렵고, 이들중약 70% 가비만성인으로성장하는것으로보고되었다 ( 국민건강영양조사, 2010). 그러므로소아비만의예방과조기발견및치료는매우중요하다. 소아비만의치료에있어서단지 덜먹고더움직이도록하라 는것을조언하는것은매우간단한일로생각될수있다. 하지만실제임상에서의소아비만의치료는치료방법의선택과적용에시간과노력이많이요구되는복잡한과정이다. 에너지섭취를어느정도제한할지, 어느정도에너지소비량을증가시킬지결정해야하는데, 아동이나청소년의경우성장과정에있기때문에성인의경우와같이일정기간내목표체중을정하여감량하는방법은발육, 발달을저해할위험이많아적절하지못하기때문이다 3). 현재 2007년미국소아과학회에서발표한소아 청소년의비만치료권고안에서는일차진료기관을포함한의료진의참여가필요함을강조하며비만예방을위한행동습관에개입함에있어서통합적인방법을사용할것을제시하고있다 4). 이에국내에서시행된소아비만의치료방법과그효과를살펴볼수있는임상논문 38편을조사하여소아비만치료연구의현재흐름을짚어보고치료대상, 치료방법, 평가지표및효과를분석하여향후임상에서효과적으로응용할수있도록보고하는바이다. II. Materials and Methods 본연구의논문검색은국내검색엔진 한국교육학술 정보원 (Research Information Service System, RISS), 한국학술정보 (Korean Studies Information Service System, KISS), 한국의학정보포탈 (Oriental Medicine Advanced Searching Integrated System, OASIS), 의학논문데이터베이스 (Korean Medical database, KMbase) 을이용하였다. 검색어는 소아비만, 비만아 로검색된논문중동물및세포실험연구, Systemic review, 의학강좌및칼럼, 일반적인논문형식을갖추지않은증례보고논문및중복되는논문은제외하였고비만아를대상으로한소아비만치료와관련된임상논문 38편을선정하여연구경향및방법, 연구대상의특성, 대상선별법, 치료법및치료기간, 치료의효과지표및결과를분석하여정리하였다. III. Results 1. 연구경향및연구방법분석선정된 38편의논문을연도별로분류한결과 2000년이전에출판된논문이 4편, 2001~2005년 9편, 2006~ 2010년 11편, 2011~2016년까지논문이 14편이었다 (Fig. 1). 논문의학회지별분류는체육학, 체육교육학및교육학회 16편, 서양의학관련 10편, 한의학관련 9편, 영양학관련학회 3편으로나눌수있었다 (Fig. 2). 논문의유형별분류로는 RCT (Randomized controlled trial) 21편, 단순임상보고 11편, Chart review 3편, 치험례 3편으로나타났다. 2. 연구대상의특성 ( 성별, 연령, 선별기준 ) 최종선정된 38편논문의연구대상의성별은남녀모두의경우 29편, 남자만의경우 5편, 여자만의경우 3편으로나타났다. 대상의연령은여러연령층을대상으로하는경우중복으로분류하였는데초등학생미만은 9편, 초등학생은 29편, 중학생은 7편, 고등학생은 4편의논문에포함되었다. 또연령의분포를알수없는연구 2편이있었다 (Fig. 3). 연구대상의선별기준또한두개이상의기준을사용한연구는중복하여조사하였다. 주로 BMI, 체지방률, 비만도, 체중을이용하였고 BMI ( 체질량지수, Body Mass Index, kg/ m2 ) 는 20편, 체지방률은 4편, 비만도는 7편, 체중은 1편에서조사되었다. 각기준수치는논문
110 Review of Korean Clinical Studies on Treatment for Childhood Obesity Fig. 1. The classification by year Fig. 2. The classification scholarly journals Fig. 3. Age of subjects Fig. 4. Diagnostic criteria of subjects
