Food insecurity and unmet healthcare needs in South Korea.

BACKGROUND: Food insecurity is a significant risk factor for chronic and infectious diseases. It is also a barrier to accessing healthcare because food insecurity tends to co-occur with other socioeconomic disadvantages. The objective of this study is to examine whether food insecure individuals in South Korea can access desired level of healthcare when needed. METHODS: This repeated cross-sectional study used data from the 2013-2015 and 2019-2021 waves of the Korean National Health and Nutrition Examination Survey. Multivariable logistic regression models were used to examine the association between household food insecurity and two indicators of unmet healthcare needs - any experience of forgoing medical service and the reasons for unmet needs (problems with availability, acceptability, and accessibility). Covariates indicating predisposing, enabling, and need factors were included in the regression analyses. RESULTS: Of the 19,394 participants aged 19-64 years, 4.5% were moderately food insecure, 0.9% were severely food insecure, and 9.3% reported unmet healthcare needs. In the adjusted model, moderate food insecurity (OR, 1.47; 95% CI, 1.19-1.82) and severe food insecurity (OR, 3.32; 95% CI, 2.27-4.85) were associated with higher odds of unmet healthcare needs in a dose-graded manner. These associations were largely due to the increased odds of accessibility-related unmet needs among participants with moderate (OR, 2.31; 95% CI, 1.68-3.19) and severe food insecurity (OR, 6.15; 95% CI, 3.91-9.68). CONCLUSIONS: Food insecurity was associated with higher odds of unmet healthcare needs among Korean adults. Competing life demands may have a cumulative impact on health over the short and long term. Efforts to address trade-offs between healthcare needs and food insecurity may improve the health and well-being of marginalized populations.

Food Insecurity, Healthcare Utilization, and Healthcare Expenditures: A Longitudinal Cohort Study.

Objective: This study examines the longitudinal association between household food insecurity and healthcare utilization and expenditure. Methods: A multi-wave longitudinal cohort study was conducted using the 2008-2019 and 2021 waves of the Korean Welfare Panel Study. The baseline data included participants aged ≥19 years with valid responses to the food insecurity and healthcare questionnaires in the 2008 wave (n = 12,166). Healthcare outcomes encompassed outpatient visits, inpatient admissions, days hospitalized, and personal healthcare expenditure. Random effects Poisson and linear regressions were estimated. Results: Severe food insecurity was associated with a higher incidence rate of outpatient visits (IRR, 1.14; 95% CI, 1.12-1.17), days of hospitalization (IRR, 1.18; 95% CI, 1.13-1.22), and inpatient admissions (IRR, 1.40; 95% CI, 1.18-1.65). Moderate food insecurity was associated with 10.4% (ß = -0.11; 95% CI, -0.14 to -0.07) or 238,276 KRW reductions in personal healthcare expenditures in the subsequent year. Conclusion: Household food insecurity was linked to increased healthcare utilization and reduced personal healthcare expenditure among Korean adults. Our findings present opportunities to identify target populations for healthcare policies and interventions.

Longitudinal Associations Between Food Insecurity and Suicidal Ideation Among Adults Aged ≥65 in the Korean Welfare Panel Study.

Objectives : This study aimed to explore longitudinal associations between food insecurity and suicidal ideation, and the moderating roles of intervention programs. Methods: Data were derived from the 2012-2019 waves of the Korean Welfare Panel Study. Participants aged ≥65 at baseline (n = 4,425) and their annual follow-up measurements for a mean of 6.58 years were included. Conditional fixed effects logistic regressions were used to test 1) associations between food insecurity and the onset of suicidal ideation; 2); whether associations were attenuated by food assistance and income support programs. Results: Food insecurity was associated with higher odds of suicidal ideation in the full sample (OR, 1.77; 95% CI, 1.37-2.29), among women (OR, 1.67; 95% CI, 1.24-2.26) and men (OR, 2.06; 95% CI, 1.25-3.40). The association between food insecurity and suicidal ideation was attenuated by participation in home-delivered meal services (OR, 0.43; 95% CI, 0.21-0.88). Conclusion: Food insecure older adults were more likely to consider committing suicide than their food secure counterparts. Food assistance through home-delivered meal services, but not other intervention programs, could weaken this link.

