Epidemiology and Health

Volume 46; 2024

Original Article

Genetic associations and parent-of-origin effects of PVRL1 in non-syndromic cleft lip with or without cleft palate across multiple ethnic populations: Ji Wan Park, Geon Kang, Seung-Hak Baek, Young Ho Kim; Epidemiol Health. 2024;46:e2024069. Published online August 9, 2024; DOI: https://doi.org/10.4178/epih.e2024069

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Abstract PDF: Abstract
OBJECTIVES
This study investigated the associations of PVRL1 gene variants with non-syndromic cleft lip with or without cleft palate (NSCL/P) by evaluating transmission distortion and parent-of-origin (POO) effects in multiple ethnic populations.
METHODS
We conducted allelic and genotypic transmission disequilibrium tests (TDT) on 10 single-nucleotide variants (SNVs) in PVRL1 using data from 142 Korean families with an affected child. POO effects were analyzed using the POO likelihood ratio test, comparing transmission rates of maternally and paternally inherited alleles. To assess generalizability and ethnic heterogeneity, we compared results from Korean families with data from the Center for Craniofacial and Dental Genetics, which included 2,226 individuals from 497 European and 245 Asian trios.
RESULTS
TDT analysis identified significant over-transmission of the rs7940667 (G361V) C allele in Korean families (p=0.007), a finding replicated in both Asian (p=6.5×10-7) and European families (p=1.6×10-10). Eight SNVs showed strong TDT evidence in larger Asian and European datasets after multiple comparison corrections (p<0.0073). Of these, 4 SNVs (rs7940667, rs7103685, rs7129848, and rs4409845) showed particularly robust association (p<5×10-8). POO analysis revealed significant maternal over-transmission of the rs10790330-A allele in Korean families (p=0.044). This finding was replicated in European families (p=9.0×10-4). Additionally, 3 other SNVs, rs7129848 (p=0.001) and the linked SNVs rs3935406 and rs10892434 (p=0.025), exhibited maternal over-transmission in the validation datasets.
CONCLUSIONS
Our findings provide robust evidence supporting the associations of PVRL1 variants with NSCL/P susceptibility. Further research is necessary to explore the potential clinical applications of these findings.; Summary

Brief Communication

The association between employee lifestyles and the rates of mental health-related absenteeism and turnover in Japanese companies: Atsuya Fujimoto, Hiroshi Kanegae, Kaori Kitaoka, Mizuki Ohashi, Kunio Okada, Koichi Node, Kenkichi Takase, Hiroshi Fukuda, Tomoyuki Miyazaki, Yuichiro Yano; Epidemiol Health. 2024;46:e2024068. Published online August 2, 2024; DOI: https://doi.org/10.4178/epih.e2024068

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Abstract PDF: Abstract
We assessed the association of employee lifestyles (e.g., smoking, exercise, drinking, and sleep habits) with mental health-related absenteeism and turnover rates utilizing data from the annual Health and Productivity Management survey by Japan’s Ministry of Economy, Trade and Industry. This analysis included data from 1,748 companies, encompassing 4,199,021 employees. The average proportions of mental health-related absenteeism and employee turnover rates were 1.1±1.0% and 5.0±5.0%, respectively. In multivariable regression models that incorporated all lifestyle factors and confounders, a 1 percentage point increase in the proportion of employees who slept well was associated with reductions in their turnover rate (mean, -0.020%; 95% confidence interval [CI], -0.038 to -0.002) and in mental health-related absenteeism (mean, -0.005%; 95% CI, -0.009 to 0.001). A similar increase in the proportion of employees engaging in regular physical activity corresponded with a 0.005% decrease in the prevalence of mental health-related absenteeism (95% CI, -0.010 to -0.001). A 1 percentage point increase in the proportion of employees who smoked was associated with a 0.013% reduction in mental health-related absenteeism (95% CI, -0.017 to -0.008). Nonetheless, the current study’s observational and cross-sectional design restricted the ability to establish causality between employee lifestyle factors and mental health issues.; Summary

Data Profile

Introduction to the forensic research via omics markers in environmental health vulnerable areas (FROM) study: Jung-Yeon Kwon, Woo Jin Kim, Yong Min Cho, Byoung-gwon Kim, Seungho Lee, Jee Hyun Rho, Sang-Yong Eom, Dahee Han, Kyung-Hwa Choi, Jang-Hee Lee, Jeeyoung Kim, Sungho Won, Hee-Gyoo Kang, Sora Mun, Hyun Ju Yoo, Jung-Woong Kim, Kwan Lee, Won-Ju Park, Seongchul Hong, Young-Seoub Hong; Epidemiol Health. 2024;46:e2024062. Published online July 12, 2024; DOI: https://doi.org/10.4178/epih.e2024062

