Gender Disparities and Oral Health on Low Back Pain among Middle and Older Korean Adults: The 6th KNHANES
Moon-Hee Kwon*1
Junghyun Kim2
1 Department of Nursing, Kyungdong University,Gangwon-do, 26495, Korea
2Department of Biomedical laboratory science, Kyungbok University,Gyeonggi-do, 11138, Korea
Abstract
Background/Objectives: Previous studies on back pain have documented but rare studies on the sex and oral health are existing. This study was aimed to observe related factors of low- back- pain.
Methods/Statistical analysis: To observe the associated factors of low- back- pain, we used crosssectional study from 6th KNHANES which was known for nationally representative data with validity and reliability. A total of 2,433 participants aged (50≤) were included and analyzed by multi-variable logistic regression of complex-sampling methods. Low back pain was defined as diagnosed by doctor. Periodontitis and chewing level were chosen for the indicators of oral health.
Findings: As results, gender(female) and oral health factors such as chewing difficulty and periodontitiswere identified as the most significant factors of low-back-pain. Next determinant factors of low-back-pain were ageing, lowering of income level and sedentary time (5hrs.≤) in order. The important point of view compared to existing studies was that we dealt with gender disparities and including periodontitis and chewing level as oral health indicators leading cause of general health. To our best knowledge, this is the first one to identify the association of gender disparities, the impact of chewing level, periodontitis as the major factors of oral health of low- back-pain. The strength of our study, we used nationally reliable data with validity.
These results might be helpful for preventing low back pain in remarkably ageing population worldwide.
Improvements/Applications: Therefore, multidisciplinary policies and strategies focusing on gender disparities and oral health might be needed to manage the low back pain caused of serious disability among this population.
Keywords: Low back pain, Gender, Oral health, Age, Income, Sedentary time
*Corresponding Author : Name :Moon-Hee Kwon
Email : [email protected] Contact :+82-010-9722-2127 Fax :033-738-1406
Date of Submission :October 5, 2020
INTRODUCTION
Low-back-pain (LBP) is rapidly growing worldwide. Recently, low-back-pain was known as being related with significant disability(Doualla M et al., 2019) causing specific mortality such as cardiovascular and cancer of older women by cohort study(Konijnenberg E et al., 2018)and being higher risk of men with chronic disease (Heuch I et al., 2019). According to occupational research, the relationshipof low back pain and work exposure was highlighted by gender specific job-exposure matrix (Azfar S M et al., 2019; Hanvold T N et al., 2019). And that, sedentary behaviors were reported to be associated with increasing occupational risks like back pain including mental health problems (Hanna F et al., 2019) as well as the association of low- back -pain, little exercise and female gender(Jonsdottir S et al., 2019). And it was reported that personal factors likegender, age, marital state, BMI(body-mass-index) and smoking were identified as not associated one with low-back-pain of physicians(Al-Ruwaili B et al., 2019).
But female gender and high body mass index were reported to beingas risk factors of chronic back-pain among oldest-old people (Mallon T et al., 2019). Also, age and pain chronicity factors were reported to be related with influencing outcomes of therapy in chronic back pain and function by prospective multicenter clinical trial (Steinmet, A et al., 2019).Especially, long duration of disabling back pain was more related with socio-demographic factors such as ageing, female gender, lower occupational-status, married status as well as health-related factors such as smoking (Claus M et al., 2019). Moreover, racial inequities among diverse individuals in low back pain were critically reported by the racially diverse sample (Trost Z et al., 2019). Low back pain emerges as significant health threatening problem (Maher C et al., 2017) and it is great need to explore the determinant factors related with the disability. And also, it was reported that biopsychosocial profiles and physical function were relatedto chronic low-back-pain especially among elderly(Weiner D K et al., 2019) as well as losing time due to back pain according to the systemic review of US recent study (Ferguson S A et al., 2019). And that, fascial system was more effective than standard physical practice in pain reduction of low back pain regardless of age and gender (Harper B et al., 2019). Additionally, physically being active was reported to be associated with lowering the risk of musculoskeletal-pain,but smoking was related tomore pain in musculoskeletal-area like low- back, neck-shoulder of general working population (Micheletti J K et al., 2019). And also, it was reported that racial inequities were identified as the critical point of view in chronic low-back-pain (Trost Z et al., 2019)., which caused of seeking medical health care and lost time (Ferguson S A et al., 2019).
