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SMN SURGICAL METABOLISM AND NUTRITION Vol. 6, No. 2, December, 2015 pissn 2233-5765, eissn 2465-8383 http://dx.doi.org/10.18858/smn.2015.6.2.17 REVIEW ARTICLE 경장영양액의분류및적용 이재길 연세대학교의과대학외과학교실 General Categorization and Application of EN Formula Jae Gil Lee, M.D., Ph.D. Department of Surgery, Yonsei University College of Medicine, Seoul, Korea Enteral nutrition is a method of nutritional support. If the gut works, its use is recommended for nutritional support. Enteral nutrition has several advantages; low cost, more physiologic, and prevention of mucosal atrophy and maintenance of gastrointestinal immunity. Enteral formula is the medical food used for enteral nutrition. Several types of enteral formula are used in clinical practice. I will hereby introduce the types and selection of enteral formula. (Surg Metab Nutr 2015;6:17-22) Key Words: Enteral nutrition, Formula, Nutrition Support, Tube feeding 서론 본론 경장영양이란입을통해특수영양식품을먹이거나, 급식관을통해서위나소장으로영양액을주입하여영양분을공급하는것을의미하며, 대부분은급식관을이용한영양공급을의미하는경우가많다.[1] 경장영양은영양불량이있거나영양불량의위험성이높은환자에서경구섭취를할수없거나, 경구섭취로충분한영양을공급할수없을때시행하게된다.[2,3] 경장영양은장점막의위축및탈락을방지하고, 장의면역체계를유지시킴으로써감염성합병증을줄일수있는것으로알려져있다. 또한장을이용하기때문에생리적으로흡수가되며, 정맥영양에비해비용이적게드는장점이있다.[4,5] 경장영양액은여러가지종류가있으며, 이는환자개개인의특성에따라경장영양액을선택하여야하는것을의미한다. 따라서경장영양액의종류와선택에대해서간략하게정리하고자한다. Received December 8, 2015. Accepted December 11, 2015. Correspondence to: Jae Gil Lee, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03772, Korea Tel: +82-2-228-2127, Fax: +82-2-313-8289 E-mail: jakii@yuhs.ac 미국식품의약품안전청 (FDA) 에서는의료용식품으로분류하고있으며, 이는약과같은제약을받지않고있다. FDA에의한의료용식품은의사의감독하에장을이용하여주입하거나소모되는식품으로, 특별한영양공급이필요한질병이나상태를치료하기위한것으로, 과학적인원칙에의거하여, 의학적으로평가가이루어진식품을의미한다.[6] 한국에서는특수용도등식품으로분류하고있으며, 이는정상적으로섭취, 소화, 흡수또는대사할수있는능력이제한되거나손상된환자또는질병이나임상적상태로인하여일반인과생리적으로특별히다른영양요구량을가진사람의식사의일부또는전부를대신할목적으로경구또는경관급식을통하여공급할수있도록제조, 가공된식품으로정의하고있다. 1. 경장영양액의조성경장영양액을통해서영양소의공급이충분히이루어져야한다. 따라서 3대영양소 ( 탄수화물, 단백질, 지방 ) 를모두포함하여야하며, 섬유소, 비타민과무기질등의미량원소가같이포함되어있다. 또한여기에는일정량의수분이같이포함되어 Copyrights c The Korean Society of Surgical Metabolism and Nutrition

