한국 성인의 우울이 건강행태(매일흡연, 고위험음주, 걷기, 아침결식)에 미치는 영향: 국민건강영양조사 결과를 중심으로
Influence of Depression on Health Behavior (Daily Smoking, Binge Drinking, Walking, Skipping Breakfast) among Korean Adults: Based on the KNHANES
Article information
Abstract
목적
본 연구는 한국 성인의 우울증이 건강행태(매일 흡연, 폭음, 걷기, 아침식사 거르기)에 미치는 영향을 살펴보고자 하였다.
방법
한국 국민건강영양조사(2014, 2016, 2018, 2020, 2022)를 활용하여 분석하였고, 최종 표본은 누락 자료를 제외한 26,732건이었다. 데이터 분석은 다변량 로지스틱 회귀분석, 카이제곱 검정을 사용하였다.
결과
통제변수로 보정한 후, 우울증은 매일 흡연할 확률을 2.51배, 폭음할 확률을 1.85배, 일주일에 5일 이상 아침 식사를 거를 확률을 1.74배 통계적으로 유의미하게 증가시켰다. 우울증은 하루 30분 이상, 일주일에 5일 이상 걷는 확률을 30.0% 감소시켰다(AOR=0.70).
결론
본 연구는 우울증이 건강행태(매일흡연, 고위험음주, 걷기, 아침결식)에 부정적인 영향을 미친다는 것을 밝혀냈다. 이에 우울증 관리는 신체건강 증진에 매우 중요한 요소임을 알고, 신체건강 증진 프로그램에서 우울증이 있는 대상자를 우선적으로 관리할 것을 제안한다.
Trans Abstract
Objectives
This study aimed to examine the influence of depression on health behaviors (daily smoking, binge drinking, walking, skipping breakfast) among Korean adults.
Methods
The data for the study were obtained from the Korea National Health and Nutrition Examination Survey (2014, 2016, 2018, 2020, 2022). the final sample consisted of 26,732 cases after excluding missing data. Multivariate logistic regression, Cross-tabulation analysis were used for data analysis.
Results
After adjusting for covariates, depression was significantly associated with 2.51 increase in the odds of smoking daily and 1.85 increase in the odds of binge drinking and 1.74 increase in the odds of skipping breakfast five or more days a week. Depression was significantly associated with 30.0% decrease (adjusted odds ratio=0.70) in the odds of walking at least 30 minutes a day, five or more days a week.
Conclusions
The study found that depression negatively affects all major health behaviors (daily smoking, binge drinking, walking, skipping breakfast). Our findings suggest that managing depression is a crucial factor in promoting physical health, and it is important to target individuals with depression in physical health promotion programs.
INTRODUCTION
Depression is a highly common disorder in psychiatry, often referred to as ‘ the mental cold of modern people’ [1]. Moreover, depression is a significant social issue due to its high association with suicide [2]. According to the results of the Korea National Health and Nutrition Examination Survey (KNHANES), the prevalence of depressive disorder among Korean adults aged 19 and above was 6.7% in 2014, 5.6% in 2016, 4.3% in 2018, 5.7% in 2020, and 5.0% in 2022, showing a prevalence rate of approximately 5-6% [3]. With 22.6 suicides per 100,000 persons in 2022 (against the OECD average of 10.6), South Korea has the highest suicide rate among Organization for Economic Cooperation and Development (OECD) countries. Suicide is also the main cause of death for those between the ages of 10 and 30 [4].