소아비만의치료에대한국내임상연구동향 111 Fig. 5. The classification of treatment 별로달랐고진단기준이명확하지않은논문과치험례논문 9편이있었다 (Fig. 4). 3. 치료방법및치료기간분석각연구에보고된치료법은운동단독치료 13편, 교육단독치료 8편, 운동과교육복합치료 9편, 한방치료가사용된연구는 7편이있었는데한방치료가사용된연구중한약단독치료는 2편이며나머지 5편에는한방치료와함께운동, 교육복합치료가포함되어있었다. 이외온천요법을이용한연구 1편이있었다 (Fig. 5). 각치료법이적용된기간을분석한결과운동단독요법을이용한논문 13편중 11편은 12주이었고 6주, 24주동안시행된연구 1편씩이있었다. 교육단독요법은 5주 ~6개월로다양했고. 운동과교육복합치료또한 4주 ~7개월로다양했다. 한방치료중한약단독치료의경우아이라진은 8주, 消肥飮은 1~2개월, 肥滿湯은 30 일이상복용하였고운동과교육치료포함된연구는 4박 5일 ~5개월로다양하였다. 온천요법은약 1개월실시하였다 (Table 1). 4. 한방치료법분석한방치료법의종류에는한약, 전침, 이침, 건부항, 아로마마사지, 적외선, 복부패드가있었다. 한방단독치법을사용한 2편의경우아이라진, 消肥飮이처방되었고, 한방치료와운동, 교육복합치료가함께사용된 5편중한약을처방한경우는 3편으로肥滿湯 1편, 體感薏苡仁湯을 2편에서사용하였다. 5. 평가지표분석각연구에서사용된소아비만치료법의효과를평가하기위한측정도구는각논문별로각각의항목은다르지만크게 7가지로분류할수있었다 (Table 2, 3). IV. Discussion 소아 청소년비만은에너지섭취와에너지소비의불균형으로발생하여세계적으로급격히증가하는질병으로, 세계보건기구 (WHO) 에서심각한공중보건학적인문제로기술하고있다 43). 우리나라또한소아청소년비만의유병률에관련하여많은연구가되었으나, 비만을진단하는기준과연구대상이통일되지않아정확하게비교할수는없었다. 비만의기준을표준체중의 120% 이상을기준으로했을때서울지역에서의비만은 1979년, 1988년과 2002년을비교하면남아 1.7% 에서 6.2%, 17.9% 로 1997년에비해 2002년에 10배증가하였고, 여아는 2.4% 에서 6.5%, 10.9% 로 1979년에비해 2002년에 4.5 배증가하였다 44). 체질량지수를비만의기준으로 2007 년소아청소년성장발육표준치를사용하여 1998년과비교했을때과체중은 1998년 13% 에서 2007년 19%, 비만은 1998년 5.8% 에서 2007년 9.7% 로 1.5배증가하였다. 또한비만과관련된대사증후군의유병율또한증가하고있다 45-6). 소아비만치료법에관한의학적최신지견은소아비만의개인별치료를위한접근으로단계적접근법이추진되고있는데 1단계예방적접근, 2단계정형화된
112 Review of Korean Clinical Studies on Treatment for Childhood Obesity Table1. Summary of Clinical Trial Study Childhood Obesity 1st Author Year Study type Yang YH 2015 5) RCT Cheon SK 2009 6) RCT Cho SR 2012 7) RCT Park MJ 2012 8) clinical study Shin JY 2005 9) RCT Kim JW 2012 10) RCT Group Control 8 Intervention 8 Control 10 Intervention 10 Control 15 Intervention 15 Subject N Age Sex Treatment Period of treatment PRI W EX 12 w MID M EX 12 w HIG M + W EX + ED 8 w Intervention 17 PRI M + W H-Therapy Control 14 Intervention 14 Intervention 1 12 Intervention 2 12 Control 12 Han SH 2012 11) clinical study Seo JH Control 10 2010 12) RCT Intervention 10 Park JH Control 13 2009 13) RCT Intervention 15 Park JH Control 10 2014 14) RCT Intervention 10 Won JS Control 28 2008 15) RCT Intervention 29 Park JK 1994 16) Intervention 18 clinical study Lim YW 2013 