Epidemiology and Health

Volume 45; 2023

Original Articles

Association of group-level segregation with cardiovascular health in older adults: an analysis of data from the Korean Social Life, Health, and Aging Project: Sung-Ha Lee, Hyeok-Hee Lee, Kiho Sung, Yoosik Youm, Hyeon Chang Kim; Epidemiol Health. 2023;45:e2023041. Published online April 4, 2023; DOI: https://doi.org/10.4178/epih.e2023041

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Abstract Summary PDF: Abstract
OBJECTIVES
The adverse health effects of individual-level social isolation (e.g., perceived loneliness) have been well documented in older adults. However, little is known about the impact of collective-level social isolation on health outcomes. We sought to examine the association of group-level segregation with cardiovascular health (CVH) in older adults.
METHODS
From the prospective Korean Social Life, Health, and Aging Project database, we identified 528 community-dwelling older adults who were aged ≥60 years or were married to those aged ≥60 years. Participants who belonged to smaller social groups separate from the major social group were defined as group-level-segregated. The CVH score was calculated as the number of ideal non-dietary CVH metrics (0-6), as modified from the American Heart Association’s Life’s Simple 7. Using ordinal logistic regression models, we assessed cross-sectional and longitudinal associations between group-level segregation and CVH.
RESULTS
Of the 528 participants (mean age, 71.7 years; 60.0% female), 108 (20.5%) were segregated at baseline. In the crosssectional analysis, group-level segregation was significantly associated with lower odds of having a higher CVH score at baseline after adjusting for socio-demographic factors and cognitive function (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43 to 0.95). Among 274 participants who completed an 8-year follow-up, group-level segregation at baseline was marginally associated with lower odds of having a higher CVH score at 8 years (OR, 0.49; 95% CI, 0.24 to 1.02).
CONCLUSIONS
Group-level segregation was associated with worse CVH. These findings imply that the social network structure of a community may influence its members’ health status.; Summary

Korean summary
본 연구는 “한국인의 사회적 삶, 건강과 노화에 대한 조사”(Korean Social Life, Health and Aging Project, KSHAP)에서 측정한 한 지역 내의 사회적 연결망 자료를 이용하여 사회적 분리와 심혈관 건강 사이의 관계를 살펴보았다. 그 결과, 사회적 분리는 비만, 고혈압, 콜레스테롤, 흡연, 음주 신체적 활동 등을 종합한 ‘라이프 심플 7’ 지표와 부정적인 관련성을 보였으며, 8년 후 추적 조사에서도 이 패턴이 유지되었다. 본 연구 결과는 사회적, 집단적 분리 현상이 신체적 건강에도 악영향을 초래할 수 있음을 시사한다.

Key Message
Using the prospective Korean Social Life, Health, and Aging Project (KSHAP) database, we discovered that group-level segregation was significantly associated with worse cardiovascular health (CVH). Also, we observed a tendency for baseline group-level segregation to be linked to worse CVH after an 8-year follow-up period. These findings emphasize the significance of group-level segregation as a potential contributing factor in the health outcomes of older adults.

Impact of statin treatment on cardiovascular events in patients with retinal vein occlusion: a nested case-control study in Korea: Joonsang Yoo, Joo Youn Shin, Jimin Jeon, Jinkwon Kim; Epidemiol Health. 2023;45:e2023035. Published online March 15, 2023; DOI: https://doi.org/10.4178/epih.e2023035

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Abstract PDF: Abstract
OBJECTIVES
Retinal vein occlusion (RVO) is associated with an increased risk of future cardiovascular events. Statin therapy is a key cornerstone in prevention for patients at high cardiovascular risk. However, little is known about the role of statin therapy for patients with RVO. This study evaluated whether statin treatment in patients with RVO was associated with a lower risk of cardiovascular events.
METHODS
A population-based, nested case-control study was conducted with a cohort of newly diagnosed RVO patients without prior cardiovascular disease between 2008 and 2020 using a nationwide health claims database in Korea. From this cohort of RVO patients, we identified cases of cardiovascular events (stroke or myocardial infarction) after RVO and matched controls based on sex, age, insurance type, antiplatelet use, and underlying comorbidities using 1:2 incidence density sampling.
RESULTS
Using a cohort of 142,759 patients with newly diagnosed RVO, we selected 6,810 cases and 13,620 matched controls. A significantly lower risk of cardiovascular events (adjusted odds ratio, 0.604; 95% confidence interval, 0.557 to 0.655) was observed in RVO patients with statin treatment than in those without statin treatment. Statin treatment was associated with a reduced risk for both stroke and myocardial infarction after RVO. Longer statin treatment after RVO was associated with a lower risk for cardiovascular events.
CONCLUSIONS
Statin treatment was associated with a lower risk for future cardiovascular events in patients with newly diagnosed RVO. Further studies are warranted to clarify the potential cardiovascular preventive role of statins in patients with RVO.; Summary