18 Surgical Metabolism and Nutrition Vol. 6, No. 2, 2015 Table 1. Types of enteral formulas Formula Type Blenderized Commercial Standard, polymeric Elemental/semi-elemental Disease specific Immune modulating Modular Definitions Formulated with a mixture of blenderized food sources (blenderized whole foods) Formula containing intact non-hydrolyzed nutrient Partially or completely hydrolyzed macronutrients to maximize asorption Targeted for organ dysfunction or specific metabolic conditions Diatetes, renal, hepatic,pulmonary, etc Contain pharmacologically active nutrients, such as arginine, glutamine, omega-3 fatty acids, and/or antioxidants Supplementation to create a formula or enhance nutrient content Protein module Table 2. Standard formulas product manufactured in Korea Standards formula Greenbia Mild Greenbia Plus Greenbia TF CareWell NewCare Nucare Omega MediWell Calorie 200 kcal 200 kcal 200 kcal 200 kcal 200 kcal 200 kcal 200 kcal Carbohydrate 30 g 29 g 34 g 29 g 30 g 28 g 28 g Fat 6 g 6 g 4.5 g 6 g 6 g 6 g 7 g Protein 8 g 7 g 8 g 8 g 7 g 9 g 8 g Fiber 1 g 6 g 3 g 1 g 1.2 g 2 g 1 g Sodium 160 mg 75 mg 120 mg 140 mg 130 mg 180 mg 180 mg Potassium 270 mg 120 mg 240 mg 250 mg 210 mg 300 mg 320 mg Calcium 140 mg 150 mg 150 mg 145 mg 154 mg 150 mg 160 mg Chloride 240 mg 121 mg 160 mg 152 mg 110 mg 270 mg 200 mg Phosphorus 140 mg 140 mg 140 mg 145 mg 140 mg 140 mg 140 mg Vitamin A 150 μg 150 μg 150 μg 150 μg 150 μg 150 μg 200 μg Vitamin B1 0.24 mg 0.24 mg 0.24 mg 0.25 mg 0.26 mg 0.26 mg 0.3 mg Vitamin B2 0.3 mg 0.3 mg 0.3 mg 0.3 mg 0.3 mg.3 mg 0.4 mg Vitamin B6 0.3 mg 0.3 mg 0.3 mg 0.3 mg 0.3 mg 0.3 mg 0.4 mg Vitamin B12 0.48 μg 0.48 μg 0.48 μg 0.48 μg 0.48 μg 0.48 μg 0.6 μg Vitamin C 20 mg 28 mg 28 mg 30 mg 28 mg 28 mg 20 mg Vitamin D3 1 μg 1 μg 1 μg 1 μg 1 μg 1.8 μg 1.4 μg Vitamin E 2 mg 2.4 mg 2.4 mg 2 mg 2 mg 3 mg 2.1 mg Vitamin K1 15 μg 15 μg 15 μg 15 μg 15 μg 15 μg 16 μg Folate 80 μg 80 μg 80 μg 75 μg 80 μg 80 μg 85 μg Niacin 3.2 mg 3.2 mg 3.2 mg 3.5 mg 3.2 mg 3.2 mg 3.2 mg Biotin 6 μg 6 μg 6 μg 7 μg 6 μg 6 μg 8 μg Pantothenic acid 1 mg 1 mg 1 mg 1 mg 2 mg 1 mg 1.4 mg Magnesium 44 mg 44 mg 44 mg 44 mg 44 mg 44 mg 60 mg Zinc 2 mg 2.8 mg 2 mg 2.4 mg 2.4 mg 4.2 mg 2.4 mg Iron 2 mg 2 mg 2 mg 2.5 mg 2.4 mg 2.4 mg 2.4 mg Manganese 0.7 mg 0.8 mg 0.46 mg 0.35 mg 0.4 mg 0.4 mg 0.7 mg Cooper 0.16 mg 0.16 mg 0.1 mg 0.15 mg 0.16 mg 0.16 mg 0.16 mg Iodine 19.5 μg 30 μg 30 μg Cholin 61 mg 60 mg 73 mg 110 mg 95 mg Taurine 22 mg 50 mg 23 mg L-Carnitine 22 mg 25 mg 23 mg Beta-Carotene 200 μg L-Arginine 500 mg 750 mg Selenium 13 μg Chromium 12 μg Molybdenum 6 μg DHA+EPA 70 mg

