Korean J Community Nutr KJCN Korean Journal of Community Nutrition 1226-0983 2287-1624 The Korean Society of Community Nutrition 10.5720/kjcn.2019.24.6.453 Research Article Effect of Geographic Area on Dietary Quality across Different Age Groups in Korea https://orcid.org/0000-0002-0965-9704 Kim Hyun Ja 1 https://orcid.org/0000-0003-3054-8758 Kim Kirang Department of Food and Nutrition, Gangneung-Wonju National University, Gangneung, Korea, Professor. Department of Food Science and Nutrition, Dankook University, Cheonan, Korea, Professor. Corresponding author: Kirang Kim. Department of Food Science and Nutrition, Dankook University, 119, Dandae-ro, Dongnam-gu, Cheonan 31116, Korea. Tel: (041)550-3472, Fax: (041)559-7955, kirangkim@dankook.ac.kr 12 2019 31 12 2019 24 6 453 464 18 09 2019 04 11 2019 04 11 2019 Copyright © 2019 The Korean Society of Community Nutrition 2019 The Korean Society of Community Nutrition This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives

The objective of this study was to examine whether dietary quality varies among different age groups and geographic areas, and whether the difference between geographic areas varies across several age groups in Korea.

 Methods

The subjects were 14,170 subjects who participated in the 2013–2015 Korea National Health and Nutrition Examination Survey. The dietary quality was assessed using the Korean Health Eating Index (KHEI). Age groups were categorized into six groupings, and areas were categorized into urban and rural according to their administrative districts. The effect of area on the KHEI score was analyzed by multiple linear regression analysis.

 Results

The KHEI was the lowest in the 20-30s group (57.7 ± 0.4 score for 20s and 61.2 ± 0.3 score for 30s) and increased with age (p<0.001), showing the highest score in the 60s (67.9 ± 0.3 score), and then decreased again in the 70s and older (64.6 ± 0.3 score). As a result of comparing the KHEI score by area, the urban areas had higher KHEI scores than did the rural areas (63.5 ± 0.2 score for urban area and 62.2 ± 0.4 score for rural area, p=0.002). The difference between areas was dependent on the age group, showing a significant difference for subjects who were aged from 50s and older (p=0.002 for 50s, p<0.001 for 60s and p<0.001 for 70s and older). After adjusting for confounding factors, the effect of area on the KHEI score was only shown for those subjects in the over 60 years old group (p=0.035 for 60s and p<0.001 for 70s and older).

 Conclusions

The dietary quality differed according to the age group and geographic area. The dietary quality was lower for younger people than that for older people, and in rural areas compared to that in urban areas, and especially for older adults. The area factor was a very important factor for the dietary quality.

 dietary quality health eating index Korea area age National Research Foundation of Korea https://doi.org/10.13039/501100003725 NRF-2019R1H1A2080093 Acknowledgments

This research was supported by a fund by Research of Korea Centers for Disease Control and Prevention and the National Research Foundation of Korea (NRF-2019R1H1A2080093).