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Abstract Summary PDF: Abstract
This research group (forensic research via omics markers in environmental health vulnerable areas: FROM) aimed to develop biomarkers for exposure to environmental hazards and diseases, assess environmental diseases, and apply and verify these biomarkers in environmentally vulnerable areas. Environmentally vulnerable areas—including refineries, abandoned metal mines, coal-fired power plants, waste incinerators, cement factories, and areas with high exposure to particulate matter—along with control areas, were selected for epidemiological investigations. A total of 1,157 adults, who had resided in these areas for over 10 years, were recruited between June 2021 and September 2023. Personal characteristics of the study participants were gathered through a survey. Biological samples, specifically blood and urine, were collected during the field investigations, separated under refrigerated conditions, and then transported to the laboratory for biomarker analysis. Analyses of heavy metals, environmental hazards, and adducts were conducted on these blood and urine samples. Additionally, omics analyses of epigenomes, proteomes, and metabolomes were performed using the blood samples. The biomarkers identified in this study will be utilized to assess the risk of environmental disease occurrence and to evaluate the impact on the health of residents in environmentally vulnerable areas, following the validation of diagnostic accuracy for these diseases.; Summary

Korean summary
환경보건 취약지역 주민을 대상으로 실시한 현장 역학 조사에서 혈액과 소변 시료를 안정적으로 확보하였다. 현장에서 확보한 시료는 즉시 이송하여 오믹스 분석을 통해 환경유해인자별, 환경성질환별 특이적인 바이오마커를 개발한다.

Key Message
Blood and urine samples were stably obtained from on-site epidemiological investigations done on residents in environmental health vulnerable areas, and samples obtained from the sites were immediately transported to the omics laboratory after separation under biobank system. Through this analysis, we aimed to develop biomarkers specific to each environmental hazard and disease.

Original Article

Toxicological evidence integration to confirm the biological plausibility of the association between humidifier disinfectant exposure and respiratory diseases using the AEP-AOP framework: Ha Ryong Kim, Jun Woo Kim, Jong-Hyeon Lee, Younghee Kim, Jungyun Lim, Yong-Wook Baek, Sunkyoung Shin, Mina Ha, Hae-Kwan Cheong, Kyu Hyuck Chung, Review Committee for the Epidemiological Correlations between Humidifier Disinfectants Exposure and Health Effects; Epidemiol Health. 2024;46:e2024060. Published online July 7, 2024; DOI: https://doi.org/10.4178/epih.e2024060

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Abstract Summary PDF: Abstract
OBJECTIVES
Exposure to humidifier disinfectants has been linked to respiratory diseases, including interstitial lung disease, asthma, and pneumonia. Consequently, numerous toxicological studies have explored respiratory damage as both a necessary and sufficient condition for these diseases. We systematically reviewed and integrated evidence from toxicological studies by applying the evidence integration method established in previous research to confirm the biological plausibility of the association between exposure and disease.
METHODS
We conducted a literature search focusing on polyhexamethylene guanidine phosphate (PHMG) and chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT), the primary ingredients in humidifier disinfectants. We selected relevant studies based on their quality and the population, exposure, comparator, outcome (PECO) statements. These studies were categorized into three lines of evidence: hazard information, animal studies, and mechanistic studies. Based on a systematic review, we integrated the evidence to develop an aggregate exposure pathway–adverse outcome pathway (AEP-AOP) model for respiratory damage. The reliability and relevance of our findings were assessed by comparing them with the hypothesized pathogenic mechanisms of respiratory diseases.
RESULTS
By integrating toxicological evidence for each component of the AEP-AOP framework for PHMG and CMIT/MIT, we developed an AEP-AOP model that elucidates how disinfectants released from humidifiers expose target sites, triggering molecular initiating events and key events that ultimately lead to respiratory damage. This model exhibits high reliability and relevance to the pathogenesis of respiratory diseases.
CONCLUSIONS
The AEP-AOP model developed in this study provides strong evidence, based on evidence-based toxicology, that exposure to humidifier disinfectants causes respiratory diseases. This model demonstrates the pathways leading to respiratory damage, a hallmark of these conditions.; Summary

Korean summary
- PHMG와 CMIT/MIT에 대한 AEP-AOP 프레임워크와 독성학적 근거종합 방법에 의해 가습기살균제의 호흡기계 손상 AEP-AOP 모델을 개발하였다. - 이 모델은 가습기살균제 복합 노출과 호흡기계 질환 간의 인과성을 규명하는 과학적 근거를 제공하며, 향후 다양한 살균제 성분의 호흡기계 건강영향을 예측하는데 활용할 수 있다.

Key Message
• The AEP-AOP model for humidifier disinfectant-induced respiratory damage developed by the AEP-AOP frameworks for PHMG and CMIT/MIT, along with the toxicological evidence integration method. • This model provides a scientific basis for establishing causality between mixed exposure to humidifier disinfectants and respiratory diseases, and can be used in the future to predict the health effects of various disinfectant ingredients.