Furthermore, people who have low back pain were reported to get the information of prognosis, treatment and self-management strategies (Lim Y Z et al., 2019). In viewing of current studies, we conducted to investigate determinant factors of low-back-pain among middle and older
Koreans using the useful and representative data of KNHANES. Considering its potentially impact on individuals and lifestyle, we used socio-demographic, health-related and oral health characteristics.
MATERIALS& METHODS
This is cross-sectional-study, population-based stratified sampling design and the data was analyzed by complex-sampling methods and used multi-variable logistic regression after exclusion of missing data with the SPSS (ver. 21.0).We used the data which was known as the representative one with necessary ethical clearance.
Study design
The combined data of 6th KNHANES, Korea-National-Health and Nutritional-Examination- Survey, which composed by health examination, health interview, and nutrition survey conducted annually, with the stratified cluster sampling methods, especially related with low back pain, were used.
Study analysis
Descriptive statistics was used for general characteristics. And chi-square test was used for the prevalence of association of low-back-pain and the determinants. To find out associated determinants of low-back-pain and impact of oral health, multi-variable logistic regression was adopted. We selected and analyzed the 2,433 participants (50≤) who submitted the informed consent and completed the survey of nutrition and health examination for identifying the determinants of low back pain of older subjects using the complex sampling methods through multi-logistic regression as well as including descriptive and analytic methods by SPSS package (ver. 21.0). The p-value (p〈.05) was employed as statistically significant.
RESULTSAND DISCUSSION
In total, 2433 participants after excluding the missing values data, were included.Table 1. shows general-characteristics of the participants. Prevalence of low back pain was 22.3%.
1410(58.0%) were female while 1023(42.0%) were male. 65 and over aged participants were 1162(47.8%). The subjects who complained low back pain were 542(22.3%). Over half of them (54.4%) were suffered from chewing difficulty and about one third (38.1%) of respondents had periodontitis.The lowest education group(elementary) group was 1044(42.9%). With life-style factors, no physical activity (76.4%), sedentary time (5 hrs.≤) (72.8%) smoking (38.1%) and drinking (80.3%)factors were showed. In view of socio-economic status, almost all subjects (98.9%) were in married status with spouse and about a quarter was in lowest income level.
Table 1: General-characteristics of the study-population
Variables N (2433) %
Gender
Male 1023 42.0
Female 1410 58.0
Age
50-64 1271 52.2
65 and over 1162 47.8
Residence
Urban(Dong) 1851 76.1
Rural(Eup, Myeon) 582 23.9
Marital status(spouse)
Yes 2406 98.9
No 27 1.1
Income level
Lowest 562 23.1
Middle-low 625 25.7
Middle-high 615 25.3
Highest 631 25.9
Education level
Elementary 1044 42.9
Middle 428 17.6
High 593 24.4
College 368 15.1
Smoking
Yes 927 38.1
No 1506 61.9
Drinking
Yes 1953 80.3
No 480 19.7
Physical activity
Yes 573 23.6
No 1860 76.4
Sedentary time
Less than 5 hrs. 662 27.2
5 hrs. and over 1771 72.8
Chewing difficulty
Severe 919 37.8
Moderate 405 16.6
None 1109 45.6
Periodontitis
Yes 927 38.1
No 1506 61.9
Back pain
Yes 542 22.3
No 1891 77.7
Table 2 presents prevalence of association between low-back-pain and determinant factors. This study explained that the associated factors of low-back-pain were no physical-activity (84.7%), sedentary time (more than 5 hours) (78.2%), female gender (74.4%), drinking (73.6%), smoking(71.4%), living urban area(70.5%), 65 aged and over (62.4%), lowest education level (60.9%), severe chewing difficulty (55.0%), periodontitis(52.2%) and lowest income level (31.5
%) in order.