17) Chart review Intervention 39 Ahn JY Intervention 1 6 2013 18) RCT Intervention 2 5 10 d (4 night 5day X 2) PRI M + W ED 12 w MID M EX 12 w Intervention 14 PRI M + W EX 12 w PRI M EX 12 w PRI M + W EX 12 w PRI M + W EX 12 w PRI M + W EX + ED 3 m PRE, PRI MID, HIG PRE PRI M + W ED 6 m M + W H-med (Biman-tang) 30 d PRI M + W EX 6 w Lee DH 2009 19) Chart review Intervention 66 Unknown M + W H-med 1~2 m Lee NH 2009 20) RCT Kang KY 2013 21) clinical study Lee HR 1998 22) RCT Control 20 Intervention continue 10 Intervention stop 6 Unknown M + W EX 24 w /12 w Intervention 20 PRI M + W Hot spring 1 m Control 17 Intervention 1 39 Intervention 2 43 PRI M + W ED 5 w Bak HG Intervention - OG 7 2009 23) RCT Intervention - NG 7 PRE M EX 12 w Yang SU Control 7 2014 24) RCT Intervention 7 PRI M + W EX 12 w Roh DJ 2012 25) clinical study Intervention 38 PRI M + W EX + ED 4 w Jang JH 2004 26) Case report Intervention 3 PRE M + W H-Therapy 54~86 d
소아비만의치료에대한국내임상연구동향 113 1st Author Year Study type Group Shin JY 2006 27) clinical study Lee SW Control 8 2011 28) RCT Intervention 8 Yoo JH 2005 29) clinical study Jung BY Control 36 2008 30) RCT Intervention 45 Lee YJ Control 10 2011 31) RCT Intervention 11 Jeong SH 2004 32) Case series Intervention 10 Subject N Age Sex Treatment Period of treatment Intervention 101 PRE, PRI M + W EX + ED 20 w PRI M + W EX 12 w Intervention 14 PRI M + W EX + ED 4 w MID W ED 12 w MID M EX 12 w PRE, PRI, MID M + W H-Therapy 6~86 d Ju JY 2003 33) Case report Intervention 1 PRE W H-Therapy 5 m Kim HJ Control 14 2007 34) RCT Intervention 14 PRI M + W EX + ED 12 w Cho YJ Control 17 2010 35) RCT Intervention 11 PRI M + W H-med 8 w Park JK 2001 36) clinical study Intervention 18 Unknown M + W ED 3 m Park JK 1999 37) clinical study Intervention 22 PRE, PRI M + W ED Unknown Cho YG 2009 38) clinical study Intervention 446 PRI M + W ED 12 w Lee HJ 1999 39) RCT Ibrahim AK 2014 40) RCT Intervention 1 - OG 4 Intervention 2 - OG 4 NG 4 Intervention - OG 21 Intervention - NG 8 Lee KY 2003 