Brief Communication

Timely access to secondary pediatric services in Korea: a key to reducing child and adolescent mortality: Minku Kang, Young June Choe, Hye Sook Min, Saerom Kim, Seung-Ah Choe; Epidemiol Health. 2024;46:e2024059. Published online July 5, 2024; DOI: https://doi.org/10.4178/epih.e2024059

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Abstract Summary PDF: Abstract
OBJECTIVES
Geographic disparities in access to secondary pediatric care remain a significant issue in countries with universal health coverage, including Korea. This study investigated the link between geographic access to secondary pediatric care and mortality rates in children and adolescents (0-19 years) in Korea.
METHODS
We analyzed district-level data to assess the percentage of those aged 0-19 years residing outside of a 60-minute travel radius from the nearest secondary pediatric care provider (accessibility vulnerability index, AVI).
RESULTS
The AVI ranged from 0% to 100% across the districts for the study period. The confidence interval (CI) was -0.30 (95% CI, -0.41 to -0.19) in 2017 and -0.41 (95% CI, -0.52 to -0.30) in 2021, indicating that the proportion of those who could not access care within 60 minutes was disproportionately higher in districts with lower socioeconomic status. We found 8% rise in mortality rates among individuals aged 0-19 years for every 10% increase in AVI (95% CI, 1.06 to 1.10).
CONCLUSIONS
The study highlights disparities in pediatric care access and their impact on child survival, emphasizing the need for improved access to achieve true universal health coverage.; Summary

Korean summary
본 연구는 한국에서 소아 의료 서비스에 대한 지리적 접근성과 아동 사망률 사이의 연관성을 조사하여, 특히 COVID-19 대유행 기간 동안 접근성 제한이 높은 사망률과 관련이 있음을 발견하였다. 이 연구는 아동 및 청소년의 예방 가능한 사망률에 대한 지역 격차를 줄이기 위해 시기적절한 치료 접근성을 개선해야 할 필요성을 강조하였다.

Key Message
The study investigated the link between geographic access to pediatric services and child mortality in South Korea, finding that limited access, particularly during the COVID-19 pandemic, was associated with higher mortality. The research highlights the need for improved access to timely care to reduce regional disparities in preventable deaths among children and adolescents.

Cohort Profile

Cohort profile: the Taiwan Initiative for Geriatric Epidemiological Research - a prospective cohort study on cognition: Pei-Iun Hsieh, Te-Hsuan Huang, Jeng-Min Chiou, Jen-Hau Chen, Yen-Ching Chen; Epidemiol Health. 2024;46:e2024057. Published online June 25, 2024; DOI: https://doi.org/10.4178/epih.e2024057

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Abstract Summary PDF: Abstract
The Taiwan Initiative for Geriatric Epidemiological Research (TIGER) was founded in 2011 to elucidate the interrelationships among various predictors of global and domain-specific cognitive impairment, with the aim of identifying older adults with an increased risk of dementia in the preclinical phase. TIGER, a population-based prospective cohort, recruited 605 and 629 (total of 1,234) older adults (aged 65 and above) at baseline (2011-2013 and 2019-2022) of phase I and II, respectively. Participants have undergone structured questionnaires, global and domain-specific cognitive assessments, physical exams, and biological specimen collections at baseline and biennial follow-ups to date. By 2022, TIGER I has included 4 biennial follow-ups, with the participants comprising 53.9% female and having a mean age of 73.2 years at baseline. After an 8-year follow-up, the annual attrition rate was 6.1%, reflecting a combination of 9.9% of participants who passed away and 36.2% who dropped out. TIGER has published novel and multidisciplinary research on cognitive-related outcomes in older adults, including environmental exposures (indoor and ambient air pollution), multimorbidity, sarcopenia, frailty, biomarkers (brain and retinal images, renal and inflammatory markers), and diet. TIGER’s meticulous design, multidisciplinary data, and novel findings elucidate the complex etiology of cognitive impairment and frailty, offering valuable insights into factors that can be used to predict and prevent dementia in the preclinical phase.; Summary

Key Message
1. The Taiwan Initiative for Geriatric Epidemiological Research (TIGER), established in 2001, aims to fill the knowledge gap regarding the longitudinal associations between environmental exposure, clinical factors, and performance in global and cognitive domains. 2. TIGER has made significant findings in various aspects, including the effects of exposure to low-level air pollutants, indoor air quality, clinical factors (brain and retinal images, dental health), nutrition, and biomarkers on cognition over time. 3. TIGER's multidisciplinary data and advanced analysis elucidate the predictors of cognitive impairment, identifying older adults at increased risk of dementia in the preclinical phase for early prevention and intervention.

Systematic Review

Tea consumption and risk of all-cause, cardiovascular disease, and cancer mortality: a meta-analysis of thirty-eight prospective cohort data sets: Youngyo Kim, Youjin Je; Epidemiol Health. 2024;46:e2024056. Published online June 21, 2024; DOI: https://doi.org/10.4178/epih.e2024056