Table 2: Association between low-back-pain and determinant factors among 50 and over aged subjects
Variables Back pain P-value*
Yes No
Gender <.001
Male 139(25.6) 884(46.7)
Female 403(74.4) 1007(53.3)
Age <.001
50-64 204(37.6) 1067(56.4)
65 over 338(62.4) 824(43.6)
Residence <.001
Urban(Dong) 382(70.5) 1469(77.7)
Rural(Eup, Myeon) 160(29.5) 422(22.3)
Marital status(spouse) 0.238
No 534(98.5) 1872(99.0)
Yes 8(1.5) 19(1.0)
Income level <.001
Lowest 171(31.5) 391(20.7)
Middle-low 146(26.9) 479(25.3)
Middle-high 116(21.4) 499(26.4)
Highest 109(20.1) 522(27.6)
Education level <.001
Elementary 330(60.9) 714(37.8)
Middle 81(14.9) 347(18.4)
High 89(16.4) 504(26.7)
College 42(7.7) 326(17.2)
Smoking <.001
No 155(28.6) 772(40.8)
Yes 387(71.4) 1119(59.2)
Drinking <.001
No 399(73.6) 1554(82.2)
Yes 143(26.4) 337(17.8)
Physical activity <.001
No 83(15.3) 490(25.9)
Yes 459(84.7) 1401(74.1)
Sedentary time <.001
Less than 5 hrs. 118(21.8) 544(28.8)
5 hrs. and over 424(78.2) 1347(71.2)
Chewing difficulty <.001
Severe 298(55.0) 621(32.8)
Moderate 91(16.8) 314(16.6)
None 153(28.2) 956(50.6)
Periodontitis <.001
No 259(47.8) 668(35.3)
Yes 283(52.2) 1223(64.7)
Results are shown asfrequency(%).
*Calculated by Chi-square test.
Table 3. explains major determinants of low back pain. By multiple logistic regression showed that gender(female) (OR 3.279; 95% CI 2.262-4.753: p<.05), severe chewing difficulty (OR 2.259; 95% CI 1.777-2.872: p<.05), and periodontitis (OR 1.674; 95% CI 1.353-2.071: p<.05)
as oral health factors were the strongest determinants of low back pain after adjustment. The next related factors were 65 and over aged group (OR 1.855; 95% CI 1.471-2.339: p<.05) compared to 50-64 aged group, lowest income level (OR 1.819; 95% CI 1.340-2.470: p<.05), and more than 5 hours of sedentary time factors (OR 1.674; 95% CI 1.353-2.071: p<.05) statistically significant.
Table 3: The determinant factors of low back pain of middle and older adults
Variables OR 95% CI P-value*
Gender
Male Reference
Female 3.279 2.262-4.753 <.001
Age
50-64 Reference
65 over 1.855 1.471-2.339 <.001
Residence
Urban(Dong) Reference
Rural(Eup, Myeon) 1.211 0.954-1.537 .116
Marital status(spouse)
No 1.703 0.665-4.357 .267
Yes Reference
Income level
Lowest 1.819 1.340-2.470 <.001
Middle-low 1.236 0.911-1.677 .174
Middle-high 0.993 0.728-1.355 .965
Highest Reference
Education level
Elementary 1.461 0.982-2.173 .061
Middle 1.155 0.751-1.778 .512
High 1.122 0.743-1.693 .585
College Reference
Smoking
No Reference
Yes 1.330 0.923-1.916 .125
Drinking
No Reference
Yes 0.916 0.710-1.182 .501
Physical activity
No 1.294 0.980-1.708 .069
Yes Reference
Sedentary time
Less than 5 hrs. Reference
5 hrs. and over 1.437 1.126-1.833 .004
Chewing difficulty
Severe 2.259 1.777-2.872 <.001
Moderate 1.575 1.161-2.136 .003
None Reference
Periodontitis
No Reference
Yes 1.674 1.353-2.071 <.001
Results are shown as odds ratios with 95% confidence intervals.
Abbreviations: OR, odds ratio; CI, confidence intervals.
*Calculated by multivariate logistic regression.