Jae Gil Lee: EN Formula 19 Table 3. Diabetic formula products manufactured in Korea Products Greenbia DM CareWell DM NewCare Diabetes Mediwell Diabetes Calorie 200 kcal 200 kcal 200 kcal 200 kcal Carbohydrate 25 g 21.5 g 22 g 22 g Fat 8 g 10 g 9.6 g 9 g Protein 10 g 9 g 9 g 10 g Fiber 5 g 3 g 3 g 5 g Sodium 155 mg 180 mg 160 mg 150 mg Potassium 260 mg 300 mg 220 mg 280 mg Calcium 140 mg 160 mg 154 mg 160 mg Chloride 170 mg 260 mg 150 mg 200 mg Phosphorus 140 mg 160 mg 140 mg 140 mg Vitamin A 150 μg 150 μg 150 μg 200 μg Vitamin B1 0.24 mg 0.25 mg 0.26 mg 0.3 mg Vitamin B2 0.3 mg 0.32 mg 0.3 mg 0.4 mg Vitamin B6 0.3 mg 0.45 mg 0.3 mg 0.4 mg Vitamin B12 0.48 μg 0.5 μg 0.48 μg 0.6 μg Vitamin C 20 mg 35 mg 28 mg 40 mg Vitamin D3 1 μg 1 μg 1 μg 1.4 μg Vitamin E 2 mg 2 mg 2 mg 4 mg Vitamin K1 9.75 μg 18 μg 15 μg 16 μg Folate 80 μg 80 μg 80 μg 85 μg Niacin 3.2 mg 5 mg 3.2 mg 3.2 mg Biotin 6 μg 6.5 μg 6 μg 8 μg Pantothenic acid 1 mg 1.5 mg 1 mg 1.4 mg Magnesium 58 mg 44 mg 44 mg 60 mg Zinc 2 mg 3.2 mg 2.4 mg 2.4 mg Iron 2 mg 2.8 mg 2.4 mg 2 mg Manganese 0.46 mg 0.6 mg 0.48 mg 0.7 mg Cooper 0.1 mg 0.32 mg 0.16 mg 0.16 mg Iodine 19.5 μg 30 μg 30 μg 30 μg Cholin 68 mg 110 mg 95 mg Taurine 22 mg 50 mg 50 mg L-Carnitine 22 mg 25 mg 50 mg Beta-Carotene 400 μg L-Arginine 1000 mg Selenium 8 μg Chromium 7 μg Molybdenum 4 μg DHA+EPA Inositol 111 mg 20 mg 170 mg 영양성분의균형을맞추게된다.[2] 환자의질병이나특수성에따라경장영양액의조성이달라질수있으며, 각영양소의성분, 조성에따라경장영양액을여러종류로분류할수있다 (Table 1).[7] 2. 경장영양액의종류 1) 혼합액화영양액 (Blenderized formula) 일반음식을급식관으로주입할수있도록혼합분쇄하여만든것으로, 음식물이나여러종류의곡물, 균형식등을혼합하여사용할수있다. 집에서도만들수도있으며, 미숫가루또는미음등을예로들수있다. 급식관조루술부위가다나았 거나감염의증거가없고안정적인환자에서사용을고려하여야하며, 급식관이쉽게막힐수있어급식관을잘관리할수있는경우에사용하는것이바람직하다. 그러나함유된영양소를정확하게파악하기어렵고농도가일정하지않는문제점이있다. 또한제조및보관시오염의가능성이높아관리에주의가필요하다. 2) 상업화된경장영양액영양공급을위해상업적으로개발된상품으로혼합액화영양액과는다르게영양소함유량이정확하게표기되어있고, 농도가일정하며, 멸균상태로제조, 보관되어있어위생적으로안전한형태이다. 그러나제조비용에따른단가가높아비교적

