View of Gender Disparities and Oral Health on Low Back Pain among Middle and Older Korean Adults: The 6th KNHANES

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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


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



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.


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.


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) %


Male 1023 42.0

Female 1410 58.0


50-64 1271 52.2

65 and over 1162 47.8


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


Yes 927 38.1

No 1506 61.9


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


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*


Male Reference

Female 3.279 2.262-4.753 <.001


50-64 Reference

65 over 1.855 1.471-2.339 <.001


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


No Reference

Yes 1.330 0.923-1.916 .125


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


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.


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.


The first two authors,Moon-Hee Kwon and Junghyun Kim contributed equally to this work.


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