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Abstract Summary PDF: Abstract
OBJECTIVES
Tea consumption has been considered beneficial to human health because tea contains phytochemicals such as polyphenols and theaflavins. We conducted a systematic review and meta-analysis on the association between tea consumption and mortality from all causes, cardiovascular disease (CVD), and cancer to provide a quantitative assessment of current evidence.
METHODS
The PubMed, Web of Science, and Scopus databases were searched through April 2024 to identify eligible studies. Random effects models were used to combine study-specific effect estimates (ESs).
RESULTS
A total of 38 prospective cohort data sets (from 27 papers) with 1,956,549 participants were included in this meta-analysis. The pooled ESs of the highest versus lowest categories of tea consumption were 0.90 (95% confidence interval [CI], 0.86 to 0.95) for all-cause mortality, 0.86 (95% CI, 0.79 to 0.94) for CVD mortality, and 0.90 (95% CI, 0.78 to 1.03) for cancer mortality. In the dose-response analysis, a non-linear association was observed. The greatest risk reductions were observed for the consumption of 2.0 cup/day for all-cause mortality (ES, 0.91; 95% CI, 0.88 to 0.94) and 1.5 cup/day for cancer mortality (ES, 0.92; 95% CI, 0.89 to 0.96), whereas additional consumption did not show a further reduction in the risk of death. A plateau was observed for CVD mortality at moderate consumption levels (1.5-3.0 cup/day), but a sustained reduction in mortality risk was observed at higher intake levels.
CONCLUSIONS
Moderate tea consumption (e.g., 1.5-2.0 cup/day) was associated with lower all-cause, CVD, and cancer mortality compared to no tea consumption. Further well-designed prospective studies are needed for a definitive conclusion.; Summary

Korean summary
차는 전세계적으로 널리 소비되는 음료로 그 공중보건학적 영향력이 크다. 차의 섭취와 만성질환의 관련성은 아직 일관성 있게 결론이 나지 않았는데 최근에 이 주제에 대하여 대규모의 코호트 연구 결과들이 발표된 바 있었다. 38개의 코호트 데이터에 근거한 본 메타분석의 결과는 하루 한 잔 반에서 두 잔의 차를 마시는 것이 총사망위험과 심혈관계질환이나 암으로 인한 사망 위험을 낮추는 것과 관계가 있음을 나타내고 있다.

Key Message
Tea is a commonly consumed beverage worldwide and has a significant public health impact. The association between tea consumption and risk of mortality from chronic disease remains inconsistent, and extensive cohort studies have been published recently. In this meta-analysis, including thirty-eight cohort studies, people who drank one and a half to two cups of tea daily had a lower risk of mortality from all causes, cardiovascular disease, and cancer than those who drank less tea.

Original Article

Comparison of HIV characteristics across 3 datasets: the Korea HIV/AIDS Cohort Study prospective, retrospective, and national reporting system: Yunsu Choi, Jun Yong Choi, Bo Youl Choi, Bo Young Park, Shin-Woo Kim, Joon Young Song, Jung Ho Kim, Sang Il Kim; Epidemiol Health. 2024;46:e2024055. Published online June 18, 2024; DOI: https://doi.org/10.4178/epih.e2024055

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Abstract Summary PDF: Abstract
OBJECTIVES
The Korea HIV/AIDS Cohort Study has been conducted prospectively for 18 years. However, it faces limitations in representing the entire population of patients with human immunodeficiency virus (HIV) in Korea. To address these limitations and validate the study design, we analyzed characteristics across several HIV datasets.
METHODS
We compared epidemiological and clinical characteristics from 3 datasets: the Korea HIV/AIDS Cohort Study (dataset 1, n=1,562), retrospective cohort data (dataset 2, n=2,665), and the national HIV reporting system of the Korea Disease Control and Prevention Agency (KDCA) (dataset 3, n=17,403).
RESULTS
The demographic characteristics of age, sex, and age at HIV diagnosis did not differ significantly across datasets. However, dataset 3 contained a higher proportion of patients diagnosed after 2008 (69.5%) than the other datasets. Regarding transmission routes, same-sex contact accounted for a greater proportion of dataset 1 (59.8%) compared to datasets 2 (20.9%) and 3 (32.6%). The proportion of patients with CD4 T-cell counts below 200/mm3 at HIV diagnosis was higher in datasets 1 (39.4%) and 2 (33.3%) compared to dataset 3 (16.3%). Initial HIV viral load measurements were not obtained for dataset 3.
CONCLUSIONS
The Korea HIV/AIDS Cohort Study demonstrated representativeness regarding the demographic characteristics of Korean patients. Of the sources, dataset 1 contained the most data on transmission routes. While the KDCA data encompassed all HIV patients, it lacked detailed clinical information. To improve the representativeness of the Korea HIV/AIDS Cohort Study, we propose expanding and revising the cohort design and enrolling more patients who have been recently diagnosed.; Summary

Korean summary
장기간 운영된 코호트 연구는 다양한 편향으로 인해 모집단의 대표성을 잃을 수 있다. 대표성을 높이기 위해서는 편향을 최소화하고 지속적으로 변화하는 임상 역학적 지침과 특성을 반영할 수 있어야 한다. 지난 18년간 운영된 한국 HIV/AIDS 코호트 연구에서는 코호트 연구 참여 기관에 방문하는 감염인 중 연구 참여자와 비참여자의 특성을 비교하고, 질병관리청 신고자료와의 분포를 비교한 결과, 코호트 연구에 참여하는 것만으로도 대상자 특성에 차이가 있음을 밝혔다. 이에 따라 편향을 최소화하고 대표성을 높일 수 있도록 코호트 연구 설계를 대대적으로 개편하고, 향후 지속될 연구 설계를 제안한다.