Korean summary

Key Message

Trends in socioeconomic inequalities in obesity among Korean adolescents: the Korea Youth Risk Behavior Web-based Survey (KYRBS) 2006 to 2020: Eunji Kim, Ga Bin Lee, Dong Keon Yon, Hyeon Chang Kim; Epidemiol Health. 2023;45:e2023033. Published online March 7, 2023; DOI: https://doi.org/10.4178/epih.e2023033

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study investigated recent trends in the prevalence of obesity among Korean adolescents and explored socioeconomic disparities in obesity.
METHODS
This study used annual self-reported data on height, weight, and socioeconomic information from the Korea Youth Risk Behavior Web-based Survey from 2006 to 2020. With a 95.8% response rate, the sample consisted of 818,210 adolescents. Obesity prevalence was calculated according to 4 socioeconomic indicators (household income, father’s educational attainment, mother’s educational attainment, and urbanicity). Socioeconomic inequality was quantified using the relative index of inequality (RII).
RESULTS
The overall prevalence of obesity increased, doubling from 5.9% in 2006 to 11.7% in 2020. Boys and high school students showed a higher prevalence. The RIIs in household income and parental educational attainments significantly increased with time, indicating a growing inequality in obesity. Socioeconomic disadvantages had a greater influence on obesity among girls. The most recent RII values for boys were 1.25 for income, 1.79 for the father’s education, and 1.45 for the mother’s education, whereas the corresponding values for girls were 2.49, 3.17, and 2.62, respectively.
CONCLUSIONS
These findings highlight growing inequalities in adolescent obesity according to household income and parental educational attainments, especially for girls and middle schoolers.; Summary

Korean summary
2006년부터 2020년까지 청소년 비만의 유병은 증가 추세에 있을 뿐 아니라, 가정의 경제상태, 부모의 학력수준에 따른 비만의 위험 격차도 점점 심해지는 추세를 보였다. 특히, 남학생과 고등학생의 비만 유병률이 높게 나타났으나, 사회경제적 지표에 따른 비만의 불평등 격차는 여학생과 중학생에서 높게 나타났다.

Key Message
Not only the prevalence but also socioeconomic inequality in adolescent obesity increased between 2006 and 2020. The potential impact of socioeconomic disparity on obesity was greater in girls and middle school students than their counterparts.

Risk of chronic periodontitis in patients with obstructive sleep apnea in Korea: a nationwide retrospective cohort study: Seon-Rye Kim, Minkook Son, Yu-Rin Kim; Epidemiol Health. 2023;45:e2023032. Published online March 6, 2023; DOI: https://doi.org/10.4178/epih.e2023032

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Abstract Summary PDF: Abstract
bacteOBJECTIVES: The aim of this study was to determine whether the development of chronic periodontitis is more likely among patients who have been newly diagnosed with obstructive sleep apnea (OSA) through an analysis of representative data from the general population.
METHODS
A nationwide, population-based, retrospective cohort study was conducted using patient records from the Korean National Health Insurance Service database. For the period 2004-2019, patient data were categorized into 2 groups: a diagnosis of OSA (747 subjects) and no diagnosis of OSA (1,494 subjects). Subsequently, 1:2 propensity score matching was performed to ensure the homogeneity of the 2 groups. To analyze the risk of incident chronic periodontitis, a Cox proportional-hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).
RESULTS
In the Kaplan-Meier curve, the disease-free probability was significantly lower in the OSA group than in the non-OSA group (p for log-rank test=0.001). The crude HR for the association between OSA and chronic periodontitis was 1.29 (95% CI, 1.16 to 1.43). The multivariable-adjusted HR was calculated at 1.28 (95% CI, 1.15 to 1.42).
CONCLUSIONS
This study confirmed a relationship between OSA and chronic periodontitis. Therefore, OSA patients require oral care to prevent the progression of chronic periodontitis from mild to severe.; Summary

Korean summary
폐쇄성수면무호흡증 환자의 만성치주염 발생위험 차이를 분석한 결과, 폐쇄성수면무호흡증 그룹에서 만성치주염의 발생위험이 높았다. 따라서 폐쇄성수면무호흡증 환자의 만성치주염 초기치료 및 질환의 진행이 되지 않도록 전문가의 효과적인 구강관리가 필요할 것이다.

Key Message
As a result of analyzing the difference in the risk of chronic periodontitis among patients with obstructive sleep apnea, the risk of chronic periodontitis was higher in the obstructive sleep apnea group. Therefore, effective oral care by experts will be necessary to prevent the initial treatment of chronic periodontitis and progression of the disease in patients with obstructive sleep apnea.