20 Surgical Metabolism and Nutrition Vol. 6, No. 2, 2015 가격이높은편이다. 영양소의양, 구성성분의차이, 질병특이적인영양액등이따로제조되어판매되고있다. 표준영양액 (standard polymeric formula), 가수분해영양액 (hydrolozed formula), 질환별특수제제 (disease-specific formula), 오메가 -3가포함되어있거나면역조절을위한면역영양제, 및특정영양소단일성분으로구성된영양강화제 (modular product) 등이있다. 3) 표준영양액일반적으로가장많이사용되는영양액으로, 특별한질병이없는환자에서사용하게된다. 가수분해되지않은탄수화물, 단백질, 지방을함유하고있으며, 1 cc 당 1 2 kcal의열량을공급할수있다. 보통 1 1.5 L 정도공급하게되면무기질과비타민을포함한대부분의영양소의일일요구량에충분히도달하게된다. 국내에서생산판매중인제품의종류와조성은 Table 2와같다. 수액공급을제한해야하는환자에서는고농축영양액을사용할수있으며, 1 cc 당 2 kcal를공급하여신부전또는심부전환자에서수액을제한하면서충분한영양소를공급하기위해사용한다. 단백질공급이많이필요한환자를위한고단백영양액을사용하기도하며, 수술또는외상후회복기에상처회복을위해사용한다. 4) 당뇨용경장영양액당뇨용경장영양액은, 탄수화물의높은함량에의해고혈당이잘발생하는표준경장영양액보다혈당을더잘조절하기위한목적으로사용된다. 탄수화물의함량이상대적으로적으며, 단백질과지방의함유량을높혀고혈당의발생을줄일수있다. 국내에서생산판매중인당뇨용경장영양액의종류와조성은 Table 3에정리하였다. 여러연구들에서당뇨용경장영양액을사용하는것이당의조절에도움이되고, 인슐린의사용량, 저혈당의발생을감소시킬수있다고보고하였다.[8,9] 5) 고단백경장영양액표준경장영양액보다단백질의함량을높인것으로급성기상태에서단백질요구량이많은환자에서사용할수있다. 환자의질소평형에따라부족한단백질을보충하기도하며, 다량의단백질이필요한경우에는단백질만들어있는모듈을추가하여공급하기도한다. 국내에서생산되어판매되는고단백경장영양액은 Table 4에정리하였다. 6) 식이섬유함유경장영양액소화관의기능을유지하거나장의기능을정상적으로유지시키는데도움을줄수있다. 급성기환자에서경장영양을하 Table 4. Formula containing high protein manufactured in Korea Greenbia High protein Products Newcare High Protein Mediwell Protein 1.5 Calorie 200 kcal 200 kcal 200 kcal Carbohydrate 28 g 24 g 28 g Fat 4.5 g 6 g 11 g Protein 13 g 13 g 13 g Fiber 2 g 2 g 1 g Sodium 185 mg 210 mg 200 mg Potassium 310 mg 210 mg 420 mg Calcium 140 mg 154 mg 210 mg Chloride 200 mg 150 mg 220 mg Phosphorus 140 mg 140 mg 200 mg Vitamin A 150 μg 150 μg 300 μg Vitamin B1 0.24 mg 0.26 mg 0.5 mg Vitamin B2 0.3 mg 0.3 mg 0.5 mg Vitamin B6 0.3 mg 0.3 mg 0.6 mg Vitamin B12 0.48 μg 0.48 μg 0.9 μg Vitamin C 20 mg 28 mg 30 mg Vitamin D3 1 μg 1 μg 2.1 μg Vitamin E 2 mg 2 mg 3 mg Vitamin K1 15 μg 15 μg 23 μg Folate 80 μg 80 μg 120 μg Niacin 3.2 mg 3.2 mg 4.8 mg Biotin 6 μg 6 μg 12 μg Pantothenic acid 1 mg 2 mg 2.1 mg Magnesium 44 mg 44 mg 75 mg Zinc 2 mg 2.4 mg 3.6 mg Iron 2 mg 2.4 mg 3 mg Manganese 0.7 mg 0.4 mg 1.05 mg Cooper 0.16 mg 0.16 mg 0.24 mg Iodine 30 μg 30 μg 45 μg Cholin 73 mg Taurine 20 mg 35 mg L-Carnitine 20 mg 35 mg Beta-Carotene 300 μg L-Arginine 1000 mg 는경우에설사가흔히발생하게된다. 식이섬유를포함한경장영양액의투여가설사를조절하는데도움이되는것으로알려져있다.[7,10] 이에따라 ASPEN 지침에서는경장영양시설사가있는환자에서는식이섬유가함유된경장영양액을사용하도록권고하고있다.[11,12] 국내에서생산되어판매되고있는섬유소특이경장영양액은 Table 5에정리되어있다. 7) 면역조절경장영양액외상또는수술후환자및중환자에서손상에따른대사반응은전신염증반응증후군과더불어역조절성항염증반응 (counter regulatory anti-inflammatory response syndrome, CARS) 이나타나게된다. 따라서이런중증환자에서영양지원을할때면역을증강시키거나염증반응을줄일수있는방법을고려할수있다. 면역조절성영양분은글루타민, 아르기닌, 오메가 3 지방산, 셀레늄과같은항산화제등이있는것으로