Cohort Profile

Cohort profile: understanding health service system needs for people with intellectual disability using linked data in New South Wales, Australia: Simone Reppermund, Preeyaporn Srasuebkul, Claire M. Vajdic, Sallie-Anne Pearson, Rachael E. Moorin, Julian N. Trollor; Epidemiol Health. 2024;46:e2024054. Published online June 12, 2024; DOI: https://doi.org/10.4178/epih.e2024054

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Abstract Summary PDF: Abstract
This cohort profile describes one of the largest linked datasets in the world concerning the health of people with intellectual disability. The cohort comprises a retrospective group of 100,089 individuals with intellectual disability who received disability and/or health services in New South Wales, Australia. Of these participants, 34% were female, with a median age at cohort entry of 3 years (interquartile range, 0-19). A separate comparator cohort included 455,677 individuals, matched by 5-year age group, sex, and residential postcode at a 5:1 ratio. Initial results indicate that between 2001 and 2018, people with intellectual disability experienced more than double the rate of hospitalisations (538 vs. 235 per 1,000 person-years), as well as markedly higher rates of emergency department presentations (707 vs. 379 per 1,000 person-years) and use of ambulatory mental health services (1,012 vs. 157 per 1,000 person-years), relative to the comparator cohort. The largest disparities in hospital admissions were for mental disorders, dialysis, and diseases of the nervous system and sense organs. Furthermore, individuals with intellectual disability had more than double the rate of dispensed medications found in the comparator cohort. Of these medications, 46.6% were for the treatment of nervous system conditions, as opposed to 24.7% for the comparator cohort. The mean±standard deviation age at death was 52±19 years for people with intellectual disability and 64±22 years for the comparator participants.; Summary

Key Message
This cohort study of individuals with intellectual disability is one of the largest internationally looking at health profiles and health service use. The goal is to improve the health and well-being of individuals with intellectual disability by informing the development of services, variations in prescribing practices, and access to preventative health services.

Original Articles

Seasonal impact of diurnal temperature range on intracerebral hemorrhage in middle-aged and elderly people in central China: Shiwen Wang, Jinyu Yin, Hao Zhou, Jingmin Lai, Guizhen Xiao, Zhuoya Tong, Jing Deng, Fang Yang, Qianshan Shi, jingcheng shi; Epidemiol Health. 2024;46:e2024053. Published online June 11, 2024; DOI: https://doi.org/10.4178/epih.e2024053

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Abstract Summary PDF: Abstract
OBJECTIVES
This study investigated the seasonal impact of diurnal temperature range (DTR) on hospitalization rates for intracerebral hemorrhage (ICH) in middle-aged and elderly adults.
METHODS
We collected data on the DTR and hospitalization records of ≥45-year-old patients with ICH in 2019 in Hunan Province, central China. Time-series analyses were performed using a distributed lag non-linear model.
RESULTS
Overall, 54,690 hospitalizations for ICH were recorded. DTR showed a non-linear relationship with ICH hospitalization in both middle-aged and elderly populations (45-59 and ≥60 years, respectively). During spring, a low DTR coupled with persistently low temperatures increased ICH risk in both age groups, while a high DTR was associated with an increased risk in the middle-aged group only (relative risk [RR], 1.24; 95% confidence interval [CI], 1.21 to 1.27). In the summer, a low DTR combined with persistently high temperatures was linked to a higher risk exclusively in the middle-aged group. A high DTR in the autumn was correlated with increased risk in both age groups. In winter, either a low DTR with a continuously low temperature or a high DTR elevated the risk solely in the elderly population (RR, 1.37; 95% CI, 1.00 to 1.69). In the elderly group, the impact of DTR on hospitalization risk manifested within a 5-day period.
CONCLUSIONS
The impact of DTR on ICH hospitalization risk differed significantly across seasons and between age groups. Elderly individuals demonstrated greater sensitivity to the impact of DTR. Weather forecasting services should emphasize DTR values, and interventions targeting sensitive populations are needed.; Summary

Key Message
In a large-scale, study of 54,690 hospitalizations for intracerebral hemorrhage (ICH) from China, we identified the seasonal impact of diurnal temperature range (DTR) on hospitalization rates for intracerebral hemorrhage (ICH) in middle aged and elderly adults. Specifically, the impact of DTR on ICH hospitalization risk differed significantly across seasons and between age groups. Elderly individuals demonstrated greater sensitivity to the impact of DTR. The findings of this study could be instrumental in the prevention and control of ICH.