Clinical traits and systemic risks of familial diabetes mellitus according to age of onset and quantity: an analysis of data from the community-based KoGES cohort study: Ju-Yeun Lee, Kyungsik Kim, Sangjun Lee, Woo Ju An, Sue K. Park; Epidemiol Health. 2023;45:e2023029. Published online February 23, 2023; DOI: https://doi.org/10.4178/epih.e2023029

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
The aim of this study was to clarify the clinical trait of familial diabetes mellitus (DM) by analyzing participants’ risk of DM according to the age of DM onset in parents and siblings, and to evaluate individuals’ risk of DM-associated cardiometabolic diseases.
METHODS
Altogether, 211,173 participants aged ≥40 years from the Korean Genome and Epidemiology Study were included in this study. The participants were divided into groups based on the number (1 or 2 relatives) and age of onset (no DM and early, common, or late onset) of familial DM. Participants’ risk of DM was assessed using a Cox regression model with hazard ratios and 95% confidence intervals (CIs). A logistic regression model with odds ratios was used to evaluate associations among the participants’ likelihood of acquiring cardiometabolic diseases such as hypertension, chronic kidney disease (CKD), and cardiovascular disease.
RESULTS
The risk of developing DM was 2.02-fold (95% CI, 1.88 to 2.18) and 2.88-fold (95% CI, 2.50 to 3.33) higher, respectively, in participants with 1 and 2 family members diagnosed with familial DM. It was 2.72-fold (95% CI, 2.03 to 3.66) higher in those with early-onset familial DM. In the early-onset group, the respective risks of hypertension and CKD were 1.87-fold (95% CI, 1.37 to 2.55) and 4.31-fold (95% CI, 2.55 to 7.27) higher than in the control group.
CONCLUSIONS
The risk of DM and related cardiometabolic diseases was positively associated with the number of family members diagnosed with DM and an early diagnosis in family members with DM.; Summary

Korean summary
본 연구는 한국인유전체역학조사사업 역학자료를 이용하여, 당뇨병을 진단받은 가족 구성원 (부모 및 형제)의 수가 많고 당뇨병이 조기에 발생할수록 개인의 당뇨발생 위험도가 높아짐을 보고하였습니다. 또한 당뇨병이 조기에 발생한 가족구성원이 있을 경우 개인의 일부 심대사질환과의 연관성이 있을 수 있음을 설명하였습니다.

Key Message
This study demonstrated that the risk of diabetes in individuals was significantly associated with the quantity and the onset of family members diagnosed with diabetes. We also explained that having a family member with early-onset diabetes can be associated with some cardiometabolic diseases in individuals.

Physical activity, sedentary behavior, and cardiovascular disease risk in Korea: a trajectory analysis: Jina Han, Yeong Jun Ju, Soon Young Lee; Epidemiol Health. 2023;45:e2023028. Published online February 22, 2023; DOI: https://doi.org/10.4178/epih.e2023028

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Abstract PDF: Abstract
OBJECTIVES
To identify the distinct trajectories of sedentary behavior (SB) and explore whether reduced cardiovascular disease (CVD) risk was associated with a distinct trajectory of physical activity (PA).
METHODS
We analyzed data from 6,425 people who participated in the Korean Health Panel Survey over a period of 10 years. The participants’ self-reported SB and PA were assessed annually, and trajectory groups were identified using a group-based trajectory model for longitudinal data analysis. Logistic regression analysis was performed to assess the association between CVD risk (10-year cumulative incidence) and the trajectories of SB and PA. The adjusted variables included socio-demographic factors, the predisposing diseases of CVD, and baseline health behaviors.
RESULTS
Trajectory analysis identified 4 SB trajectory groups: SB group 1 (low and slightly increasing trend, 53.1%), SB group 2 (high and rapidly decreasing trend, 14.7%), SB group 3 (high and slightly decreasing trend, 9.9%), and SB group 4 (low and rapidly increasing trend, 22.2%). The 3 PA trajectory groups were PA group 1 (moderate and slightly decreasing trend, 32.1%), PA group 2 (low and slightly decreasing trend, 57.3%), and PA group 3 (maintained inactivity, 10.7%). By the 10-year follow-up, 577 cases of incident CVD had occurred. We also noted a 50% reduction in the risk of CVD when SB group 4 was accompanied by PA group 1 (odds ratio, 0.50; 95% confidence interval, 0.28 to 0.90).
CONCLUSIONS
Despite increased time spent in SB, maintaining PA about 2 days to 3 days per week reduced the occurrence of CVD.; Summary

