Journal of Nutrition and Health

The Korean Nutrition Society (한국영양학회)
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The Clinical and Cost Effectiveness of Medical Nutrition Therapy for Patients with Type 2 Diabetes Mellitus

제2형 당뇨병환자에서 임상영앙치료의 임상적 효과와 비용효과 연구

  • Cho, Youn-Yun (Department of Dietetics, Samsung Medical Center) ;
  • Lee, Moon-Kyu (Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Jang, Hak-Chul (Department of Internal Medicine, College of Medicine, Seoul National University) ;
  • Rha, Mi-Yong (Department of Dietetics, Samsung Medical Center) ;
  • Kim, Ji-Young (Department of Dietetics, Samsung Medical Center) ;
  • Park, Young-Mi (Department of Nutrition Care Services, Seoul National University of Bundang Hospital) ;
  • Sohn, Cheong-Min (Major in Food & Nutrition, Wonkwang University, Research institute of Human Resources Development, Wonkwang University)
  • 조영연 (삼성서울병원 영양파트) ;
  • 이문규 (성균관대학교 의과대학 삼성서울병원 내분비학교실) ;
  • 장학철 (서울대학교 의과대학 내과학교실) ;
  • 라미용 (삼성서울병원 영양파트) ;
  • 김지영 (삼성서울병원 영양파트) ;
  • 박영미 (분당서울대학교병원 영양실) ;
  • 손정민 (원광대학교 식품영양학, 원광대학교 생활자원개발연구소)
  • Published : 2008.03.31
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Abstract

Medical nutrition therapy (MNT) is considered a keystone of medical treatment of chronic diseases. However, only few studies have evaluated medical and economical outcome of MNT. The study was performed on the patient with type 2 diabetes mellitus to evaluate the effect of clinical and cost-effective outcomes of MNT. Subjects from two general hospitals were randomly assigned to two different groups; One receiving basic nutritional education (BE) (n = 35), and the other receiving intensive nutritional education (IE) (n = 32) for a 6-month clinical trial. The group which received BE had a single visit with a dietitian, while the other group which received IE had an initial visit with a dietitian addition to two visits during the first 4 weeks of the study periods. Anthropometric parameters, blood components, and dietary intake were measures at the beginning of study period and after 6 month. Cost-effective analysis included direct labor costs, educational materials and medication cost difference during 6 months. After 6 month, subjects from IE group showed significant reduction of body weight (p <0.05) and systolic blood pressure (p <0.05), whereas BE group did not show any significant changes. Result from biochemical indices showed glycated hemoglobin concentration was significantly reduced by 0.7% (p <0.05) only in the IE group. The ratio of energy intake to prescribed energy intake decreased significantly in both groups (p <0.05). Mean time taken for a dietitian to educate the subject was 67.9 ${\pm}$ 9.3 min/person for BE group, while 96.4 ${\pm}$ 12.2 min/person for IE group. Mean number of educational materials was 1.9 ${\pm}$ 0.7/person for BE group and 2.5 ${\pm}$ 0.7/person for IE group. Change in glycated hemoglobin level along the 6 month period of study can be achieved with an investment of \88,510/% by implementing BE and \53,691/% by implementing IE. Considering the net cost-effect of blood glucose control and HbA Ic, IE which provides MNT by dietitian had a cost efficiency advantage than that of BE. According to this study, MNT provided by dietitian had a significant improvements in medical and clinical outcomes compared to that of BE intervention. Therefore, MNT protocol should be performed by systemic intensive nutrition care by dietitian in clinical setting to achieve good therapeutic results of DM with lower cost.