Inequality in dental flossing behavior among Korean adults based on household income levels: Zi-Lan Wang, Eun-Jae Choi, Seung-Hee Ryu, Seon-Jip Kim, Hyun-Jae Cho; Epidemiol Health. 2024;46:e2024052. Published online May 24, 2024; DOI: https://doi.org/10.4178/epih.e2024052

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Abstract Summary PDF: Abstract
OBJECTIVES
The aim of this study was to estimate the association between household income and dental flossing.
METHODS
This cross-sectional study investigated the impact of household income on flossing among 9,391 adults aged 30+ with ≥20 natural teeth, utilizing data from the seventh Korea National Health and Nutrition Examination Survey (2016-2018). Outcome measures included flossing (yes/no), with income categorized into 4 levels: lowest, medium to low, medium to high, and highest. Logistic regression, adjusted for age, gender, brushing frequency, recent dental exams, periodontitis, smoking, and alcohol use, was employed to evaluate the influence of socioeconomic status on oral hygiene practices.
RESULTS
In the highest income group, flossing was 62.6% more prevalent than in the lowest income group (adjusted odds ratio [aOR], 1.63; 95% CI, 1.27 to 2.08). The strongest association between income levels and flossing was observed in individuals aged ≥70 years (aOR, 3.64; 95% CI, 1.86 to 7.11), with a decreasing strength of association in the 60s (aOR, 1.72; 95% CI, 1.05 to 2.84) and 50s age groups (aOR, 1.69; 95% CI, 1.07 to 2.68). Higher-income women demonstrated a higher frequency of flossing than their lower-income counterparts (aOR, 1.67; 95% CI, 1.24 to 2.23). Higher-income individuals without periodontitis were more likely to floss (aOR, 1.64; 95% CI, 1.23 to 2.18), and among those with periodontitis, flossing was significantly associated only with the highest income category (aOR, 1.64; 95% CI, 1.10 to 2.44).
CONCLUSIONS
The findings of this study indicate a significant correlation between higher household income levels and an increased prevalence of flossing.; Summary

Korean summary
이 연구는 치실 사용이 개인의 건강행동 습관뿐만 아니라 사회경제적 지위에 의해 크게 영향을 받는다는 점을 강조합니다. 높은 소득층이 치실을 더 자주 사용하는 경향이 있으며, 이는 교육 수준과 건강 문해력, 경제적 여유와 관련이 있습니다. 공중보건 계획에서 경제적 요인을 고려하고, 치과 위생 교육과 제품 접근성을 개선해야 합니다.

Key Message
This study highlights that the use of dental floss is significantly influenced not only by personal health behavior habits but also by socioeconomic status. Individuals in higher income classes tend to use dental floss more frequently, which is associated with higher levels of education, health literacy, and economic resources. Public health planning should take economic factors into account and focus on improving dental hygiene education and access to dental care products.

Dietary mercury intake, the IL23R rs10889677 polymorphism, and the risk of gastric cancer in a Korean population: a hospital-based case-control study: Ji Hyun Kim, Madhawa Gunathilake, Jeonghee Lee, Il Ju Choi, Young-Il Kim, Jeongseon Kim; Epidemiol Health. 2024;46:e2024051. Published online May 21, 2024; DOI: https://doi.org/10.4178/epih.e2024051

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Abstract Summary PDF: Abstract
OBJECTIVES
Mercury can stimulate immune responses through T helper 17 (Th17). The gene IL23R is a key factor in Th17 function, which may also contribute to digestive tract diseases. The aim of this study was to identify the associations between dietary mercury and gastric cancer (GC) and to investigate whether the IL23R rs10889677 polymorphism modifies those associations.
METHODS
This case-control study included 377 patients with GC and 756 healthy controls. Dietary mercury intake (total mercury and methylmercury) was assessed using a dietary heavy metal database incorporated into the food frequency questionnaire. IL23R genetic polymorphism rs10889677 (A>C) was genotyped. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using unconditional logistic regression models with adjustments for potential confounders.
RESULTS
A higher dietary methylmercury intake was associated with an elevated risk of GC (OR for the highest vs. lowest tertile [T3 vs. T1], 2.02; 95% CI, 1.41 to 2.91; p for trend <0.001). The IL23R rs10889677 reduced the risk of GC in individuals who carried at least 1 minor allele (OR, 0.62; 95% CI, 0.46 to 0.83; p=0.001; AC/CC vs. AA). Individuals with a C allele exhibited a lower susceptibility to GC through methylmercury intake than those with the AA genotype (OR for the T3 of methylmercury and AA carriers, 2.93; 95% CI, 1.77 to 4.87; and OR for the T3 of methylmercury and AC/CC genotype, 1.30; 95% CI, 0.76 to 2.21; p-interaction=0.013).
CONCLUSIONS
Our findings suggest that a genetic polymorphism, rs10889677 in IL23R, plays a role in modifying the association between dietary methylmercury intake and the risk of GC.; Summary

Korean summary
본 연구는 식이 수은과 위암 간의 연관성을 탐색하고, microRNA-lethal-7의 예측된 결합 부위 내에 위치한 IL23R rs10889677 다형성이 이러한 연관성에 영향을 미칠 수 있는지 규명하고자 합니다. 식이 메틸수은 섭취량에 비례하여 위암 발생 위험이 증가하는 경향이 확인되었고, IL23R rs10889677 다형성은 식이 메틸수은으로 의한 위암 발생 위험을 조절하는 인자로 작용할 수 있음을 시사합니다.