Korean summary

Key Message

Dynamic changes in clinical biomarkers of cardiometabolic diseases by changes in exercise behavior, and network comparisons: a community-based prospective cohort study in Korea: JooYong Park, Jaesung Choi, Ji-Eun Kim, Sang-Min Park, Joo-Youn Cho, Daehee Kang, Miyoung Lee, Ji-Yeob Choi; Epidemiol Health. 2023;45:e2023026. Published online February 16, 2023; DOI: https://doi.org/10.4178/epih.e2023026

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Abstract Summary PDF: Abstract
OBJECTIVES
Lifestyles, including exercise behaviors, change continually over time. This study examined whether the clinical biomarkers (CBs) related to cardiometabolic diseases (CMDs) and their relationships differed with changes in exercise behavior.
METHODS
The Ansan-Ansung cohort study (third to fifth phases; n=2,668) was used in the current study. Regular exercise behavior was investigated using a yes/no questionnaire. Changes in exercise behavior were classified into 4 groups: Y-N, N-Y, Y-Y, and N-N, with “Y” indicating that a participant regularly engaged in exercise at a given time point and “N” indicating that he or she did not. Fourteen CBs related to CMDs were used, and the associations between changes in exercise behavior and relative changes in CBs were examined. CB networks were constructed and topological comparisons were conducted.
RESULTS
Y-N was associated with increases in fasting blood sugar and insulin levels in men, and increased total cholesterol and low-density lipoprotein cholesterol levels in women. Meanwhile, N-Y was inversely associated with body fat percentage, visceral fat percentage, fasting insulin, and triglyceride level. Waist circumference played a central role in most networks. In men, more edges were found in the N-Y and Y-Y groups than in the N-N and Y-N groups, whereas women in the N-Y and Y-Y groups had more edges than those in the N-N and Y-N groups.
CONCLUSIONS
Consistent exercise or starting to engage in regular exercise had favorable effects on CBs related to CMDs, although their network patterns differed between the sexes.; Summary

Korean summary
한국 지역사회기반 코호트 자료를 이용하여, 운동 행태 변화에 따른 심혈관대사질환 관련 임상 생체 지표들의 변화가 남녀에 따라, 변화 행태에 따라 다르게 나타남을 확인하였다. 이런 변화와 차이는 네트워크 분석을 통한 구조적인 차이로도 확인되었다.

Key Message
This study examined that changes in the clinical biomarkers related to cardiometabolic diseases differed with changes in exercise behavior using a community-based prospective cohort study in Korea. Consistent exercise or change into exercise behavior had favorable effects on CB related to CMD, although their network patterns differed between the sexes.

COVID-19: Brief Communication

Prevalence of SARS-CoV-2 infection among urban cleaning and solid waste management workers during transmission of the Omicron variant in Brazil: Paulo Ricardo Martins-Filho, Joyce Thayane da Conceição dos Santos, Márcia Santos Rezende, Fernanda Oliveira de Carvalho, Érica Santos dos Reis, Waneska de Souza Barboza, Taise Ferreira Cavalcante, Cliomar Alves dos Santos, Lucindo José Quintans-Júnior, Renata Grespan, Cristiane Bani Corrêa, Tatiana Rodrigues de Moura, Dulce Marta Schimieguel, Jullyana de Souza Siqueira Quintans, Adriano Antunes de Souza Araújo; Epidemiol Health. 2023;45:e2023025. Published online February 16, 2023; DOI: https://doi.org/10.4178/epih.e2023025

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Abstract PDF: Abstract
This study estimated the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in urban cleaning and solid waste management workers during the transmission of the Omicron variant in one of the poorest regions of Brazil (the state of Sergipe). Nasopharyngeal swabs were collected from 494 workers, and the presence of SARS-CoV-2 RNA was tested by quantitative reverse-transcriptase polymerase chain reaction. Data on socio-demographic characteristics, comorbidities, vaccination status, mask use, and use of public transport to commute to the workplace were collected. The prevalence with a 95% confidence interval (CI) was calculated from the proportion of SARS-CoV-2 positive cases among the total number of individuals tested. The prevalence ratio (PR) with a 95% CI was the measure of association used to evaluate the relationship between SARS-CoV-2 infection and the exposure variables. The prevalence of SARS-CoV-2 infection was 22.5% (95% CI, 19.0 to 26.4). Individuals under the age of 40 had a higher prevalence of infection (PR, 1.53; 95% CI, 1.03 to 2.30) as well as those who did not believe in the protective effect of vaccines (PR, 1.78; 95% CI, 1.05 to 2.89). Our results indicate the need for better guidance on preventive measures against coronavirus disease 2019 among urban cleaning and solid waste management workers.; Summary

Korean summary

Key Message
Urban cleaning and waste management workers in Brazil faced a significant risk of SARSCoV-2 infection during the Omicron variant transmission, with higher rates observed among younger individuals and those skeptical about vaccine protection.