41) Chart review Intervention 42 PRI M + W EX + ED 8 w PRI, MID, HIG M + W EX + ED 6 m PRE, PRI, MID, HIG M + W ED Mean time 90 d Youn HN 2002 42) clinical study Intervention 16 PRI M + W EX + ED 6 w PRE: Preschooler, PRI: Primary school child, Mid: Middle school child, HIG: High school child, M: Man, W: Woman, EX: Excercise, ED: Education, OG: Obesity group, NG: Normal group 체중조절, 3단계포괄적다면적처치, 4단계삼차기관처치로구분된다. 1단계예방적접근단계는과체중및비만아와그가족에게기초적인건강한식생활과활동방식을배우고체험하도록하는것이다. 2단계정형화된체중조절은변화된행동을생활습관으로익히기위하여구조화된내용으로지지하는단계이고 3단계포괄적다면적처치는행동수정의강도가높아지며방문횟수도증가하여야한다. 각분야의전문가가참여하여야하며일차진료기관의범주를넘을수도있다. 4단계삼차기관처치는이전단계실행으로호전이없는경우또는고도비만소아 청소년에게강도높은처 치가요구되는단계로 sibutramine, orlistat 등의약물과초열량식사를이용한식이제한그리고체중관리위한수술적방법등을고려할수있다. 소아청소년비만치료를한단계에서시작하여 3-6개월간시행후기대했던호전이관찰되지않으면다음단계로진행한다 47). Whitake 등의연구 48) 에따르면 6세이상의비만하지않은소아청소년이성인비만이될가능성은 10% 정도이지만, 과체중이나비만의경우는 50% 나넘게성인비만으로이환될수있다. 성인비만은제 2 당뇨병, 이상지질혈증, 특정암발생등의심각한질병을초래하고, 사망위험이높아져 49-50), 개인및사회에게다양
114 Review of Korean Clinical Studies on Treatment for Childhood Obesity Table 2. Category of Evaluation Methods Category 1. Anthropometric parameters Evaluation Methods HT (Hight), WT (Weight), BMI (Body Mass Index), RI (Rὂhler Index), OI (Obesity Index), LBM (Lean Body Mass), Fat mass, Body fat %, SMM (Skeletal Muscle Mass), Body circumference, Skin-fold thickness Total cholesterol, Triglyceride, HDL-cholesterol, LDL-cholesterol, Blood glucose, AST, ALT, los hs-crp, Insulin, 2. Biochemical parameters log HOMA-IR, Leptin, HbA1c, TSH, Free T4, CBC (NKcell, IgA, IgD, IgG, IgM, IgG, IgM, MCH, MCHC, MCV, Platelet, RBC, WBC, Hct, Hb), se-selectin, Nitric Oxide, Serum mineral (Ca, MG, Fe, Zn, Cu) 3. Cardiorespiratory fitness SBP, DBP, HRmax, Exercise frequency, time, kg, counting number, VO 2 max, physical activity level 4. Energy intake and activity 5. Life Habit, Psychology, Knowledge about obesity 6. Brain, Nerve, Hormone 7. Etc Intake: Calorie, Protein, Fat, Carbohydrate, Cholesterol, Fiber, Ca, Phosphorus, Fe, Na, P, Zn, Vitamin A, Vitamin B 1, Vitamin B 2, Vitamin C, Niacin