Predicting adherence to COVID-19 preventive measures among South Korean adults aged 40 to 69 Years using the expanded health empowerment model.

The public health environment in South Korea is advancing toward the late stages of the COVID-19 pandemic. However, there is limited knowledge about the extent of individuals' compliance with preventive measures during this transitional period and the potential predictors that determine such compliance behaviors. In this study, we employed the expanded health empowerment model to investigate factors associated with COVID-19 preventive behaviors among Korean adults in late 2022. Our theoretical framework integrates the knowledge-attitude-behavior model with the health belief model to conceptualize health empowerment underlying the formation of preventive behaviors. We collected data from 1100 Korean adults aged 40-69 years through an online survey conducted in October 2022. Participants responded to questions about their knowledge of COVID-19, attitudes towards the disease, adherence to preventive measures, infection history, and sociodemographic characteristics. Structural equation modeling was employed to assess the relationships between knowledge, attitudes, and preventive behaviors related to COVID-19. Results showed that attitudes toward the disease predict adherence to preventive behaviors. We also found that COVID-19 knowledge partially determined the attitudes toward the disease. However, COVID-19 knowledge was not directly associated with adherence to preventive behaviors. Additionally, the associations between knowledge, attitudes, and preventive behaviors did not differ between infected and never-infected individuals. Overall, this study finds empirical support for the expanded health empowerment model, which connects knowledge to preventive behaviors through positive attitudes toward the disease, while underscoring the limited role of infection history in this association. These findings can help policymakers understand individual responses to public health guidelines in the late pandemic era and develop policies to mitigate further transmission of COVID-19.

More than just a bad day? Traumatic life events and self-control in old age.

The behavioral economics literature suggests that exposure to traumatic events shifts preference features including risk aversion and time preference. In this study, we examined the association between traumatic life events and self-control in old age. Data were obtained from the Health and Retirement Study, which offers retrospective data on trauma exposure and early life characteristics. The results showed that experiences of serious physical attacks or assaults is associated with a 3.1% reduction in self-control, adjusted for demographic and childhood socioeconomic characteristics. The attacks or assaults were experienced approximately 30 years prior to the survey, indicating that traumatic life events exert a lasting influence on self-control. Further analyses found no difference in the association between the experience of serious physical attacks or assaults and self-control according to the timing of occurrence. Our findings are consistent with the evidence that experiences of natural disasters or armed conflicts increase impatience among survivors.

Machine learning prediction of suicidal ideation, planning, and attempt among Korean adults: A population-based study.

Background: Suicide remains the leading cause of premature death in South Korea. This study aims to develop machine learning algorithms for screening Korean adults at risk for suicidal ideation and suicide planning or attempt. Methods: Two sets of balanced data for Korean adults aged 19-64 years were drawn from the 2012-2019 waves of the Korea Welfare Panel Study using the random down-sampling method (N = 3292 for the prediction of suicidal ideation, N = 488 for the prediction of suicide planning or attempt). Demographic, socioeconomic, and psychosocial characteristics were used to predict suicidal ideation and suicide planning or attempt. Four machine-learning classifiers (logistic regression, random forest, support vector machine, and extreme gradient boosting) were tuned and cross-validated. Results: All four algorithms demonstrated satisfactory classification performance in predicting suicidal ideation (sensitivity 0.808-0.853, accuracy 0.843-0.863) and suicide planning or attempt (sensitivity 0.814-0.861, accuracy 0.864-0.884). Extreme gradient boosting was the best-performing algorithm for predicting both suicidal outcomes. The most important predictors were depressive symptoms, self-esteem, income, consumption, and life satisfaction. The algorithms trained with the top two predictors, depressive symptoms and self-esteem, showed comparable classification performance in predicting suicidal ideation (sensitivity 0.801-0.839, accuracy 0.841-0.846) and suicide planning or attempt (sensitivity 0.814-0.837, accuracy 0.874-0.884). Limitations: Suicidal ideation and behaviors may be under-reported due to social desirability bias. Causality is not established. Discussion: More than 80% of individuals at risk for suicidal ideation and suicide planning or attempt could be predicted by a number of mental and socioeconomic characteristics of respondents. This finding suggests the potential of developing a quick screening tool based on the known risk factors and applying it to primary care or community settings for early intervention.