Original Articles

Quantifying the effects of anomalies of temperature, precipitation, and surface water storage on diarrhea risk in Taiwan: Gerry Andhikaputra, Ayushi Sharma, Amir Sapkota, Hao He, Yu-Kai Lin, Li-Wen Deng, Yu-Chun Wang; Epidemiol Health. 2023;45:e2023024. Published online February 15, 2023; DOI: https://doi.org/10.4178/epih.e2023024

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Abstract PDF: Abstract
OBJECTIVES
Diarrheal disease continues to be a significant cause of morbidity and mortality. We investigated how anomalies in monthly average temperature, precipitation, and surface water storage (SWS) impacted bacterial, and viral diarrhea morbidity in Taiwan between 2004 and 2015.
METHODS
A multivariate analysis using negative binomial generalized estimating equations was employed to quantify age-specific and cause-specific cases of diarrhea associated with anomalies in temperature, precipitation, and SWS.
RESULTS
Temperature anomalies were associated with an elevated rate of all-cause infectious diarrhea at a lag of 2 months, with the highest risk observed in the under-5 age group (incidence rate ratio [IRR], 1.03, 95% confidence interval [CI], 1.01 to 1.07). Anomalies in SWS were associated with increased viral diarrhea rates, with the highest risk observed in the under-5 age group at a 2-month lag (IRR, 1.27; 95% CI, 1.14 to 1.42) and a lesser effect at a 1-month lag (IRR, 1.18; 95% CI, 1.06 to 1.31). Furthermore, cause-specific diarrheal diseases were significantly affected by extreme weather events in Taiwan. Both extremely cold and hot conditions were associated with an increased risk of all-cause infectious diarrhea regardless of age, with IRRs ranging from 1.03 (95% CI, 1.02 to 1.12) to 1.18 (95% CI, 1.16 to 1.40).
CONCLUSIONS
The risk of all-cause infectious diarrhea was significantly associated with average temperature anomalies in the population aged under 5 years. Viral diarrhea was significantly associated with anomalies in SWS. Therefore, we recommend strategic planning and early warning systems as major solutions to improve resilience against climate change.; Summary

Korean summary

Key Message
New study reveals the impact of climate on diarrheal diseases in Taiwan. Anomalies have been adopted to represent the changes in the historical context of climate. Temperature anomaly was linked to increased infectious diarrhea, especially in the young population. Anomaly in surface water storage (SWS) was associated with higher rates of viral diarrhea. Extreme weather events further contribute to the risks. Urgent need for strategic planning and early warning systems to combat climate change and improve resilience are recommended.

Trends and all-cause mortality associated with multimorbidity of non-communicable diseases among adults in the United States, 1999-2018: a retrospective cohort study: Mengzi Sun, Ling Wang, Xuhan Wang, Li Tong, Lina Jin, Bo Li; Epidemiol Health. 2023;45:e2023023. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023023

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Abstract PDF Supplementary Material: Abstract
OBJECTIVES
Multimorbidity of non-communicable diseases (NCDs) has brought enormous challenges to public health, becoming a major medical burden. However, the patterns, temporal trends, and all-cause mortality associated with NCD multimorbidity over time have not been well described in the United States.
METHODS
All adult participants were sourced from nationally representative data from the National Health and Nutrition Examination Survey. In total, 55,081 participants were included in trend analysis, and 38,977 participants were included in Cox regression.
RESULTS
The 5 NCDs with the largest increases over the study period were diabetes, osteoporosis, obesity, liver conditions, and cancer. The estimated prevalence of multimorbidity increased with age, especially for middle-aged participants with 5 or more NCDs; in general, the prevalence of NCD multimorbidity was higher among females than males. Participants with 5 or more NCDs were at 4.49 times the risk of all-cause mortality of participants without any diseases. Significant interactions were found between multimorbidity and age group (p for interaction <0.001), race/ethnicity (p for interaction<0.001), and educational attainment (p for interaction=0.010).
CONCLUSIONS
The prevalence of multiple NCDs significantly increased from 1999 to 2018. Those with 5 or more NCDs had the highest risk of all-cause mortality, especially among the young population. The data reported by this study could serve as a reference for additional NCD research.; Summary

Korean summary

Key Message
This study included a series-cross sectional study and a retrospective cohort study, utilizing nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Multimorbidity of non-communicable diseases (NCDs) has brought enormous challenges to public health, becoming a major medical burden. This study aimed to explore the patterns, temporal trends, and all-cause mortality of multimorbidity of NCDs in the United States from 1999 to 2018, by gender-specific and age-specific. The data reported by this study could serve as a reference for additional NCD research.