This is the first to investigate the association between gender disparities and the impact of oral health specifically on low back pain within to our knowledge.The major findings of our study were that female gender, chewing ability and periodontitis factors as the indicators of oral health were predominantly pointed as the strongest determinants of low back pain, which was known as the cause of work loss and significant disability, through analyzing with 2433 participants (≤50) of representative nation-wide study, the 6th Korea- National-Health and Nutrition-Examination-Survey. Next major risk determinants of low-back- pain were ageing (≤65) group compared to 50-64 aged group, lower income level and long sedentary time (5hrs.≤) in order significantly. The prevalence of low back pain was 22.3% of middle and elderly Koreans. In view of gender disparities, especially female gender was identified to be in accordance with low-back-pain and it was also reported through other similar researches(Alin C K et al.,2019; Jonsdottir S et al.,2019; Mallon T et al.,2019) while both genders were related to low-back- pain in recent another study of considering of gender-specific job exposure(Hanvold T N et al.,2014) . And these results were not consisted with another study which low-back-pain was more being prevalent in men especially among physicians (Al-Ruwaili B et al., 2019) and in more men among low back pain patients (Azfar S M et al., 2019). On the other hand, the reason of more females than men having low back pain might be explained in aspects of physiological, anatomical and structural difference and especially in experiencing menopause.
But in men, which was diagnosed of diabetes, they were reported to have the more risk of chronic low-back- pain while women, they have no association according to population-based cohort study (Heuch I et al.,2019).Chewing ability, as the leading indicator of oral health, which was identified as the most influencing factor of low back pain through our study, was recognized as the great implications for preventing of pathologies and improving quality of life as well as related with general health and well-being. And it was reported that orofacial pain was significantly related with poorer quality of life including psychological distress in middle- aged women (Bäck K, 2019). Moreover, chewing discomfort was reported to be clearly associated with memory declining and physical health such as limitations of daily life (Shin S M, 2020)Regarding periodontitis, as the disease of chronic inflammation, which was indicated in low- back-pain of our study was partially in consistent with another study(Bäck K, 2019). but oral health including periodontitis was still not known well despite of its importance(Abu- Gharbieh E et al.,2019).Ageing, which was suggested as the influencing factor of low back pain, was, some part of them, similar to other researches which was reported to be correlated with biopsychosocial profiles and function declining among adults or older adults (Claus M et
al.,2019; Doualla M et al.,2019; Weiner D K et al.,2019). And age and pain chronicity factors were reported to be seemed to being influenced therapy outcomes (Steinmet, A et al.,2019). In terms of Income level, lowest income was highlighted as the important determinant factor of low-back-pain of our study, these results were in common being with other studies which significant inequalities of socio-economic status were related with low back pain of elderly (Claus M et al.,2019; Ikeda Tet al.,2019).Long sedentary time (5 hrs.≤) was showed as the important determinant of worsening low-back- pain of our results, and higher BMI, and little exercise as lifestyle factors were also related to increasing the risk of chronic back-pain and those results were similar to those one of other studies (Alnaami I et al.,2019; Hanna F T et al.,2019; Jonsdottir S et al.,2019; Mallon T et al.,2019; Micheletti J.K et al.,2019; Monnier A et al.,2019). And another point of view, vitamin D deficiency was reported to be closely related with muscle atrophy of low-back- pain patients (Dzik K P et al.,2019).Additionally, it may be more important for early intervention to prevent low-back-pain in advance cause of being no effective status of even intensive education in developing acute low back pain (Traeger A C et al.,2019).Some major strengths of our study were using nation-wide representative data, the socio-economic differences of this population were small and suggesting the universality of clear themes. And we highlighted on low-back-pain and on subjects, middle-older adults who are vulnerable to be related with adverse conditions, for preparing of successful ageing against super-aged society of the world as well as for rapidly ageing Korea. Our findings may contribute for early intervening on planning and preparing strategies against preventing low back pain which was remarkably resulted in worsening disability and lowering quality of life.
Some of our study limitations include racial criteria not to be generalized and lack of specific anatomical and clinical findings. Considering these kinds of limitations, findings of our population-based study might be generalized and provide some evidences with validity for remarkably increasing of ageing population of Korea.Multidisciplinary cooperation policies and strategies highlighting on gender disparities and good oral health considering socio-economic and health related factors by healthcare professionals might be prepared to manage low back pain cause of disability and death among these elderly populations. Further robust researches will be needed to explore links on low-back-pain and gender disparities, oral health and socio- demographic factors in order to manage early interventions and treatment of low-back-pain in view of primary-health-care for future directions.