우리나라의 경제적 발달과 문화 수준의 향상으로 질병 양상과 사망 원인에 많은 변화가 있는데, 그 중에서도 최근 당뇨병의 유병률의 상승 현상이 두드러지게 나타나고 있으며, 사망 원인의 수위를 차지하고 있다. 그러므로 이를 예방하고 당뇨병 합병증을 예방하기 위한 구체적이고 근거중심인 영양치료 방법의 제시가 절실한 실정이다. 미국영양사협회에서는 지속적으로 증가하는 당뇨병 유병율을 낮추기 위하여 생활습관의 개선을 목표로 임상영양치료의 표준화 지침을 제시하고 이에 따른 치료 효과 연구가 활발히 진행되고 있으나, 아직 국내에서는 많은 연구가 진행되고 있지 않은 현실이다. 따라서 본 연구에서는 이미 국외에서 사용되고 있는 지침에 근거하여 심층영양교육 방법을 실시하여 그 효과를 1회 교육만으로 시행되는 기본교육 방법과 비교하여 다음과 같으나 결과를 얻었다. 심층 및 기본영양교육 즉, 두 가지 교육 방법을 비교하였을 때 심층영양치료 방법을 실시한 경우 기본영양교육을 실시한 경우보다 혈당, 혈압 및 체중 강하 효과 면에서 유의적으로 개선효과가 있는 것으로 나타났다. 비용효과 면에서 장기간의 혈당변화 상태를 알 수 있는 당화혈색소의 경우 1%를 낮추기 위하여 소요되는 비용은 심층영양교육군에서 더 적었으며, 교육의 잠재 효과를 고려하였을 경우, 모든 혈당 검사 지표의 영양치료 비용 대비 효과 면에서 심층영양교육 방법이 기본영양교육 방법보다 앞서는 것으로 나타났다. 저비용 고치료 효과를 보여주고 있는 임상영양치료는 당노병과 같은 만성질환의 중요한 기본치료로 주목되고 있는 현 시점에서 영양치료행위의 의료 보험 급여화는 국민의 건강을 증진시키고, 국가적으로는 의료비 지출을 감소시키며 국민의 건강을 증진시키는데 큰 기여를 하는 합리적인 방안이라 생각된다. 따라서 현 비급여 수가로 되어 있는 교육수가를 급여화하여 많은 환자들에게 의료 혜택을 주는 일이 필요하리라 사료된다.