Changes in mental health service utilization before and during the COVID-19 pandemic: a nationwide database analysis in Korea: Kyoung Hoon Kim, Sang Min Lee, Minha Hong, Kyu-Man Han, Jong-Woo Paik; Epidemiol Health. 2023;45:e2023022. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023022

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
The present study examined the impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health service utilization through a comparative analysis of nationwide data regarding inpatient care users, outpatient visits, emergency department (ED) visits, and admissions via the ED before and during the pandemic.
METHODS
Data from approximately 350,000 Koreans diagnosed with mental illness were analyzed in terms of hospitalization, outpatient visits, and ED visits between January 2018 and June 2021. An interrupted time series analysis was conducted to determine the significance of changes in mental health service utilization indicators.
RESULTS
The number of hospital admissions per patient decreased by 1.2% at the start of the pandemic and 0.7% afterward. The length of hospital stay increased by 1.8% at the outbreak of the pandemic, and then decreased by 20.2%. Although the number of outpatients increased, the number of outpatient visits per patient decreased; the number of outpatient visits for schizophrenia (3.4%) and bipolar disorder (3.5%) significantly decreased immediately post-outbreak. The number of ED visits per patient decreased both immediately post-outbreak and afterward, and ED visits for schizophrenia (19.2%), bipolar disorder (22.3%), and depression (17.4%) decreased significantly immediately post-outbreak. Admissions via the ED did not show a significant change immediately post-outbreak.
CONCLUSIONS
Mental health service utilization increased during the pandemic, but medical service use decreased overall, with a particularly significant decrease in ED utilization. As the pandemic worsened, the decline in outpatient visits became more pronounced among those with severe mental illness.; Summary

Korean summary
이 연구는 COVID-19 전후 정신질환 의료서비스 이용 변화를 분석하였다. 팬데믹 기간 중에 정신질환 의료서비스는 전반적으로 감소하였고, 특히 중증 정신질환의 외래 방문이 감소하였다. 따라서, 정신질환자의 진료 연속성을 보장하기 위한 조치가 요구된다.

Key Message
This study examined the impact of the COVID-19 pandemic on mental health service utilization. The mental health service utilization decreased overall after the outbreak of COVID-19, especially outpatient visits for severe mental illness significantly decreased. Therefore, countermeasures are needed to maintain the continuity of care.

Changes in the treatment rate of patients newly diagnosed with stage IV cancer near the end of life from 2012 to 2017 in Korea: Kyuwoong Kim, Hyun Jung Jho, So Jung Park, Bohyun Park, Jin Young Choi; Epidemiol Health. 2023;45:e2023021. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023021

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study aimed to evaluate changes in the cancer treatment rate among patients newly diagnosed with stage IV cancer using socio-demographic and clinical subgroups in a nationwide cohort of Korean patients.
METHODS
This retrospective, national-level study used the Korea Central Cancer Registry (KCCR), which is linked to the National Health Insurance Service (NHIS) database, from January 1, 2012 to December 31, 2017. The records of patients newly diagnosed with stage IV of the 5 cancers with the highest cancer-related mortality rate were identified to analyze changes in the treatment rate. The main outcome examined in this study was the change in the cancer treatment rate between 2012 and 2017, as measured using the annual percent change (APC).
RESULTS
A total of 106,082 patients with newly diagnosed gastric, colorectal, liver, pancreatic, and lung cancers at the end of life (EoL) were identified from the KCCR-NHIS database. Of these patients, 76,533 (72.1%) received cancer treatment. Over the study period (2012-2017), the proportion of patients who received cancer treatment at EoL decreased by 8.3%, with an APC of -2.1% (95% confidence interval, -2.6 to -1.6). This declining trend of cancer treatment among patients with advanced cancer stage at EoL was consistent among socio-demographic and clinical subgroups.
CONCLUSIONS
The proportion of untreated patients with stage IV cancer is increasing in the Korea. For patients who are not undergoing standard cancer treatment near EoL, an alternative care plan, such as early palliative care, should be considered.; Summary

Korean summary
국민건강보험공단과 중앙암등록본부 자료를 활용하여 4기 암환자의 암 치료 비율 추이를 분석한 결과 2012년부터 2017년까지 위암, 대장암, 간암, 췌장암, 폐암으로 진단받은 4기 암환자들의 암 치료 비율의 연간비율변화는 8.3% 감소하는 것으로 나타났다. 이러한 결과는 인구사회학적 및 임상적 특성에 관계없이 일관되었다. 본 연구결과는 말기에 가까운 4기 암 환자들이 표준 치료를 받지 못하는 경우, 조기 완화의료와 같은 대안적인 계획을 고려할 필요가 있음을 시사한다.