Key Message
This study aimed to investigate the associations between dietary mercury and gastric cancer (GC) and to determine whether the IL23R rs10889677 polymorphism, located within a predicted binding site for microRNA-lethal-7, may modify these associations. A higher dietary methylmercury intake was associated with an increased risk of GC, while the IL23R rs10889677 polymorphism may modify the detrimental effect of dietary methylmercury on gastric carcinogenesis.

Methods

Expansion of a food composition database for the food frequency questionnaire in the Korean Genome and Epidemiology Study (KoGES): a comprehensive database of dietary antioxidants and total antioxidant capacity: Jiseon Lee, Ji-Sook Kong, Hye Won Woo, Mi Kyung Kim; Epidemiol Health. 2024;46:e2024050. Published online May 10, 2024; DOI: https://doi.org/10.4178/epih.e2024050

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study constructed a comprehensive database of dietary antioxidants and total antioxidant capacity (TAC) to facilitate the estimation of daily antioxidant intake using a food frequency questionnaire (FFQ). This database was applied to 3 general population-based cohorts (n=195,961) within the Korean Genome and Epidemiology Study (KoGES).
METHODS
To establish a database of 412 foods derived from recipes of a 106-item FFQ, we followed a pre-established standardized protocol. This included the selection of source databases, matching of foods, substitution of unmatched items with identical foods and input of values, and assessment of coverage. For each food, the TAC was estimated by summing the individual antioxidant capacities, calculated by multiplying the amount of each antioxidant by its vitamin C equivalent antioxidant capacity.
RESULTS
We identified 48 antioxidants across 5 classes: retinol, carotenoids, vitamins C and E, and flavonoids, with flavonoids divided into 7 subclasses. TAC values were then established. Coverage exceeded 90.0% for retinol, carotenoids, vitamin C, and vitamin E, while coverage for flavonoids was 60.9%. The daily intakes of 4 antioxidant classes—all but vitamin E—were higher in women than in men. The Ansan-Ansung cohort exhibited the highest levels of dietary TAC, vitamin E, and flavonoids, while the Health Examinees Study cohort displayed the highest values for retinol, carotenoids, and vitamin C.
CONCLUSIONS
We customized a comprehensive antioxidant database for the KoGES FFQ, achieving relatively high coverage. This expansion could support research investigating the impact of dietary antioxidants on the development of chronic diseases targeted by the KoGES.; Summary

Korean summary
본 연구는 한국인유전체역학조사사업(KoGES) 식품섭취빈도조사(FFQ)에 특화된 항산화 데이터베이스를 확장하여 개발한 첫 번째 연구로, 48종의 항산화제와 TAC 값을 포함하여 기존 연구의 부족한 부분을 채웠습니다. 코호트 별로 식이 항산화제 섭취량에서 큰 차이가 나타났으며, 지역사회 기반 코호트에서는 비타민 E와 플라보노이드 섭취가 가장 높았고, 도시 기반 코호트에서는 레티놀, 카로티노이드, 비타민 C 섭취에서 가장 높았습니다. 반면, 농촌 기반 코호트에서는 대부분의 항산화제 섭취량이 가장 낮았습니다. 또한 성별, 연령, 및 교육 수준에 따른 섭취량의 차이도 확인되었으며, 주로 여성, 젊은 연령층, 그리고 교육 수준이 높은 사람들이 더 많은 항산화제를 섭취한 반면, 고령자와 흡연자는 섭취량이 적게 나타났습니다.

Key Message
This study is the first to develop an expanded antioxidant database specifically for the Korean Genome and Epidemiology Study (KoGES) FFQ, addressing a critical gap in research by including a broad range of 48 antioxidants and total antioxidant capacity (TAC). Significant differences in dietary antioxidant intake were observed across different cohorts, with participants in the Ansan and Ansung (ASAS) study consuming the most vitamin E and flavonoids, while those in the Health Examinee (HEXA) study had the highest intake of retinol, carotenoids, and vitamin C. In contrast, the Cardiovascular Disease Association Study (CAVAS) showed the lowest intake of most antioxidants. Demographic differences were also evident, with women, younger individuals, and those with higher education levels consuming more antioxidants, while older adults and smokers consumed less.

Original Article

Association of healthy lifestyle factors with the risk of hypertension, dyslipidemia, and their comorbidity in Korea: results from the Korea National Health and Nutrition Examination Survey 2019-2021: Ji-Sook Kong, Mi Kyung Kim; Epidemiol Health. 2024;46:e2024049. Published online May 1, 2024; DOI: https://doi.org/10.4178/epih.e2024049