Association of Food Insecurity With Allostatic Load Among Older Adults in the US.

Importance: Allostatic overload, a biomarker of wear and tear, could be the potential pathway through which food insecurity leads to increased morbidity risk. Objective: To assess the association of food insecurity with allostatic load (AL) among US adults aged 50 years or older. Design, Setting, and Participants: A multiwave longitudinal cohort study was conducted using data from the 2006 to 2014 waves of the Health and Retirement Study in a national cohort study setting. The data comprise 26 509 person-years observations from 14 394 noninstitutionalized individuals aged 50 years or older during the study period. Data were analyzed from September 1 to December 14, 2020. Exposures: Moderate food insecurity (not enough money to buy the food needed) and severe food insecurity (reduced food intake due to financial constraints) measured at the household level. Main Outcomes and Measures: The AL score (0-9, with higher scores indicating a greater risk of physiologic dysregulation) and binary indicators of dysregulated inflammatory (C-reactive protein), cardiovascular (systolic and diastolic blood pressure, pulse rate, and cystatin C), and metabolic (hemoglobin A1c, body mass index, waist-to-height ratio, total cholesterol to high-density lipoprotein cholesterol ratio) systems. Results: Of 14 394 participants included in the analysis, the median age was 60 (IQR, 56-69) years, 8143 (56.6%) were women, 517 (3.6%) were moderately food insecure, and 804 (5.6%) were severely food insecure. In adjusted models, the incidence rate of AL was 1.05 (95% CI, 1.00-1.09) times higher for the participants with moderate food insecurity and 1.11 (95% CI, 1.07-1.15) times higher for the participants with severe food insecurity, compared with those who were food secure. The increased incidence rate of AL among participants with severe food insecurity was associated with C-reactive protein level (odds ratio [OR], 1.22; 95% CI, 1.04-1.44), cystatin C level (OR, 1.23; 95% CI, 1.01-1.51), hemoglobin A1c level (OR, 1.27; 95% CI, 1.01-1.59), body mass index (OR, 1.84; 95% CI, 1.41-2.40), waist-to-height ratio (OR, 1.54; 95% CI, 1.26-1.88), and total to high-density lipoprotein cholesterol ratio (OR, 1.32; 95% CI, 1.10-1.59) inflated to the high-risk range. The interaction between moderate food insecurity and Supplemental Nutrition Assistance Program (SNAP) enrollment (ß = -0.18; P = .001) and the interaction between severe food insecurity and SNAP enrollment (ß = -0.09; P = .02) were associated with a reduction in AL. Conclusions and Relevance: In this national cohort study of US adults aged 50 years or older, food insecurity was associated with higher AL, mainly through dysregulation of the inflammatory and metabolic systems. SNAP enrollment may modify this association between food insecurity and AL.

Relative deprivation and suicide risk in South Korea.

Psychosocial stress and the related biochemical response have been hypothesized as a potential mechanism underlying the link between relative deprivation and mortality. While suicide is known as the likely manifestation of severe mental illness, less is known about the effect that relative deprivation has on suicide risk. Using the 2012 to 2018 waves of the Korean Welfare Panel Study, we examined the association between relative deprivation in income and suicide risk among South Koreans aged 25 or older. Relative deprivation is assessed with the Yitzhaki index, Deaton index, and income rank within the reference group, and suicide risk is measured as suicidal ideation and suicide planning or attempt in the preceding year. Adjusted for absolute income and other socioeconomic characteristics, the odds ratios of reporting suicidal ideation for each 10000 k KRW (8300 USD) increase in the Yitzhaki index were around 1.42 (95% CI: 1.08-1.87) to 1.72 (95% CI: 1.30-2.28). The estimated odds ratios were in the range of 1.70 (95% CI: 1.04-2.78) to 1.95 (95% CI: 1.26-3.02) for suicide planning or attempt. The association between relative deprivation in income and suicidal ideation was found significant only for men, not for women. The inferences were robust to various definitions of relative deprivation and reference group. Taken together, our findings suggest that relative deprivation in income is independently associated with higher odds of suicidal ideation and suicide planning or attempt over and above the effect of absolute income and material living conditions. Narrowing the income gap between individuals would be an effective policy response to a suicide epidemic in South Korea.