Key Message
● Between 2012 and 2017, there was a significant decrease in the treatment rate among these patients, though most still received cancer treatment. ● Alternative clinical choices, such as the early utilization of hospice and palliative care, may improve quality of life and reduce the need for aggressive care for such patients.

Evaluation of an air quality warning system for vulnerable and susceptible individuals in Korea: an interrupted time series analysis: YouHyun Park, Jun Hyuk Koo, Hoyeon Jeong, Ji Ye Jung, Changsoo Kim, Dae Ryong Kang; Epidemiol Health. 2023;45:e2023020. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023020

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study was conducted to elucidate the effects of an air quality warning system (AQWS) implemented in January 2015 in Korea by analyzing changes in the incidence and exacerbation rates of environmental diseases.
METHODS
Data from patients with environmental diseases were extracted from the National Health Insurance Service-National Sample Cohort database from 2010 to 2019, and data on environmental risk factors were acquired from the AirKorea database. Patient and meteorological data were linked based on residential area. An interrupted time series analysis with Poisson segmented regression was used to compare the rates before and after AQWS introduction. Adjustment variables included seasonality, air pollutants (carbon monoxide, nitrogen dioxide, sulfur dioxide, particulate matter less than 10 μm in diameter, and ozone), temperature, and humidity.
RESULTS
After AQWS implementation, the incidence of asthma gradually decreased by 20.5%. Cardiovascular disease and stroke incidence also significantly decreased (by 34.3 and 43.0%, respectively). However, no immediate or gradual decrease was identified in the exacerbation rate of any environmental disease after AQWS implementation. Sensitivity analyses were performed according to age, disability, and health insurance coverage type. Overall, the AQWS effectively mitigated the occurrence of most environmental diseases in Korea. However, the relationships between alarm system implementation and reduced incidence differed among diseases based on the characteristics of vulnerable and sensitive individuals.
CONCLUSIONS
Our results suggest that by tailoring the AQWS to demographic and sociological characteristics and providing enhanced education about the warning system, interventions can become an efficient policy tool to decrease air pollution-related health risks.; Summary

Korean summary
한국에서 미세먼지경보제의 시행은 환경성질환의 발생률을 점진적으로 감소시켰으나, 민감·취약계층 특징에 따라 정책 시행에 영향을 받은 환경성질환 종류는 상이하였다. 한편, 기존 환경성질환 환자의 악화(입원 또는 응급실 방문)의 경우 미세먼지경보제 시행으로 인한 영향은 파악되지 않았다.

Key Message
Air Quality Warning System (AQWS) effectively mitigated the occurrence of most environmental diseases in Korea. The relationships between alarm system implementation and reduced incidence differed among diseases based on the characteristics of vulnerable and sensitive individuals.

COVID-19: Special Article

Changes in mental health of Korean adolescents before and during the COVID-19 pandemic: a special report using the Korea Youth Risk Behavior Survey: Bomi Park, Jihee Kim, Jieun Yang, Sunhye Choi, Kyungwon Oh; Epidemiol Health. 2023;45:e2023019. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023019

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We aimed to study the effects of the coronavirus disease 2019 (COVID-19) pandemic on adolescents’ mental health in Korea.
METHODS
We used data from the Korea Youth Risk Behavior Survey 2018-2021 with 227,139 students aged 12-18 years. We estimated the differences in depressive symptoms, suicidal ideation, and stress perception before (2018-2019) and during (2020-2021) the pandemic, as well as before (2019), the first year (2020) of, and the second year (2021) of the pandemic. We also examined whether COVID-19 is statistically associated with mental health.
RESULTS
In both male and female adolescents, the prevalence of depressive symptoms, suicidal ideation, and stress perception was higher in the “not living with family,” “low household economic status,” and “self-rated unhealthy status” subgroups. The prevalence of depressive symptoms and stress perception was higher in middle school students. Adolescents were less likely to experience depressive symptoms (adjusted odds ratio [aOR], 0.86; 95% confidence interval [CI], 0.83 to 0.89), suicidal ideation (aOR, 0.80; 95% CI, 0.76 to 0.83), and stress perception (aOR, 0.76; 95% CI, 0.74 to 0.79) in 2020 than in 2019. However, there were more depressive symptoms (aOR, 1.06; 95% CI, 1.02 to 1.09), suicidal ideation (aOR, 1.15; 95% CI, 1.10 to 1.21), and stress perception (aOR, 1.19; 95% CI, 1.16 to 1.23) in 2021 than in 2020.
CONCLUSIONS
The COVID-19 pandemic had positive impacts on mental health of adolescents in its early stages but has had negative impacts as the pandemic continues. Attention should be paid to adolescents who are particularly vulnerable to the mental health effects of the pandemic.; Summary

Korean summary
The results from a nationally representative data showed that mental health in adolescents was improved in the first year of the COVID-19 pandemic compared to before the COVID-19 pandemic, but it was deteriorated in the second year of the pandemic compared to the first year.