Mental health and physical health doesn’ t operate independently; rather, they influence one another in both directions. Thus, a number of studies [5-17] have investigated the relationship between depression and health behaviors. Smoking [5,6,8,10-12,18] and drinking alcohol [6,12,13] have been linked to an increased risk of depression, according to numerous research. Several studies have reported that increased physical activity is associated with decreased depression [6,9,11,13,14], skipping meals is associated with increased depression, and eating more seafood is associated with decreased depression [6,7,10,17]. However, there has been little research on the impact of mental health on health behaviors (such as smoking, drinking, physical activity, and nutrition), with the majority of studies examining the relationship between mental health and physical health behaviors focusing on the influence of health behaviors on mental health (depression). Although there are some studies on the effects of mental health on health behaviors, most of the studies [19-22] have examined the effects on alcohol consumption and smoking, and there is a lack of research on physical activity and nutrition. Therefore, this study hypothesizes that depression will have a negative impact on health behaviors (smoking, alcohol consumption, physical activity, and nutrition), and by conducting a study to comprehensively confirm this hypothesis, this study aims to provide basic data for the establishment of health care policies.
METHODS
Study design
This study aimed to investigate the influence of depression on health behaviors (daily smoking, binge drinking, walking, skipping breakfast) among Korean adults. This study analyzed integrated data from five years (2014, 2016, 2018, 2020, 2022) in which the PHQ-9 (Patient Health Questionnaire-9), a tool for assessing depression, was investigated in the Korea National Health and Nutrition Examination Survey. Thus, the final sample consisted of 26,732 cases after excluding missing data.
Data source
The KNHANES utilized in this study is a nationwide survey conducted under Article 16 of the National Health Promotion Act established in 1995. This survey aims to investigate the health status, health behaviors, food and nutrition intake patterns of the Korean population, providing nationally representative and reliable data. It was conducted every three years from 1998 to 2005, and since 2007, it has been conducted annually to enhance the timeliness of national statistics. The survey employs a sample design to extract representative samples of Korean nationals residing in South Korea. This study analyzed the raw data in accordance with the regulations for public release and utilization of data set forth by KDCA (Korea Disease Control and Prevention Agency) [23]. This study utilized secondary data (KNHANES), so that the investigation agency obtained IRB approval before conducting the investigation. Additionally, we obtained an exemption of the IRB approval at our university (IRB No.: 2024-03(교)).
Variables
In this study, depression was designated as the independent variable, while health behaviors (daily smoking, binge drinking, walking, skipping breakfast) were set as dependent variables. Based on previous literature, variables (gender, age, household income, education level, marital status) that could potentially influence health behaviors were established as control variables [24-26].
Depression
The KNHANES includes 2 items related to depression such as ‘ a question about whether you have felt depressed’ and ‘ Patient Health Questionnaire-9 (PHQ-9).’ ‘ A question about whether you have felt depressed’ consists of a single question, asking ‘ Have you felt sad or hopeless for two weeks or more in the past 12 months?’ with response options ‘ yes’ or ‘ no.’ It is considered that using this item may have limitations in comprehensively capturing various dimensions of depressive symptoms in individuals. Therefore, this current study used the PHQ-9 for an in-depth evaluation of depressive symptoms. In the KNHANES, Participants were asked, ‘ How often have you been bothered by any of the following symptoms over the last 2 weeks?’ The PHQ-9 consist of 9 items to measure the severity of depression symptoms. Each of the 9 items was rated on a 4-point scale of 0 (not at all), 1 (several days), 2 (more than a week), and 3 (every day), and the answers were summed to obtain the total PHQ-9 score [23]. Based on previous studies, subjects with PHQ-9 score ≥10 (of 27 points) were defined as having depression in this study [27].
Health behavior
We defined those who reported smoking at least five packs (100 cigarettes) of lifetime and smoking every day currently as ‘ daily smoking group’ and all other subjects as ‘ non-daily smoking group.’ ‘ Binge drinking group’ was defined as consuming an average of more than 7 drinks per occasion for men or more than 5 drinks per occasion for women, and drinking twice a week or more. ‘ Walking group’ was defined as walking more than five days a week for at least 30 minutes per occasion. Regarding skipping breakfast, participants were asked, ‘ How many times did you have breakfast in a week during the past year?’ Answering ‘ never’ or ‘1-2 times a week’ was categorized as ‘ skipping breakfast group,’ while answering ‘3-4 times a week’ or ‘5-6 times a week’ was categorized as ‘ non-skipping breakfast group’ [23].