Activity: Energy expenditure, Time-sleep, light activity, moderate activity, high activity Fat/thin habit test score (Life style techniques, Exercise techniques, Attitude techniques, Relationship techniques, Nutrition techniques) Dietary attitude, Weight control behavior score, Self esteem, Body image BDNF (Brain derived neurotrophic factor), Norepinephrine, Serotonin, Brain activity (SMR, Theta wave, SMR/Theta ratio), Growth hormone, Cardiac autonomic nervous system activity (GPX, SOD) Blood Vessel function - VEGF (Vascular endothelial growth factor), CIMT (Carotid intima-media thickness), CLD (Carotid luminal diameter), PS (Carotid peak-systolic flow velocity), ED (End-diastolic flow velocity), Pulse amplification index, Femoral pulse wave velocity, AI (Augmentation index), ED (Endothelila dysfunction), SEVR (Subendocardial viability ratio), Abdominal CT Table 3. Including Evaluation Methods of The Each Clinical Study 1st Author 1 2 3 4 5 6 7 1st Author 1 2 3 4 5 6 7 Yang YH Yang SU Cheon SK Roh DJ Cho SR Jang JH Park MJ Shin JY Shin JY Lee SW Kim JW Yoo JH Han SH Jung BY Seo JH Lee YJ Park JH Jeong SH Park JH Ju JY Won JS Kim HJ Park,JK Cho YJ Lim YW Park JK Ahn JY Park JK Lee DH Cho YG Nam HY Lee HJ Kang KY Ibrahim AK Lee HR Lee KY Bak HG Youn HN : Include 1. Antropometric parameters. 2. Biochemical parameters. 3. Cardiorespiratory fitness. 4. Energy intake and activity. 5. Life Habit, Psychology index, Obesity knowledge. 6. Relation of Brain, Nerve, Hormone. 7. Etc (Blood vessel function, Abdominal CT) 한부담을발생시킨다. 이렇게적절한치료를필요로하는소아비만은성인비만의치료법에비해연구자료가충분하지않다. 성인비만의경우한양방의학모두에서약물요법에대해연구를활발하게진행하고있고수술요법역시여 러방법으로시행및고안되고있으나, 소아청소년비만의경우에는윤리적인문제나성장및발육에지장이있을수있어연구수행자체가어렵기때문이다. 최근들어서야고전적비만치료에반응하지않고비만으로인해생명에지장을줄수있는합병증을가진