 World Health Organization Diet, nutrition and the prevention of chronic diseases Geneva World Health Organization 2003 916 World Health Organization Global action plan for the prevention and control of noncommunicable diseases 2013–2020 Geneva World Health Organization 2013 Forouzanfar MH Afshin A Alexander LT Anderson HR Bhutta ZA Biryukov S Global, regional, and national comparative risk assessment of behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015 Lancet 2016 388 10053 1659 1724 10.1016/S0140-6736(15)00128-2 Kennedy ET Ohls J Carlson S Fleming K The healthy eating index: design and applications J Am Diet Assoc 1995 95 10 1103 1108 Haines PS Siega-Riz AM Popkin BM The diet quality index revised: a measurement instrument for populations J Am Diet Assoc 1999 99 6 697 704 10.1016/S0002-8223(99)00168-6 Kim S Haines PS Siega-Riz AM Popkin BM The diet quality index-international (DQI-I) provides an effective tool for cross-national comparison of diet quality as illustrated by China and the United States J Nutr 2003 133 11 3476 3484 10.1093/jn/133.11.3476 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ Update of the healthy eating index: HEI-2010 J Acad Nutr Diet 2013 113 4 569 580 10.1016/j.jand.2012.12.016 Woodruff SJ Hanning RM Development and implications of a revised Canadian healthy eating index (HEIC-2009) Public Health Nutr 2010 13 6 820 825 Yook SM Park S Moon HK Kim K Shim JE Hwang JY Development of Korean Healthy Eating Index for adults using the Korea National Health and Nutrition Examination Survey data J Nutr Health 2015 48 5 419 428 10.4163/jnh.2015.48.5.419 Korea Centers for Disease Control and Prevention The Sixth Korea National Health and Nutrition Examination Survey (KNHANES 2013–2015) Microdata user guide Osong Korea Centers for Disease Control and Prevention 2019 Variyam JN Blaylock J Smallwood D Basiootis PP USDA's Healthy Eating Index and Nutrition Information Washington, DC Economic Research Service and Center for Nutrition Policy and Promotion, USDA 1998 Al-Ibrahim AA Jackson RT Healthy eating index versus alternate healthy index in relation to diabetes status and health markers in U.S. adults: NHANES 2007-2010 Nutr J 2019 18 1 26 10.1186/s12937-019-0450-6 Subhan FB Chan CB Diet quality and risk factors for cardiovascular disease among South Asians in Alberta Appl Physiol Nutr Metab 2019 44 8 886 893 10.1139/apnm-2018-0868 Morton LW Bitto EA Oakland MJ Sand M Accessing food resources: Rural and urban patterns of giving and getting food Agric Hum Values 2008 25 1 107 119 Sharkey JR Johnson CM Dean WR Food access and perceptions of the community and household food environment as correlates of fruit and vegetable intake among rural seniors BMC Geriatr 2010 10 1 32 Dean WR Sharkey JR Rural and urban differences in the associations between characteristics of the community food environment and fruit and vegetable intake J Nutr Educ Behav 2011 43 6 426 433 10.1016/j.jneb.2010.07.001 Caspi CE Sorensen G Subramanian SV Kawachi I The local food environment and diet: A systematic review Health Place 2012 18 5 1172 1187 10.1016/j.healthplace.2012.05.006 Lee JH The regional health inequity, and individual and neighborhood level health determinants Health Soc Welf Rev 2016 36 2 345 384 10.15709/hswr.2016.36.2.345 Yoon TH Regional health inequalities in Korea: The status and policy tasks J Crit Soc Welf 2010 30 8 49 77 Yun S Development and status of Korean Healthy Eating Index for adults based on the Korea National Health and Nutrition Examination Survey Nutrition and Dietetics 2019 42 2 14 19 Ministry of Health and Welfare A study on the establishment of the life cycle-based dietary guidelines for Koreans Sejong Ministry of Health and Welfare 2016 Jung HW Kim SW Kim IY Lim JY Park HS Song W Protein intake recommendation for Korean older adults to prevent sarcopenia: Expert consensus by the Korean Geriatric Society and the Korean Nutrition Society Ann Geriatr Med Res 2018 22 4 167 175 10.4235/agmr.18.0046 Kim HR A study on the association of diet quality and risk of mortality and major chronic diseases from nationally representative longitudinal data Health Soc Welf Rev 2013 33 3 5 30 10.15709/hswr.2013.33.3.5 Park GA Kim SH Kim SJ Yang YJ Health and nutritional status of Korean adults according to age and household food security: Using the data from 2010~2012 Korea National Health and Nutrition Examination Survey J Nutr Health 2017 50 6 603 614 10.4163/jnh.2017.50.6.603 Lee JH The regional health inequity, and individual and neighborhood level health determinants Health Soc Welf Rev 2016 36 2 345 384 10.15709/hswr.2016.36.2.345 Lytle LA Measuring the food environment: State of the science Am J Prev Med 2009 36 4 Suppl S134 S144 10.1016/j.amepre.2009.01.018 Yoon H Kwoun J Lee S Nutritional status and energy expenditure in the elderly in a rural community Korean J Community Nutr 2002 7 3 336 344 Cho YE Lee SL Cho EH Lomeda RL Kwak EH Kim YH Comparison of nutrient intakes of Korean elderly people living in rural area between 24-hour recall and food frequency method J Korean Soc Food Sci Nutr 2006 35 6 698 707 10.3746/jkfn.2006.35.6.698 Lee Y Choi Y Park HR Song KH Lee KE Yoo CH Comparative analysis of dietary behavior and nutrient intake of elderly in urban and rural areas for development of “Village Lunch Table” program: Based on 2014 Korea National Health and Nutrition Examination Survey data J Nutr Health 2017 50 2 171 179 10.4163/jnh.2017.50.2.171 Choi HJ Yoo JH The effect of depression and self-efficacy on health promotion behavior among the elderly living alone in rural area J East West Nurs Res 2011 17 2 149 155 10.14370/jewnr.2011.17.2.149 Lee MS Health-related factors influencing the quality of life of rural elderly subjects-activities of daily living, cognitive functions, prevalence of chronic diseases and nutritional assessment Korean J Community Nutr 2012 17 6 772 781 10.5720/kjcn.2012.17.6.772 Park E A comparison of community health status by region and an investigation of related factors using community health indicators J Korean Acad Community Health Nurs 2012 23 1 31 39 10.12799/jkachn.2012.23.1.31 Glanz K Sallis JF Saelens BE Frank LD Healthy nutrition environments: Concepts and measures Am J Health Promot 2005 19 5 330 333 10.4278/0890-1171-19.5.330 Sharkey JR Johnson CM Dean WR Food access and perceptions of the community and household food environment as correlates of fruit and vegetable intake among rural seniors BMC Geriatr 2010 10 1 32 Lee KI Hwang YJ Lee DS Kim GY Lee YN Kim K Strategic approach toward vitalizing food assistance programs Naju Korea Rural Economic Institute 2012 680 Lee CH Lee SE Jang MJ Choe JS Park YH Kim Y An analysis of food purchase accessibility and availability for rural households: The cases of Bibong-myeon and Maesong-myeon, Hwaseong-si Korean J Community Living Sci 2014 25 4 581 600 10.7856/kjcls.2014.25.4.581 Shim JE Kim SJ Kim K Hwang JY Spatial disparity in food environment and household economic resources related to food insecurity in rural Korean households with older adults Nutrients 2018 10 10 E1514 10.3390/nu10101514 Shim JE Hwang JY Kim K Objective and perceived food environment and household economic resources related to food insecurity in older adults living alone in rural areas BMC Geriatrics 2019 19 1 234 10.1186/s12877-019-1231-y Oh MH Choe JS Kim Y Lee SE Paik HY Jang MJ Customer perception and expert assessment in restaurant food environment by region: Focused on restaurants in Suwon, Hwaseong city J Nutr Health 2014 47 6 463 474 10.4163/jnh.2014.47.6.463 General characteristics of adults aged 19 years and older, 2013–2015 KNHANES