Key Message
본 연구에서는 대규모 건강조사를 이용하여 코로나19가 장기화됨에 따른 영향을 평가하고자 하였다. 2018년-2021년 청소년건강행태조사에 참여한 만 12-18세 청소년 227,139 명을 대상으로 분석한 결과, 코로나19 유행 첫번째 해(2020년)에는 코로나19 유행 이전에 비해 정신건강이 개선되었으나, 코로나19 유행 두 번째 해(2021년)에는 코로나19 유행 첫 번째 해에 비해 청소년 정신건강이 나빠졌다. 또한 가족과 함께 거주하지 않는 경우, 가정 경제 수준이 낮은 경우, 본인이 건강하지 않다고 인지하는 경우에 더 취약하였다.

COVID-19: Special Article

Changes in health behaviors and obesity of Korean adolescents before and during the COVID-19 pandemic: a special report using the Korea Youth Risk Behavior Survey: Chang-Mo Oh, Yangha Kim, Jieun Yang, Sunhye Choi, Kyungwon Oh; Epidemiol Health. 2023;45:e2023018. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023018

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study aimed to investigate changes in health behaviors, including cigarette smoking, alcohol drinking, physical activity, dietary behaviors, and obesity, before and during the coronavirus disease 2019 (COVID-19) pandemic using the Korea Youth Risk Behavior Survey (KYRBS) database.
METHODS
KYRBS data from 2015 to 2021 were used in this study. Differences in health behaviors between before (pre-pandemic period: 2018-2019) and during (pandemic period: 2020-2021) the pandemic were examined. Differences were compared using linear regression and the chi-square test considering the complex survey design after adjusting for grade level.
RESULTS
The prevalence of current cigarette smoking and current alcohol drinking significantly decreased in both male and female students during the pandemic compared to the pre-pandemic period. However, the prevalence of obesity significantly increased in both male and female students during the same period. When examining physical activity and dietary behaviors closely related to obesity, fast food consumption increased and fruit consumption decreased during the pandemic in both male and female students, whereas no significant changes in physical activity were observed in either male or female students.
CONCLUSIONS
The deterioration of adolescent dietary behaviors and an increase in the prevalence of obesity can increase the future disease burden, and concerted efforts at the individual and national levels are needed to reduce obesity and promote healthy dietary behaviors.; Summary

Korean summary
이 연구는 한국 청소년건강행태조사자료(KYRBS)를 사용하여 코로나19 유행 전후의 우리나라 청소년들의 흡연, 음주, 신체활동, 식습관, 비만 등의 건강행태의 변화에 대하여 살펴보고자 하였다. 이 연구에서는 2015년부터 2021년까지의 청소년건강행태조사자료를 사용하여, 코로나19 유행 이전 (2018-2019년)과 코로나 유행 이후 (2020-2021년) 기간의 건강행태의 변화에 대하여 조사하였다. 학년레벨을 보정한 후, 복합표본설계를 고려하여 로지스틱 회귀분석과 카이제곱검정을 이용하여 코로나19 유행 이전 (2018-2019년)과 비교하여, 코로나 유행 이후 (2020-2021년) 기간의 건강행태의 변화가 있었는지에 대하여 확인하였다. 그 결과, 코로나19 유행 이전 (2018-2019년)과 비교하여, 코로나19 유행 기간(2020-2021년) 동안에 현재흡연율과 현재음주율이 유의하게 감소하였다. 그러나 동일한 기간 동안에 남학생과 여학생 모두에서 비만율이 유의하게 증가하였는데, 비만율과 관련된 신체활동 및 식습관에 대하여 살펴보았을 때, 신체활동에서는 유의한 변화가 없었던 반면, 남학생과 여학생 모두에서 패스트푸드 섭취는 증가하고 과일섭취가 감소한 것으로 나타났다. 따라서 코로나19 유행기간 동안 흡연율 및 음주율 등의 청소년 건강에 유익한 변화도 있었으나, 비만율도 같이 증가한 것을 확인할 수 있었다. 청소년기의 식습관의 악화 및 비만율의 증가는 미래 우리나라의 질병부담을 증가시킬 수 있기 때문에, 청소년의 비만율을 낮추고 건강한 식습관을 증진시키기 위한 개인 및 사회 차원의 노력이 필요하다.

Key Message
-The current cigarette smoking and current alcohol drinking rates significantly decreased among Korean adolescents during the pandemic period compared to the pre-pandemic period. -On the other hand, the obesity rate increased significantly especially among Korean male adolescents, which is accompanied by changes in dietary habits such as an increase in fast food intake and a decrease in fruit intake.

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