CONCLUSION
Through our study which was based on nationally reliable data, we suggested that gender(female), the level of chewing difficulty and periodontitis problems were remarkably related with low- back-pain, which is connected with serious disability and lowering quality of
life. And ageing group (≤65) compared to 50-64 aged one, in lower income level group and long sedentary time more than 5hrs. factors were also associated with low back pain in order significantly. We used and analyzed the data of a total of 2433 participants aged 50 and over in nation-wide study design, from 6th Korea-National-Health-and-Nutrition-Examination-Survey.
Government, local authorities and public professionals should prepare preventive policies and strategies focusing on gender disparities and oral health in primary care health aspects. Further researches might be urgently continued on the association of low-back-pain and other unhealthy determinants as well as the close physical and psychological mechanisms to prevent low back pain.
Acknowledgment
The first two authors,Moon-Hee Kwon and Junghyun Kim contributed equally to this work.
References
1. Abu-Gharbieh E., Saddik B., El-Faramawi M., Hamidi S., and Basheti, M., 2019. Oral health knowledge and behavior among adults in the United Arab Emirates. BioMed research interna tional.
2. Al-Ruwaili B., and Khalil T., 2019. Prevalence and Associated Factors of Low Back Pain A mong Physicians Working at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia. Op en Access Macedonian Journal of Medical Sciences, 7(17), pp.2807.
3. Alin C.K., Uzunel E., Kronhed A.C.G., Alinaghizadeh H., and Salminen H., 2019. Effect of t reatment on back pain and back extensor strength with a spinal orthosis in older women with osteoporosis: a randomized controlled trial. Archives of osteoporosis, 14(1), pp.5.
4. Alnaami I., Awadalla N.J., Alkhairy M., Alburidy S., Alqarni A., Algarni A.,mandMahfouz, A.A., 2019 Prevalence and factors associated with low back pain among health care workers i n southwestern Saudi Arabia. BMC musculoskeletal disorders, 20(1), pp.56.
5. Azfar S.M., Murad M.A., Azim S., and Baig, M., 2019. Rapid Assessment of Physical Activi ty and its Association Among Patients with Low Back Pain. Cureus, 11(12).
6. Bäck K., 2019. Temporomandibular disorders in women—symptoms and signs in population -based studies.
7. Claus M., Schuster M., Webendörfer S., Groneberg D.A., Jähner J., and Schiffmann D., 2019 . Prevalence of back pain in employees of a German chemical company: results of a large cro ss-sectional study. Journal of Occupational Medicine and Toxicology, 14(1), pp.16.
8. Doualla M., Aminde J., Aminde L.N., Lekpa F.K., Kwedi F.M., Yenshu, E.V., and Chichom A. M., 2019. Factors influencing disability in patients with chronic low back pain attending a tertiary hospital in sub-Saharan Africa. BMC musculoskeletal disorders, 20(1), pp.25.
9. Dzik K.P., Skrobot W., Kaczor K.B., Flis D.J., Karnia M.J., Libionka W., and Kaczor J.J., 20 19. Vitamin D deficiency is associated with muscle atrophy and reduced mitochondrial functi on in patients with chronic low back pain. Oxidative medicine and cellular longevity.
10. Ferguson S.A., Merryweather A., Thiese M.S., Hegmann K.T., Lu M.L., Kapellusch J.M., an d Marras W.S., 2019. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC musculos keletal disorders, 20(1), pp.1-8.
11. Hanna F., Daas R.N., Elshareif T.J., Almarridi H.H.F.H., Al-Rojoub Z.M.D.B., and Adegboy e D., 2019. The relationship between sedentary lifestyle, back pain and psychosocial correlate s among university employees. Frontiers in public health, 7, pp.80.
12. Hanvold T.N., Sterud T., Kristensen P., and Mehlum IS., 2019. Mechanical and psychosocial work exposures: the construction and evaluation of a gender-specific job exposure matrix (JE M). Scandinavian journal of work, environment &health, 45(3), pp.239-247.