소아비만의치료에대한국내임상연구동향 115 소아및청소년비만에서약물요법이나수술요법을제한적적용할수있다는주장이조금씩제기되고있는정도이다 47,51). 이에소아비만에관하여추가적인연구가필요하다사료되어현재까지발표된비만아대상으로시행된국내임상연구 38편을통해각연구에서이용된치료대상, 치료방법, 치료방법평가지표및치료효과를분석해보았다. 총 38편의임상논문을연도별로분류하면꾸준히소아비만에관한임상연구가진행되었으나 2009년부터증가추세에있으며 (Fig. 1), 논문의학회지별분류로체육학, 교육학, 영양학등관련논문에비해한의학및의학관련학회지의연구수는상대적으로부족한실정이었다. 이는소아비만의약물및수술등의적극적인치료의제한점이많기때문으로사료된다. 조사한논문의연구방법은전향적연구 32편중 RCT 21편, 단순임상보고 11편과후향적연구 3편, 치험례 3편으로조사되었다. 각논문의연구대상의성별분포는남녀모두를대상으로한 29편, 남자만을대상으로한 5편, 여자만은대상으로한 3편으로분류되었으나이에따른치료법, 효과등의차이나특이점은없었다. 연령분포에서는초등학교이전의유아는 9편, 초등학생은 29편, 중학생은 7편, 고등학생은 4편에포함되어유아에서초등학생까지를대상으로치료및연구를많이하였음을알수있었다. 치료대상의선별기준으로는 BMI, 체지방률, 비만도, 체중등를사용하였고각기준의수치도다양하였다. 그중 BMI ( 체질량지수, Body Mass Index) 를기준으로한논문이가장많았다. 이는소아비만의진단기준이시기및연구시행자에따라차이가있었고아직까지각기준에대한신뢰성에대해논란이많기때문일것이다. 각연구에사용된치료법중에는운동단독치료가가장많았고교육단독치료, 운동과교육복합치료도있었는데이세가지치료방법은총 38편중 30편으로치료로논문의 70% 를넘게차지했다 (Fig. 2). 30편의논문은체육및교육학연구뿐아니라양방의학논문도포함되어있었다. 이는소아를대상으로약물및수술등의치료에대한연구의한계때문일것으로사료된다. 그리고한방적치료법을사용한연구 7편은한약단독치료와한방적치료및운동과교육의복합치료법이함께사용된것으로나눌수있었다. 또한온천요법을이용한연구 1개가추가로있었다. 교육단독치료및운동과교육복합치료 17편중 8 편 7,16,22,25,29,34,41-2) 은부모교육이포함되어있는데이는 Barlow SE 등의연구 47) 에서소아비만치료는행동요법이중심이되며식사, 운동및부모의참여를포함한포괄적인체중관리프로그램이효과적이라고한것과연관될것이다. 물론교육단독치료내용에는모두운동관련내용이포함되어있어운동을실시한연구대상이다수일것이므로교육단독치료와운동과교육복합요법의정확한구분은한계가있을것이다. 각치료법이적용된기간을분석해보면운동단독요법의경우 12주가가장많았으나다른방법들을이용한논문의경우기간의특이성은찾기어려웠다. 한방치료중치료로사용된한약중아이라진은 8주, 消肥飮은 1~2달, 肥滿湯은 30일이상복용하였고 2편의논문에서사용된體感薏苡仁湯은 10일 8), 5개월 33) 처방되었다. 온천요법의경우 1개월간실시하였다. 한약복용의경우 1개월이최소기간이었고 2~3개월이상이다수였다. 한방치료법에는한약, 저주파전침, 이침, 건부항, 아로마마사지, 적외선, 복부패드가있었다. 그중사용된한약을분석해보면한방치료법뿐아니라운동과교육복합요법을함께사용한논문 4편중 2편에서體感薏苡仁湯이라는동일명의한약을이용하였으나두약의구성및용량은차이가있었다. 두한약의공통구성약재는薏苡仁, 熟地黃, 甘草, 黃芪, 枸杞子, 山茱萸, 厚朴, 鹿角, 川芎, 紅花, 淫羊藿, 蘇木, 蔓荊子, 當歸였다. 그리고다른 3편에사용된한약은아이라진 1)*, 消肥飮 2) *, 肥滿湯 3) * 이이었는데박에의한연구 52) 에의하면 2006년부터 2010년까지국내에서성인및소아의전체비만치료에사용되었다고보고된약은防風通聖散, 麻黃複合方, 肥滿 1 戶防, 少陽人肥滿方, 體感薏苡仁湯, 太陰調胃湯등이있었고이약의구성은본연구에서소아에게사용한약에포함된약재들과차이가크지않았다. 전침을이용한논문 4편에서자극부위는腹부위 ( 任脈穴, 肝經穴 ) 를이용한논문 3편, 부위가언급되지않은논문 1편이있었고사용한주파수와시간을분석해보면 20 Hz로 40분, 50 Hz로 10분자극한 1편, 25 1) * 아이라진 : 澤瀉, 大黃, 乾薑, 甘草, 肉桂, 芍藥, 牧丹皮, 柴胡, 豬苓, 半夏, 升麻등 2) * 消肥飮 : 桔梗 12 g, 麻黃 6 g, 紫蘇葉 6 g, 麥門冬 4 g, 黃芩 4 g, 杏仁 4 g 3) * 肥滿湯 : 麻黃 4 g, 天花粉 4 g, 薏苡仁 3 g, 麥門冬 3 g, 天門冬 2 g, 陳皮 2 g, 當歸 2 g
