This study used the Korea Community Health Survey to examine the health behaviors of patients with major chronic diseases with regard to smoking, drinking, and physical activity, and compared these with those of the general population. We analyzed these trends from 2008 to 2017. Patients with major chronic diseases did not show notably better health behaviors; some showed worse health behaviors than did the general population. Although the smoking rate decreased, the decrease in patients with major chronic diseases was smaller than that in the general population. Regional variations were larger in the health behaviors of patients with major chronic diseases, compared to those of the general population.
Improved health behaviors can prevent NCDs and reduce their recurrence risk and severity, improve health-related quality of life, and extend life expectancy.31,32 Hence, the importance of health behaviors should be conveyed to the general population, to improve NCD patients’ health behaviors. Given the general difficulty of changing health behaviors,12 effective strategies should be developed, and resources assigned accordingly. Rather than focusing only on chronic disease patients’ medication adherence, strategies must be devised to encourage smoking cessation, reduce alcohol consumption, and increase patients’ walking rate. This study holds significance, as it presented empirical evidence to enable goal setting, so as to improve chronic disease patients’ health behaviors, and provided reasons for such improvement.
Smoking cessation has been highlighted for its potential to prevent or stabilize NCDs.33 In particular, an NCD diagnosis is expected to serve as an important opportunity for smokers to change their smoking behaviors; in fact, the smoking rate has shown decline after a stroke,34 cancer,22 and diabetes23 diagnosis. However, findings that >3 out of 4 patients still smoked 2 years after a stroke diagnosis, and that only 20% of patients with lung diseases quit smoking within 2 years,14 suggest that a diagnosis does not necessarily translate into smoking cessation. In this study, the current smoking rate of hypertension (16.6% as of 2017) and diabetes patients (19.2% as of 2017) did not differ substantially from that of the general population (20.2% as of 2017), suggesting a need for more active treatment for smoking cessation for chronic disease patients.
We assumed that smoking was particularly concerning in patients with mental disorders. Smoking increased only among depression patients (17.2% in 2009 to 18.9% in 2013) in this study, and the current smoking rate of patients experiencing depression symptoms (21.9% as of 2017) was higher than that of the general population. These results were consistent with those of previous studies, showing a higher smoking rate among patients with mental disorders, that these patients accounted for a higher proportion of smokers, and that they were less likely to quit smoking successfully.35,36 A study reported that smoking cessation led to depression,37 suggesting that it might be better to let depressed patients smoke, thereby discouraging the smoking cessation recommendation to these patients. However, given mounting evidence on how to treat smoking patients with mental disorders,38 and the latest empirical evidence suggesting that smoking cessation actually decreases depression,39,40 it is worth focusing more on smoking cessation among patients with conditions such as depression.
This study also found a higher drinking rate in chronic disease patients. While chronic disease patients’ monthly drinking rate was lower than that of the general population, those with cerebrovascular and cardiovascular diseases displayed a higher rate. Of more concern was that the high-risk drinking rate of patients with depression symptoms, hypertension, and diabetes was higher than that of the general population. Drinking is generally associated various NCDs including cancer, hypertension, hemorrhagic stroke, and liver diseases.41 While small amounts of alcohol reportedly show preventative effects on diabetes,42 they also increase the risk of chronic diseases such as atrial fibrillation43 and cataracts.44 We cannot recommend small alcohol amounts to prevent some diseases, at the risk of others developing, nor can we recommend such to current chronic disease patients. Moreover, given drinking’s high correlation with smoking,45 we cannot rule out the possible effect of drinking on smoking behaviors.
More focus should be directed towards drinking in Korea, considering increases in the monthly and high-risk drinking rates in both the general population and patients with major chronic diseases. A permissive drinking culture has developed in Korea, with drinking considered to represent non-verbal communication, demonstrate a sense of community, and serve as a bridge between work and leisure. This permissive culture may have contributed to 6 out of 10 Korean adults drinking once or more per month. The higher the average drinking rate, the likelier problematic drinking is. Thus, drinking reduction strategies for the general population and chronic disease patients are necessary. To reduce drinking among the latter, physicians should assess their drinking patterns at each consultation, inform them of the harm associated with drinking, and actively recommend drinking cessation.
Physical activity is important for chronic disease management. The benefits of physical activity for hypertension and diabetes patients are well known; regular physical activity is recommended in the treatment guidelines for these diseases.46,47 Furthermore, exercise’s confirmed depression alleviation effect48 has prompted its recommendation to depression patients. Moreover, despite exercise seeming somewhat risky for diseases like myocardial infarction, exercise-centered cardiac rehabilitation improves quality of life and reduces the mortality rate for myocardial infarction.49 Therefore, exercise must be recommended to chronic disease patients, and the level of physical activity (e.g., the walking rate) must be evaluated as an indicator. The current study showed that the walking rate of patients with major chronic diseases was lower than that of the general population; there were annual declining trends in the walking rates of the general population and patients with major chronic diseases. Although the obesity rate in Korea is lower than that in other countries, a declining walking rate may be related to a consistently increasing obesity rate. Programs for increasing the walking rate in chronic disease patients and the general population are necessary.
Notably, although variations are affected by the sample sizes, regional variations in health behaviors were larger in chronic disease patients than in the general population. For instance, the standard deviation for the general population’s current smoking rate was 1.1% as of 2017, and 2.9% for patients experiencing depression symptoms. While for the former, the standard deviation for the monthly drinking rate was 3.2%, it was 4.5% for hypertension patients. Although the life expectancy gap between different regions in Korea has narrowed, a quality-adjusted life expectancy gap of 4.6 years has been shown between regions.50 While many factors such as unequal health resources and income gaps ostensibly contribute towards this gap, a regional gap in health behaviors may also explain this phenomenon. More studies are needed to explain the regional health behavior gap.
This study had limitations. First, changes in health behaviors, based on a chronic disease diagnosis, were not examined due to the nature of this study’s data source. Future studies could use panel or patient cohort data to examine changes in chronic disease patients’ health behaviors over time before and after diagnosis. Second, chronic diseases were self-reported. The accuracy of these self-reports of physician diagnosis and health behaviors used in the Korea Community Health Survey, cannot be determined. A follow-up study would need to confirm the diagnoses and the health behaviors in relation to physical assessments or healthcare use data. Third, although this study focuses on patients with 13 chronic diseases, cancer—one of the leading NCDs—was excluded. Studies could analyze annual trends and regional variations in cancer patients’ health behaviors, using this study’s methodology. In addition, the gender differences in the smoking rate or health behavior of chronic disease patients could be a good research topic which we will consider in the future.