13. Hanvold T.N., Wærsted M., Mengshoel A.M., Bjertness E., Twisk J., and Veiersted K.B. , 20 14. A longitudinal study on risk factors for neck and shoulder pain among young adults in the transition from technical school to working life. Scandinavian journal of work, environment
& health, 597-609.
14. Harper B., Steinbec, L., and Aron A., 2019. Fascial manipulation vs. standard physical therap y practice for low back pain diagnoses: A pragmatic study. Journal of Bodywork and Movem ent Therapies, 23(1), pp.115-121.
15. Heuch I., Hagen K., Sørgjerd E.P., Åsvold B.O., and Zwart J.A., 2019. Does diabetes influen ce the probability of experiencing chronic low back pain? A population-based cohort study: t he Nord-Trøndelag Health Study. BMJ open, 9(9), e031692.
16. Ikeda T., Sugiyama K., Aida J., Tsuboya T., Watabiki N., Kondo K., and Osaka, K., 2019. So cioeconomic inequalities in low back pain among older people: the JAGES cross-sectional st udy. International journal for equity in health, 18(1), pp.15.
17. Jonsdottir S., Ahmed H., Tómasson K., and Carter, B., 2019. Factors associated with chronic and acute back pain in Wales, a cross-sectional study. BMC musculoskeletal disorders, 20(1), pp.215.
18. Konijnenberg E., Carter S.F., Ten Kate M., Den Braber A., Tomassen J., Amadi C., and Dem uru, M., 2018. The EMIF-AD Preclin AD study: study design and baseline cohort overview.
Alzheimer's research &therapy, 10(1), pp.75.
19. Lim Y.Z., Chou L., Au R.T., Seneviwickrama K.M.D., Cicuttini F.M., Briggs A.M., and Wlu ka A.E., 2019. People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. Journa
l of physiotherapy, 65(3), pp.124-135.
20. Maher C., Underwood M., and Buchbinder R., 2017. Non-specific low back pain. The Lancet , 389(10070), pp.736-747.
21. Mallon T., Eisele M., König H.H., Brettschneider C., Röhr S., Pabs, A., and Fuchs, A., 2019.
Lifestyle Aspects As A Predictor Of Pain Among Oldest-Old Primary Care Patients–A Longi tudinal Cohort Study. Clinical Interventions in Aging, 14, pp.1881.
22. Micheletti J.K., Bláfoss R., Sundstrup E., Bay H., Pastre C.M., and Andersen L.L., 2019. Ass ociation between lifestyle and musculoskeletal pain: cross-sectional study among 10,000 adul ts from the general working population. BMC Musculoskeletal Disorders, 20(1), pp.1-8.
23. Monnier A., Larsson H., Nero H., Djupsjöbacka M., and Äng B.O., 2019. A longitudinal obs ervational study of back pain incidence, risk factors and occupational physical activity in Swe dish marine trainees. BMJ open, 9(5), e025150.
24. Shin S.M., 2020. Associations of Food-Chewing Discomfort with Health Behaviors and Cog nitive and Physical Health Using Pooled Data from the Korean Health Panel (2010–2013). N utrients, 12(7), pp.2105.
25. Steinmet, A., Psczolla M., Seidel W., Niemier K., Derlien S., and Nisser J., 2019. Effect of su bgroup-specific multimodal therapy on chronic spinal back pain and function—a prospective inpatient multicentre clinical trial in Germany. Medicine, 98(1).
26. Traeger A.C., Lee H., Hübscher M., Skinner I.W., Moseley G.L., Nicholas M.K., and Hush J.
M., 2019. Effect of intensive patient education vs placebo patient education on outcomes in p atients with acute low back pain: a randomized clinical trial. JAMA neurology, 76(2), pp.161- 169.
27. Trost Z., Sturgeon J., Guck A., Ziadni M., Nowlin L., Goodin B., and Scott W., 2019. Exami ning injustice appraisals in a racially diverse sample of individuals with chronic low back pai n. The Journal of Pain, 20(1), pp.83-96.
28. Weiner D.K., Gentili A., Coffey-Vega K., Morone N., Rossi M., and Perera S., 2019. Biopsy chosocial profiles and functional correlates in older adults with chronic low back pain: A prel iminary study. Pain Medicine, 20(7), pp.1300-1310.