Sociodemographic characteristics
We used sex, age, income, education level, and marital status as confounding variables. Income was divided into quintiles, education level was categorized into four groups: elementary school or below, middle school, high school, and college or above. Marital status was categorized into ‘ spouse group’ and ‘ no spouse group (including single, divorced, separated, widowed)’ [24-26].
Statistical methods
The KNHANES utilized a complex sampling design to ensure the representativeness of the sample for the population. Therefore, analysis was conducted considering stratification, cluster, and weights. Cross-tabulation analysis was used to determine differences in health behaviors (daily smoking, binge drinking, walking, skipping breakfast) according to demographic characteristics and depression. To assess the influence of depression on health behaviors among Korean adults, complex sample logistic regression analysis was performed. Statistical analysis was conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
RESULTS
Characteristics of the study sample
The final sample included of 26,732 participants, and 50.4% were females. The age group of 35-64 years comprised the largest group at 56.8%, followed by 19-34 years at 26.5% and 65 years and older at 16.7%. Regarding education level, those with a college degree or higher comprised the largest group at 41.4%, followed by high school graduates at 36.9%, an elementary school education or below at 13.5%, and middle school graduates at 8.2%. Marital status indicated that 65.0% were living with a spouse, while 35.0% were living without spouse (single, divorced, separated, or widowed).
Depression was defined as a PHQ-9 score of 10 or above, with 5.3% having depression. Daily smoking was reported by 17.8% of the participants, and binge drinking was observed in 13.3% of the population. 40.2% of participants reported walking more than five days a week for at least 30 minutes per occasion, and 30.6% reported skipping breakfast more than five days a week (Table 1).
Characteristics of the study sample and health behavior (daily smoking, binge drinking, walking, skipping breakfast) according to characteristics
Differences in health behaviors (daily smoking, binge drinking, walking, skipping breakfast) by sociodemographic characteristics and depression
Rates of daily smoking were statistically significantly higher among men, young adults (19-34) and middle-aged adults (35-64), those with lower income, high school graduates, those not living with a spouse, and those who were depressed. Rates of binge drinking were statistically significantly higher among men, young adults (19-34) and middle-aged adults (35-64), high school graduates, and those who were depressed (Table 1).
Among young adults (19-34), higher income, higher education, not living with a spouse, and not depressed were statistically significantly associated with higher rates of walking (walking at least 30 minutes a day, five or more days a week). Breakfast skipping (not eating breakfast five or more days in a week) was statistically significantly higher among young adults (19-34), those with lower income, higher education, not living with a spouse, and those who were depressed (Table 1).
Influence of depression on health behavior (daily smoking, binge drinking, walking, skipping breakfast)
The association of depression with health behavior (daily smoking, binge drinking, walking, skipping breakfast) by multivariable binary logistic regression is shown in Table 2. After adjusting for covariates (sex, age, income, education level, marital status), depression was significantly associated with 2.51 increase in the odds of smoking daily and 1.85 increase in the odds of binge drinking and 1.74 increase in the odds of skipping breakfast five or more days a week. Depression was significantly associated with 30.0% decrease (adjusted odds ratio, AOR=0.70) in the odds of walking at least 30 minutes a day, five or more days a week.
Influence of depression on health behavior (daily smoking, binge drinking, walking, skipping breakfast)
DISCUSSION
The current study is to investigate the influence of depression on health behaviors (daily smoking, binge drinking, walking, skipping breakfast) among Korean adults. The important findings and discussions of this study are as follows.