Jae Gil Lee: EN Formula 21 Table 5. Special formula manufactured in Korea Fiber specific Specialized formula Greenbia Fiber Newcare Fiber Mediwell Fiber Newtriwell Fiber Carewell Advancer Carewell 1.5 Plus Greenbia 1.5 Calorie 200 kcal 200 kcal 200 kcal 200 kcal 200 kcal 300 kcal 300 kcal Carbohydrate 31 g 28 g 28 g 30 g 30 g 40 g 41 g Fat 6 g 7 g 6 g 6 g 6 g 10 g 9 g Protein 9 g 8 g 9 g 8 g 8 g 13 g 13 g Fiber 4.3 g 3 g 4 g 3 g 3 g 1 g Sodium 150 mg 180 mg 140 mg 140 mg 180 mg 210 mg 180 mg Potassium 250 mg 300 mg 280 mg 280 mg 270 mg 310 mg 300 mg Calcium 140 mg 140 mg 160 mg 160 mg 150 mg 185 mg 140 mg Chloride 205 mg 140 mg 200 mg 110 mg 250 mg 250 mg 150 mg Phosphorus 140 mg 140 mg 140 mg 140 mg 150 mg 185 mg 140 mg Vitamin A 150 μg 150 μg 200 μg 200 μg 180 μg 230 μg 225 μg Vitamin B1 0.24 mg 0.26 mg 0.3 mg 0.3 mg 0.25 mg 0.5 mg 0.36 μg Vitamin B2 0.3 mg 0.3 mg 0.4 mg 0.4 mg 0.35 mg 0.5 mg 0.45 mg Vitamin B6 0.3 mg 0.3 mg 0.4 mg 0.4 mg 0.35 mg 0.5 mg 0.45 mg Vitamin B12 0.48 μg 0.48 μg 0.6 μg 0.6 μg 0.5 μg 1.2 μg 0.72 μg Vitamin C 20 mg 28 mg 20 mg 20 mg 35 mg 45 mg 30 mg Vitamin D3 1 μg 1 μg 1.4 μg 1.4 μg 2 μg 3 μg 15 μg Vitamin E 2 mg 2 mg 2.1 mg 2.1 mg 2 mg 3 mg 3 mg Vitamin K1 15 μg 15 μg 16 μg 16 μg 18 μg 22 μg 22.5 μg Folate 80 μg 80 μg 85 μg 85 μg 80 μg 120 μg 120 μg Niacin 3.2 mg 6 mg 3.2 mg 3.2 mg 5 mg 7 mg 4.8 mg Biotin 6 μg 6.4 μg 8 μg 8 μg 6.5 μg 9 μg 9 μg Pantothenic acid 1 mg 1.4 mg 1.4 mg 1.4 mg 1.5 mg 2 mg 1.5 mg Magnesium 58 mg 40 mg 60 mg 44 mg 45 mg 45 mg 51 mg Zinc 2 mg 2.6 mg 2.4 mg 2.4 mg 3.2 mg 3.2 mg 2 mg Iron 2 mg 2.2 mg 2 mg 2 mg 2.3 mg 2.3 mg 2 mg Manganese 0.7 mg 0.8 mg 0.7 mg 0.7 mg 0.7 mg 0.7 mg 0.7 mg Cooper 0.16 mg 0.4 mg 0.16 mg 0.16 mg 0.4 mg 0.4 mg 0.16 mg Iodine 30 μg 22 μg 30 μg 30 μg 30 μg 30 μg Cholin 110 mg 110 mg 110 mg 73 mg Taurine 40 mg 23 mg 25 mg 50 mg 50 mg 22 mg L-Carnitine 40 mg 23 mg 26 mg 25 mg 25 mg 22 mg Beta-Carotene 200 μg 200 μg L-Arginine 750 mg 750 mg Selenium 6 μg 8 μg 12 μg 8.25 μg Chromium 6 μg 7 μg 11 μg 7.5 μg Molybdenum 3 μg 4 μg 6 μg 3.75 μg Inositol 20 mg 20 mg 알려져있다. 면역조절성경장영양액의효과는발표자마다연구결과의상이성이있어논란이있으나, 비교적중환자에서사용을권고하고있다.[13-15] 국내에서는아직까지면역강화경장영양액이생산되고있지는않다. 3. 경장영양액의선택경장영양액을선택할때는환자의영양상태와혈역학적인안정성을먼저확인하여야하며, 고혈당또는당뇨, 신장기능및투석여부, 간기능여부, 소화관의사용가능성등을전반적으로고려하여야한다. 환자의상태에맞게영양요구량을계산하고, 전해질상태등을고려하여적절한경장영양액을선택하여야한다. 결론 경장영양액을선택하는데있어서경장영양액의조성과특성에대한이해가필요하고, 환자의상태를고려하는것이중요하다. 여러가지경장영양액이있지만환자의상태에맞는제제를선택하여야하며, 주입에따른합병증과부적응등이나타날수있으므로적극적인관리가필요하다. 또한환자의상태에적절하지않다면빠른시간내에제제를변경하는것을고려하여야할것이다.