116 Review of Korean Clinical Studies on Treatment for Childhood Obesity Hz로 40분, 50 Hz 10분자극한 1편, Hz가언급되지않고 45분을자극한 2편이있었다. 전기침은전류가흐르면열상승이발생하여중성지방이글리세린과지방산으로가수분해된후미세순환을통해제거되는것으로지방분해를돕는효과가있어 53) 비만과대사증후군의진단기준인복부둘레의감소에도움을줄것이다. 이침을사용한논문은 3편으로사용된혈자리는脾, 胃, 飢點, 內分泌등을이용한 1편, 口點, 胃點, 脾點, 神門點, 內分泌點, 飢點, 皮質下點를이용한 2편이있었다. 이침혈위치료는편리함과비용의저렴함, 지속적인자극을줄수있다는장점으로비만치료에많이사용되고있다. 이침혈위중비만치료에많이응용되는혈자리는氣點과胃點, 神門등이있다 54-8). 이중氣點은포만감을증가시키고배고픔을억누르는작용을하며 59), 神門은뇌피질의기능을조절하고진정효과가있다 60). 외이는미주신경, 설인신경, 삼차신경, 안면신경과그분지와연관되어있다 61). 따라서외이의자극이미주신경의분지를자극하여위장관계에영향을주어식욕을억제하는효과를줄수있다 62). 건부항을이용한논문은 1편으로복부및대퇴나상박과같이지방분포가많은부위의피부표면에약 10 분간부항컵을고정시켜고음압상태를유지하였다. 부항요법은국소부위의혈액순환촉진과전신적인祛瘀生新의효능이있다 63). 아로마마사지를이용한논문은 2편으로모두 jojoba oil을 base로하여 Fennel, Juniper, Black pepper를일정비율로혼합하여 2% 농도로희석하여 5~10분간복부마사지를실시하였다. 적외선치료법을이용한논문은 2편으로모두저주파전침요법과아로마마사지치료받는동안적외선조사를이용하여온열효과를통한지방분해촉진을이용하였다. 복부패드방법은 2편에서이용하였는데자침에대해두려움을갖는환아에게한정적으로시행하였다. 마사지를하기전에패드에물을묻히고단자가엇갈리게하여복부에벨트를통해저주파진동을주었다. 저주파치료기는자율신경자극및온열효과로비만치료에도움이된다고입증되었다 64). 각논문에서사용된치료효과를평가하기위한측정도구를분석해보면 7가지분류로나눌수있는데 (Table 2) 1 분류인신체계측및체조성관련평가도구는모든논문에서사용되었다. 체중, 신장및체질량지수 (BMI), 비만도 (OI), 체지방률 (Body fat %) 등이포함되어있는데이들은비만진단에사용되어지는지 표로비만의치료효과를보는데기본일것이다. 이외에신체둘레 11,30) 및피부두겹두께 7) 를사용하였는데신체둘레중복부둘레는대사증후군을진단하는기준중하나로사용되어지고또한피부두겹두께지표는피부바로아래에위치한체지방을평가하기위한간단한방법으로총지방량에영향을미친다 7). 이외의평가지표를분석해보면 2, 3, 6, 7의분류에서비만뿐아니라여러질환의지표로사용할수있는혈액검사수치, 심폐능력평가수치및뇌, 신경, 혈관의기능과관련된지표등이사용되었다. 이는비만이단순한체중의증가만을의미하는것이아닌대사장애등과같은신체이상을유발하는질환이기때문에사용되었을것이다. 구체적으로는심혈관계질병의예측지수로혈중지질수준을검사하고 1 METs의심페체력이증가할때마다심혈관계질병의위험도는약 12% 감소한다고한다. 또한최대산소섭취량의증가는심혈관계의생활습관병을감소시키는것으로보고되었다 66). 4, 5 분류에서는비만치료법의기본인행동습관의변화에미치는영향력을평가하는식습관, 운동습관등의지표를사용하였다. 또한 5 분류에서사용된자아존중및자아상등을나타내는지표는비만아동들과청소년들은삶의질지수인 HRQOL (Health-Related Quality of Life) 가화학요법을받고있는소아암환자의지수와비슷한수준임을감안할때소아비만치료효과의측정지표중중요한의미를지닌기준일것이다. 총 38편논문의치료효과를분석해보면 1 분류인신체계측및체조성의지표가비만의진단기준수치이므로치료효과의필수적인기준일것이다. 하지만나머지 2, 3, 6, 7분류는체중및지방의증가로인해발생하는다양한신체이상이나질환의지표이므로이것을통해각논문에서사용된치료법들의효과를비교하는것은한계가있을것이다. 또한 4, 5 분류도비만의치료로인해발생하는효과이므로 2~7 지표는각논문에서사용한치료법의효과를증명하기위해부가적으로사용된것이다. 그러므로본연구는각논문의 1 분류인신체계측및체조성의지표에대한효과를중심으로분석하였다. 총 38편의모든논문중 9편을제외한 29편에서는모두유의한치료효과를나타내었다. 유의하지않는결과를가진 8편 7,14-5,23-4,27,30-1) 에서는모든 1 분류에속하는일부지표가각연구에서는수치적인효과는있었으나통계적으로유의할만큼의차이는아닌것이대부분이었다.