KNHANES, Korea National Health and Nutrition Examination Survey.

1) All % (SE) were calculated by applying sampling weights assigned to individual participants in the nutrition survey.

2) P-values for % differences between urban and rural area were calculated using the chi-square test

3) Including housewives or student

 Mean value of each KHEI item by age group and region

KHEI, Korean Health Eating Index; SFA, saturated fatty acid; CHO, carbohydrate

All values were calculated by applying sampling weights assigned to individual participants in the nutrition survey.

1) Sex-adjusted means ± SE

2) Age- and sex-adjusted means ± SE

3) P-values for mean differences by age group and region were calculated using multivariate linear regression after adjusting for sex.

4) P-values for mean differences by age group and region were calculated using multivariate linear regression after adjusting for age (continuous) and sex.

 Difference of mean value of each KHEI item between urban and rural area according to age group

KHEI, Korean Health Eating Index; SFA, saturated fatty acid; CHO, carbohydrate

All values were calculated by applying sampling weights assigned to individual participants in the nutrition survey.

1) Sex-adjusted means ± SE

2) P-values for mean differences between urban and rural area were calculated using multivariate linear regression after adjusting for sex.

 Mean value of KHEI total score by factors related to KHEI

KHEI, Korean Health Eating Index

All values were calculated by applying sampling weights assigned to individual participants in the nutrition survey.

1) Age- and sex-adjusted means ± SE

2) P-values for mean differences of KHEI total score by factors related to KHEI using multivariate linear regression after adjusting for age (continuous) and sex. Different alphabets indicate significant differences by Tukey's test.

3) P-values for mean differences of KHEI total score by area and factors related to KHEI using multivariate linear regression after adjusting for age (continuous) and sex. Different alphabets indicate significant differences by Tukey's test.

 Region effect on KHEI total score after adjusting for confounding factors by age group

KHEI, Korean Health Eating Index

All values were calculated by applying sampling weights assigned to individual participants in the nutrition survey.

1) Beta for rural area vs. urban

Model was adjusted for sex, household type, marital status, household income, education level, job status, weight status, smoking, alcohol drinking, walking exercise, nutritional education, eating with others, food assistance program participation, and food security.