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We investigated the association of individual healthy lifestyle factors (HLFs) and their combined healthy lifestyle score (HLS) with hypertension and/or dyslipidemia.
METHODS
We analyzed data from 10,693 adults aged ≥19 from the 2019 to 2021 Korea National Health and Nutrition Examination Survey. HLS was evaluated based on smoking status, alcohol consumption, body mass index (BMI), diet, and physical activity. Using logistic regression models, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate the associations of HLFs and HLS with hypertension, dyslipidemia, and their comorbidity.
RESULTS
The prevalence of hypertension alone, dyslipidemia alone, and their comorbidity was 8.7%, 24.6%, and 15.0%, respectively. Multivariable models showed an inverse association of hypertension (OR, 0.37; 95% CI, 0.30 to 0.46) and dyslipidemia (OR, 0.36; 95% CI, 0.32 to 0.41) with healthy BMI. Hypertension was inversely associated with healthy alcohol consumption (OR, 0.46; 95% CI, 0.35 to 0.61) and diet (OR, 0.79; 95% CI, 0.63 to 0.99), whereas dyslipidemia was inversely associated with non-smoking (OR, 0.51; 95% CI, 0.43 to 0.60). Physical activity was inversely associated with their comorbidity (OR, 0.69; 95% CI, 0.56 to 0.85). Adherence to HLS was associated with significantly lower odds of hypertension (81%), dyslipidemia (66%), and their conditions (89%) (all ptrend<0.001). Stratified analyses consistently showed inverse associations between HLS and hypertension and/or dyslipidemia independently of demographic factors (pinteractions>0.05).
CONCLUSIONS
HLFs were associated with lower risk for hypertension and/or dyslipidemia. Obesity may contribute significantly to the risk of these conditions, while relevant HLFs for individual chronic diseases may vary significantly.; Summary

Korean summary
건강한 생활 습관 요인(HLFs)의 개별 구성 요인들은 고혈압 및 이상지질혈증의 동반 위험과 각각의 상태와 음의 연관성을 보였다. 다양한 HLFs 중에서 BMI 상태가 중요한 요인으로 확인되었지만, 개별 만성 질환에 대한 관련 HLFs는 상당히 다를 수 있다. 또한, 명확한 용량-반응 관계가 관찰되어, 더 HLFs를 준수할수록 고혈압, 이상지질혈증 및 그들의 동반 가능성이 유의미하게 감소하는 것으로 나타났다.

Key Message
Individual components of healthy lifestyle factors (HLFs) were inversely associated with the risk of comorbid hypertension and dyslipidemia, as well as with each condition. Among the various HLFs, BMI status was identified as a significant factor, while relevant HLFs for individual chronic diseases may vary significantly. Additionally, clear dose-response associations were observed, indicating that adherence to more HLFs was significantly associated with decreasing odds of hypertension, dyslipidemia, and their comorbidity.

Cohort Profile

Korea Nurses’ Health Study and the health of reproductive-aged women: a cohort profile: Chiyoung Cha, Heeja Jung, Sue Kim, Jung Eun Lee, Kwang-Pil Ko, Eunyoung Cho, Hyun-Young Park, Joong-Yeon Lim, Bo Mi Song, Sihan Song, Soojin Park, Aram Cho; Epidemiol Health. 2024;46:e2024048. Published online April 30, 2024; DOI: https://doi.org/10.4178/epih.e2024048

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Abstract Summary PDF: Abstract
The Korea Nurses’ Health Study (KNHS) is an ongoing, large-scale, prospective cohort study of women nurses, focusing on the effects of occupational, environmental, and lifestyle factors on the health of women. The first KNHS survey was performed in 2013-2014 (n=20,613). As of December 2023, 11 follow-up surveys have been conducted. Participants who were pregnant were asked to participate in the early pregnancy survey (n=2,179) and postpartum survey after giving birth (n=2,790). The main variables included socio-demographic, work-related, lifestyle, physical, mental, and women’s health factors. Blood, urine, and toenail samples were collected from a participant subgroup of the first survey (n=1,983). The subgroups of the second survey completed a food frequency questionnaire in 2019 (n=300) and 2021 (n=871). In 2020, a subgroup of the first survey answered a coronavirus disease 2019-related survey (n=975). To examine various health-related factors in young adults, new participants were added to the KNHS cohort in the 11th (n=1,000) and 12th (n=1,002) surveys. The KNHS cohort will help identify health and illness determinants in Korean women. Data can be accessed at https://coda.nih.go.kr/frt/index.do.; Summary

Korean summary
한국간호사건강연구(Korea Nurses’ Health Study, KNHS)는 2013년부터 수행되고 있는 대규모 전향적 추적관찰 코호트 연구이다. 본 연구는 질병력, 약물복용력, 임신력, 여성건강, 정신건강(우울, 스트레스, 피로 등), 생활습관(흡연, 음주, 신체활동, 수면 등), 근무특성을 조사하여 여성건강에 장기적으로 미치는 영향을 파악하고 한국 고유의 여성건강 결정요인을 도출하는 것을 목표로 한다.

Key Message
The Korea Nurses' Health Study (KNHS) is a large-scale, prospective cohort study that has been conducted since 2013. It measures various factors affecting reproductive-aged women, including disease history, medication usage, pregnancy, women's health characteristic, mental health (such as depression, stress, and fatigue), lifestyle characteristic (including smoking, drinking, and physical activity, sleep), and work-related characteristics. The study aims to understand the long-term impact on women's health and identify unique determinants of women's health specific to Korea.

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