소아비만의치료에대한국내임상연구동향 117 비만은분명치료를필요로하는질환에속함에도불구하고그치료방법은약물및수술치료등이주된치료방법인일반적인질환과차이가존재한다. 앞에서언급한바와같이과거와달리현재의식생활및신체적활동정도의감소가비만의유병율을증가시키는원인이된것이므로비만치료는생활습관및태도의변화가요구된다. 하지만소아는성인과자기통제력및비만치료의필요성을인지하는정도의차이가있으므로부모, 교사및의료진의개입을필요로한다. 이에본연구에서분석한비만치료관련논문 38편중절반이체육및교육학, 영양학관련논문이며대부분비만아를대상으로한운동및교육프로그램에해당하였다. 그러나생활습관의변화의기본인에너지섭취및소비량의변화정도를결정하는데있어, 성장과정에있는아동이나청소년의경우이는발육, 발달을저해할위험이많아운동및교육프로그램만으로는한계가있을것이다. 이에 2007년미국소아과학회에서발표한소아청소년의비만치료권고안에언급된일차진료기관을포함한의료진참여의필요성을찾을수있을것이다 47). 또한권고된소아비만의단계적접근법에는서양의학적주치료방법인적극적인약물치료및수술은마지막 4단계에포함되어있어제한적이므로본연구에서조사된 9편의한의학적치료의효용성을찾아볼수있을것이다. 한의학적비만치료는성인의경우박등의연구 52) 와같이한방적처치및한약복약의효과및방법에관해연구가많이되어있어소아에게도시도해볼수있을것이나성인과같은효과를기대할수있을지에대해서는한계가있어소아를대상으로한안정성이검증된추가연구들이밑받침되어야할것이다. 소아비만의각치료법의효과평가는소아비만의진단과직접관계된 BMI, 체질량지수및비만도등과같은신체계측및체조성관련수치의변화를비교하는것이기본이다. 하지만본연구에서조사된논문에서는이것뿐아니라체성분조사및심폐체력, 에너지섭취및소비량, 생활습관및심리적수치를사용하였는데대다수의논문에서는신체계측및체조성관련수치의효용성을보였으나다른치료법효과평가도구에서유효성이없었던논문이존재한것을통해각소아비만의치료법의효과및가치를좀더정확하게알아볼수있었고역으로 BMI, 체질량지수, 비만도와같은비만진단법의정확성및유효성을알아보는데도움을줄수있을것이다. V. Conclusion 본연구는국내검색엔진 한국교육학술정보원, 한국학술정보, 한국의학정보포탈, 의학논문데이터베이스 를이용하여검색한소아비만치료의임상논문들을고찰한결과다음과같은결론을얻었다. 1. 선정된 38편의논문중 2000년이전출판된 4편, 2001~2005년 9편, 2006~2010년 11편, 2011~2016년까지논문이 14편이있었으며체육학및교육학회지논문 16편, 양방의학회지논문 10편, 한방의학회지논문 9편, 영양학관련학회지 3편으로나눌수있었다. 또한그중 RCT 21편, 단순임상보고 11편, Chart review 3편, 치험례 3편이있었다. 2. 각논문의연구대상의성별은 29편은남녀모두, 5편은남자만, 3편은여자만을대상으로하였고연령별분포는초등학생미만유아는 9편, 초등학생은 29 편, 중학생은 7편, 고등학생은 4편에포함되어있었다. 연구대상의선별기준은 BMI 20편, 체지방율 4편, 비만도 7편, 체중 1편, 진단기준이명확하지않은논문과치험례논문은총 9편이있었다. 3. 각논문의치료법은운동단독치료 13편, 교육단독치료 8편, 운동과교육복합치료 3편, 한방치료가사용된 7편이있었고그중한약단독치료 3편, 한방치료및운동과교육복합치료가함께사용된 4편이있었다. 또기타로온천요법이용한 1편있었다. 각치료법이적용된기간에는운동단독요법의경우 12주가가장많았고나머지치료법의기간은다양하였다. 4. 한방치료의종류에는한약, 전침, 이침, 건부항, 아로마마사지, 적외선, 복부패드가있었고한약의종류는體感薏苡仁湯 2편, 아이라진, 消肥飮, 肥滿湯이있었다. 5. 각논문에서사용된치료법의평가지표로는신체계측및체조성과혈액검사상수치, 혈압및심폐체력, 에너지소비및영양소섭취, 비만관련습관, 지식및심리수치, 그리고기타지표로 7가지분류로나누었다. 6. 평가지표중신체계측및체조성을사용한논문중 9편을제외한 29편에서는모두유의한치료효과를나타내었다. 7. 2~7 분류에속한평가지표들은각각 18편, 16편, 9편, 9편, 5편, 6편에서사용되었다. 각평가지표들의효능은논문마다다양하였다.
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