First, our data found that depression increases the likelihood of daily smoking. Previous study [26] targeting 242,952 individuals from low-to middle-income countries has reported a 1.41 increase in the odds of smoking, emphasizing the importance of targeting individuals with depression in smoking cessation programs. Xiaoling et al. [22] found that depression increased the likelihood of smoking, and a systematic review of longitudinal studies in adolescent populations [28] reported that depression predicts smoking. Spring et al. [29] reported that when given a choice of pleasant activities, patients with major depression chose smoking twice as often compared with patients without psychiatric disorders.
Second, our data showed that depression increased the likelihood of binge drinking. A study conducted in the United States found that depression increased the likelihood of binge drinking by 1.18 times [22]. A study [20] targeting elderly individuals with multiple chronic health conditions (MCCs) in the United States insisted that those with MCCs and depression were nearly five times as likely to experience problem drinking as those with MCCs and no depression.
Third, the current study provides an evidence that depression reduce the odds of walking more than five days a week for at least 30 minutes per occasion. A study [21] conducted on Americans indicated that depression reduce the odds of vigorous physical activity by 37.0%, aligning with our findings. A study [19] based on the KNHANES reported that suicidal ideation reduces the odds of physical activity (AOR=0.69), while there was no statistically significant association between depression and physical activity. In the study, depression was assessed using a binary item indicating whether the participants had experienced depression, rather than the PHQ-9 scale. That might have acted as a limitation in the depth and accuracy of depression evaluation.
Fourth, In the current study, depression was associated with an increased likelihood of skipping breakfast for five or more days a week. It was difficult to find studies that examined the effect of skipping breakfast on depression. A few studies [7,10] in adults reported that skipping meals (breakfast or lunch) increases depression, whereas many studies [30,31] in adolescents found that skipping breakfast increases depression. These studies investigated the effect of skipping meals on depression, so they are not directly comparable to the results of our study, which analyzed the effect of depression on skipping meals. However, the findings of these studies are consistent with our analysis in that they show a positive correlation between skipping meals and depression.
The potential associations between depression and health risk behaviors (daily smoking, binge drinking, low walking practices, skipping breakfast) have important implications for health promotion interventions. An and Xiang [22] reported that depression increases smoking and heavy drinking, highlighting that health promotion programs should be mind-ful of these relationships in order to improve intervention effectiveness. In a study of childcare teachers in South Korea, Lee et al. [32] found that depression, social support, and self-efficacy influenced health promotion behaviors, suggesting that mental health care should be considered in physical health promotion programs.
In discussing the limitations of this study, the interpretation of causality between depression and health behaviors has limitations, because the data from the KNHANES used in this study were collected cross-sectionally. Therefore, future longitudinal studies are needed to elucidate the relationship between depression and health behaviors. In addition, depressive experiences were assessed using a self-report questionnaire rather than a physician diagnosis, which may differ from clinical depression [12].
Nevertheless, the current study holds significance for the following reasons. First, the data used in this study were collected through rigorous procedures by a reputable national agency, ensuring representativeness of the entire Korean population through stratified cluster sampling. Therefore, the results of this study can be presented as a general phenomenon among Korean adults. Second, to minimize confounding effects on health behaviors, our study adjusted for variables such as sex, age, household income, education level, and marital status during analysis. Third, our study evaluated the presence of depression more accurate-ly and comprehensively through using the PHQ-9 score, overcoming the limitations of dichotomous responses to a single question like ‘ Do you feel depressed?’ Fourth, most previous studies have primarily focused on investigating the influence of health behaviors (such as smoking, drinking, physical activity and nutrition) on mental health outcomes (such as depression). However, the current study delved into the influence of depression on health behaviors, and sought to fully understand how depression affects all major health behaviors (daily smoking, binge drinking, Low walking practices, skipping breakfast). Therefore, our study found that depression has a negative impact on all major health behaviors.
Our study discovered that depression had a detrimental impact on all main health (daily smoking, binge drinking, walking, skipping breakfast). Our findings indicate that addressing depression is essential for enhancing physical health, and it is imperative to focus on individuals with depression in physical health promotion initiatives.