The long-term effects of cancer survivorship on household assets.

BACKGROUND: Less is known about the impact of cancer on household assets and household financial portfolio during which cancer survivors face higher mortality risk. Economic theory predicts that cancer survivors would deplete their wealth in such a way that meets immediate financial needs for treatment and that hedges the risk of anticipated medical expenses associated with recurrence. Building upon this prediction, we examine long-term changes in household assets in response to cancer diagnosis among middle-aged and elderly Americans (age ≥ 50). RESULTS: Using the 2000-2014 waves of the Health and Retirement Study, we estimated the household fixed effects regression that regresses household assets on time elapsed since cancer diagnosis (≤ 2 years, > 2 but ≤4 years, > 4 but ≤6 years, and > 6 but ≤8 years). Regression estimates were adjusted for demographic characteristics, general health condition, employment outcomes, and household economic attributes. Household assets were measured by total net worth as well as the amount of savings held in each asset category. The loss of household assets attributable to cancer was estimated to be $125,832 in 2015 dollars per household with a cancer patient. This change came from statistically significant reductions in investment assets, miscellaneous savings, real estate equity, and business equity, and increases in unsecured debt. We also found 17.2-28.0% increases in cash and cash-equivalent assets from + 2 years since diagnosis through the rest of the study periods. The accumulation of cash was observed for both the well-insured group (multiple coverages) and those with limited insurance (single coverage). CONCLUSIONS: The results showed evidence of both asset depletion and precautionary accumulation of liquid assets among cancer survivors, which reduces risk exposure of household financial portfolio. Our findings highlighted that household asset is an important source of liquidity to finance cancer care and to absorb the expected expenditure risk associated with cancer recurrence. We also showed that health insurance provides limited coverage of health risks associated with cancer.

Welfare stigma as a risk factor for major depressive disorder: Evidence from the Supplemental Nutrition Assistance Program.

BACKGROUND: Negative public attitude about welfare is known to impair feelings of self-worth and psychological well-being in welfare recipients. What is missing in the extant literature is whether the stress of being on welfare increases the risk for clinically severe depression. To fill this gap, the present study examines the association between participation in the food stamp program and major depressive disorder. METHODS: Study data is drawn from the 2008-2014 waves of the Health and Retirement Study (N = 67076). Depressive symptom is assessed with the Composite International Diagnostic Interview - Short Form, and modeled by a continuous score of major depressive symptoms (0-7) and a binary indicator for three or more symptoms. A fixed effects regression is used to estimate changes in depressive symptoms explained by the food stamp participation, adjusted for confounding covariates. RESULTS: Food stamp participation was associated with an average of 19% increases in depressive symptoms (p < 0.001) and 29% higher odds of having major depression (p < 0.01). The associations were statistically significant only for men, middle-aged adults, Whites, and those without disability - groups that are more likely to be stigmatized by the social norm for not being able to rise above poverty. LIMITATIONS: Depression outcomes are self-reported. Causality remains not established. The recession during the study periods may have dampened the stigma effects. CONCLUSIONS: Welfare participation is a risk factor for clinical depression in a low-income setting. Depressive symptoms induced by welfare stigma need to be clinically targeted through counseling and cognitive therapy programs.

Food stamps, food insecurity, and health outcomes among elderly Americans.