22 Surgical Metabolism and Nutrition Vol. 6, No. 2, 2015 REFERENCES 1. Lochs H, Allison SP, Meier R, Pirlich M, Kondrup J, Schneider S, et al. Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics. Clin Nutr 2006;25:180-6. 2.Lee HS. Selection of enteral formula. J Korean Soc Parenter Enter Nutr 2010;3:27-32. 3. Kolaček S. Enteral nutrition. World Rev Nutr Diet 2013;108: 86-90. 4. Kim SH, Kim KS. Advantages of enteral nutrition. J Korean Soc Parenter Enter Nutr 2010;3:3-8. 5. Lee SH, Jang JY, Kim HW, Jung MJ, Lee JG. Effects of early enteral nutrition on patients after emergency gastrointestinal surgery: a propensity score matching analysis. Medicine (Baltimore) 2014;93:e323. 6. Draft guidance for indusry: frequently asked questions about medical foods. http://www.fda.gov/food/guidanceregulation/ GuidanceDocumentsRegulatoryInformation/MedicalFoods/ucm054048. htm/accessed December 5, 2015. 7. Brown B, Roehl K, Betz M. Enteral nutrition formula selection: current evidence and implications for practice. Nutr Clin Pract 2015;30:72-85. 8. Cresci G, Lefon J, Esper DH. Enteral Formulations. In: Gottschlich MM, ed. The ASPEN adult nutrition support core curriculum. 2nd ed. Silver Spring: American Society for Parenteral and Enteral Nutrition, 2012:185-205. 9. Frankenfield DC, Beyer PL. Soy-polysaccharide fiber: effect on diarrhea in tube-fed, head-injured patients. Am J Clin Nutr 1989;50:533-8. 10. Elia M, Engfer MB, Green CJ, Silk DB. Systematic review and meta-analysis: the clinical and physiological effects of fibre-containing enteral formulae. Aliment Pharmacol Ther 2008;27:120-45. 11.Martindale RG, McClave SA, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for parenteral and enteral nutrition: executive summary. Crit Care Med 2009;37:1757-61. 12.McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;33:277-316. 13. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;25:210-23. 14.Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006;25:224-44. 15. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr 2009;33:122-67.