Keywords

References

  1. Lim HS, Chun JH, Kim YS, Nam MS. Effect of nutrition education on diabetic management in diabetic patients. Korean J Nutr 2001; 34(1): 69-78
  2. Park SW, Kim DJ, Min KW, Baik SH, Choi KM, Park IB, Park JH, Son HS, Ahn CW, Oh JY, Lee JY, Chung CH, Kim JY, Kim HY. Current status of diabetes management in Korea using national health insurance database. J Korean Diabetes Assoc 2007; 31 (4): 362-367 https://doi.org/10.4093/jkda.2007.31.4.362
  3. Kim JY, Kim HY, Kim HY, Min KW, Park SW, Park IB, Park JH, Baik SH, Son HS, Ahn CW, Oh JY, Lee SH, Lee JY, Chung CH, Choi KM, Choi IJ, Kim DJ. Current status of the continuity of ambulatory diabetes care and its impact on health outcomes and medical cost in Korea using national insurance database. J Korean Diabetes Assoc 2006; 30(5): 377-387 https://doi.org/10.4093/jkda.2006.30.5.377
  4. Delahanty L, Simkins SW, Camelon K. Expanded role of the dietitian in the diabetes control and complications trial: Implications for clinical practice. J Am Diet Assoc 1993; 93(7): 758- 764 https://doi.org/10.1016/0002-8223(93)91748-F
  5. The DCCT Research Group. Nutrition interventions for intensive therapy in the Diabetes Control and Complications Trial. J Am Diet Assoc 1993; 93(7): 768-772 https://doi.org/10.1016/0002-8223(93)91750-K
  6. The DCCT Research Group. The Diabetes Control and Complications Trial (DCCT) design and methodologic considerations for the feasibility Phase. Diabetes 1986; 35: 530-545 https://doi.org/10.2337/diabetes.35.5.530
  7. Franz MJ, Barry B, McClain K, Weaner T, Cooper N, Upham P, Bergenstal R, Mazze RS. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulindependent diabetes mellitus: A randomized, controlled, clinical trial. J Am Diet Assoc 1995: 95(9): 1009-1017 https://doi.org/10.1016/S0002-8223(95)00276-6
  8. Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ. Practice guidelines for medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 1995: 95(9): 999-1006 https://doi.org/10.1016/S0002-8223(95)00274-X
  9. Powers MA. Handbook of Diabetes Medical Nutrition Therapy. Silver spring: An ASPEN Publication; 1996. p.33-60
  10. Johnson EQ, Valera S. Medical Nutrition Therapy in non-insulin- dependent diabetes mellitus improves clinical outcome. J Am Diet Assoc 1995; 95(6): 700-701 https://doi.org/10.1016/S0002-8223(95)00192-1
  11. Franz MJ, Splett PL, Monk A, Barry B, McClain K, Weaver T, Upham P, Bergenstal R, Mazze RS. Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with noninsulin- dependent diabetes mellitus. J Am Diet Assoc 1995; 95(9): 1018-1024 https://doi.org/10.1016/S0002-8223(95)00277-4
  12. Moon SJ, Sohn CY, Kim JH, Kim HS, Lim HS, Lee HC, Huh KB. Measurement of nutrition counseling effects for diabetes mellitus patients. Korean J Nutr 1994; 27(10): 1070-1077
  13. Woo YJ, Lee HS, Kim WY. Individual diabetes nutrition education can help management for type II diabetes. Korean J Nutr 2006; 39(7): 641-648
  14. Sohn CM, Nho MR, Lee YH, Lim JH. The clinical and cost effectiveness of medical nutrition therapy in persons with hypercholesterolemia. J Korean Diet Assoc 1999; 9(1): 32-39
  15. Wing RR, Koeske R, Epstein LH, Nowalk MP, Becker D. Longterm effects of modest weight loss in type II diabetic patients. Arch Intern Med 1987; 14
  16. Watts NB, Spanheimer RG, DiGirolamo M, Gebhart SS, Musey VC, Siddiq K, Phillips LS. Prediction of glucose response to weight loss in patients with non-insulin-dependent diabetes mellitus. Arch Intern Med 1990; 150: 803-806 https://doi.org/10.1001/archinte.150.4.803
  17. Park YK, Lee JH, Yoon JY, Park EJ, Chung YS, Lee HC, Huh KB. Effects of weight loss on glucose and lipid metabolism in overweight or obese NIDDM patients. J Korean Diabetes Assoc 1994; 18(1): 31-39
  18. Sonnichsen AC, Richter WO, Schwandt P. Benefit from hypocaloric diet in obese men depends on the extent of weight-loss regarding cholesterol and a simultaneous change in body fat distribution regarding insulin sensitivity and glucose tolerance. Metabolism 1992; 41: 1035-1039 https://doi.org/10.1016/0026-0495(92)90134-V
  19. U.K prospective diabetes study (UKPDS) group. Tight blood pressure control and risk of microvascular and macrovascular complications in type 2 diabetes. Br Med J 1998: 317(7160): 703-713 https://doi.org/10.1136/bmj.317.7160.703
  20. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002; 25: 608-613 https://doi.org/10.2337/diacare.25.3.608
  21. American Diabetes Association. Summary of revision for the 2008 clinical practice recommendations. Diabetes Care 2008; 31(suppl 1): S3-S4 https://doi.org/10.2337/dc08-S003
  22. American Diabetes Association. Nutrition Recommendations and interventions for diabetes-A position statement of the American Diabetes Association. Diabetes Care 2008; 31(suppl 1): S61-S78 https://doi.org/10.2337/dc08-S061
  23. Stratton IM, Adler AI, Neil HAW, Mattews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. Br Med J 2000; 321: 405-412 https://doi.org/10.1136/bmj.321.7258.405
  24. Kim HA, Yan IS, Lee HY, Lee YE, Park EC, Nam CM. Evaluation of cost-effectiveness of medical nutrition therapy: Metaanalysis. Korean J Nutr 2003; 36(5): 515-527