This study examined associations between very low food security and health outcomes in older adults, and tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) mitigates adverse health consequences associated with very low food security. Data were drawn from the 1998-2014 waves of the Health and Retirement Study (N = 148,138 from 27,281 persons). A longitudinal analysis of the relationship between very low food security and health condition depending on SNAP participation was conducted using the individual fixed effects regression. Respondents' health status was assessed by self-rated health, grip strength, and depressive symptoms. The correlations between very low food security and physical health outcomes were negatively significant prior to SNAP enrollment (p < 0.05) but became insignificant upon participation, indicating that SNAP may have prevented poor physical health resulting from very low food security. However, results concerning mental health showed that SNAP enrollment does not modify the association between very low food security and depression; very low food security remained a significant risk factor of depressive symptoms conditional on SNAP enrollment (p < 0.001). Further analyses showed that SNAP participation is correlated with negative self-attitudes (p < 0.05), and that the correlation between SNAP and depression becomes insignificant after controlling for self-attitudes. These results suggest that a stigma effect arising from welfare use may have reduced self-esteem and resulted in depressive moods. Future research needs to delve into whether reforms to the food assistance program aimed at reducing stigma can help alleviate emotional distress among welfare recipients.

The impact of Medicare Part D on cognitive functioning at older ages.

Research has shown that the establishment of Medicare prescription drug benefit in 2006 leads to improvement in medication adherence and mortality outcomes. Despite a clear connection between physical/mental health and the risk of dementia, little is known about the extent to which this reform has affected the cognitive functioning of the elderly. Using data from the Health and Retirement Study and difference-in-differences approach, this study provides the first evidence on the cognition-enhancing effects of Medicare Part D. Our estimates show that Part D implementation is associated with 1.6% increase in cognitive functioning or 1.1-year delay of cognitive aging among benefit-eligible persons. Further analyses indicate that most of the cognitive benefits accrue to the vulnerable populations who previously lacked prescription drug coverage, and that a reduction in cardiovascular mortality is the most likely pathway through which the expansion improved cognitive functioning.

Measuring and tracking obesity inequality in the United States: evidence from NHANES, 1971-2014.

BACKGROUND: Because people care about their weight relative to peers and society, obesity inequality plays a role in explaining obesity incidence and the impacts of being obese on subjective well-being. While the increase in obesity prevalence and mean body mass index (BMI) is well documented, the measurement of distributional changes and corresponding obesity inequality is yet to be fully explored. METHODS: The present study analyzed BMI data for adults aged 20 to 74 from the National Health and Nutritional Examination Survey (NHANES) I (1971-1974), II (1976-1980), III (1988-1994), and continuous NHANES (1999-2014). We applied tools developed to measure income inequality to analyze the inter-temporal variation in the BMI distribution among US adults. Using stochastic dominance tests, we construct partial orderings on cumulative BMI distributions during the study period. Shapley decompositions and inequality indices are employed to quantify the source and extent of temporal variation and decompose the inequality into within and between-group components considering age, gender, and race. RESULTS: The BMI distribution of each NHANES study first-order stochastically dominated the BMI distribution of the previous wave from 1971-1974 to 2003-2006, whereas more recent comparisons failed to reject the null hypothesis of non-dominance. The Shapley decomposition analysis revealed that horizontal shifts of BMI distributions accounted for a majority of the increase in obesity prevalence since 1988-1991. Especially in recent years when the rate of obesity growth has slowed down, the contribution of the redistribution component dropped significantly and even became negative between 2007-2010 and 2011-2014. The inequality indexes consistently show a worsening of obesity inequality from the mid-1970s to the mid-2000s regardless of population subgroups, and this disproportionate shift of the BMI distribution is unlikely to be a result of a changing ethnic composition of the US population. CONCLUSION: Our findings demonstrate that seemingly similar increases in obesity prevalence can be accompanied by very different patterns of distribution change. We find that the early phase of the obesity epidemic in the US was largely driven by increasing skewness, whereas more recent growth is a population-wide experience, regardless of demographic characteristics. Increasing morbid obesity certainly played an important role in the initial phase of the epidemic, but more recently the BMI distribution has largely horizontally shifted to the right.