Health behaviors and illness according to marital status in ...

Marital status is an important social factor associated with human health and longevity. In many studies, married adults show better health ... SkiptoMainContent Advertisement Journals Books SearchMenu Menu NavbarSearchFilter JournalofPublicHealthThisissue PublicHealthandEpidemiologyBooksJournalsOxfordAcademic MobileMicrositeSearchTerm Search SignIn Issues MoreContent Advancearticles Editor'sChoice Supplements Submit AuthorGuidelines SubmissionSite OpenAccess Purchase Alerts About AboutJournalofPublicHealth AbouttheFacultyofPublicHealthoftheRoyalCollegesofPhysiciansoftheUnitedKingdom EditorialBoard Self-ArchivingPolicy DispatchDates AdvertisingandCorporateServices JournalsCareerNetwork JournalsonOxfordAcademic BooksonOxfordAcademic Issues MoreContent Advancearticles Editor'sChoice Supplements Submit AuthorGuidelines SubmissionSite OpenAccess Purchase Alerts About AboutJournalofPublicHealth AbouttheFacultyofPublicHealthoftheRoyalCollegesofPhysiciansoftheUnitedKingdom EditorialBoard Self-ArchivingPolicy DispatchDates AdvertisingandCorporateServices JournalsCareerNetwork Close NavbarSearchFilter JournalofPublicHealthThisissue PublicHealthandEpidemiologyBooksJournalsOxfordAcademic MicrositeSearchTerm Search AdvancedSearch SearchMenu ArticleNavigation Closemobilesearchnavigation ArticleNavigation Volume40 Issue2 June2018 ArticleContents Abstract Introduction Materialandmethods Results Discussion Conflictofinterest References ArticleNavigation ArticleNavigation JournalArticle Healthbehaviorsandillnessaccordingtomaritalstatusinmiddle-agedKoreans AreumKim, AreumKim GraduateStudent DepartmentofFamilyMedicine,AsanMedicalCenter,UniversityofUlsanCollegeofMedicine,88Olymphic-Ro43-Gil,Songpa-gu,Seoul,SouthKorea Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar JungAhLee, JungAhLee ClinicalAssistantProfessor DepartmentofFamilyMedicine,AsanMedicalCenter,UniversityofUlsanCollegeofMedicine,88Olymphic-Ro43-Gil,Songpa-gu,Seoul,SouthKorea Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar HyeSoonPark HyeSoonPark Professor DepartmentofFamilyMedicine,AsanMedicalCenter,UniversityofUlsanCollegeofMedicine,88Olymphic-Ro43-Gil,Songpa-gu,Seoul,SouthKorea AddresscorrespondencetoHye-SoonPark,E-mail:[email protected] Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar JournalofPublicHealth,Volume40,Issue2,June2018,Pagese99–e106,https://doi.org/10.1093/pubmed/fdx071 Published: 09August2017 Articlehistory Received: 24January2017 Accepted: 06June2017 Published: 09August2017 PDF SplitView Views Articlecontents Figures&tables Video Audio SupplementaryData Cite Cite AreumKim,JungAhLee,HyeSoonPark,Healthbehaviorsandillnessaccordingtomaritalstatusinmiddle-agedKoreans,JournalofPublicHealth,Volume40,Issue2,June2018,Pagese99–e106,https://doi.org/10.1093/pubmed/fdx071 SelectFormat Selectformat .ris(Mendeley,Papers,Zotero) .enw(EndNote) .bibtex(BibTex) .txt(Medlars,RefWorks) Downloadcitation Close PermissionsIcon Permissions Share Email Twitter Facebook More NavbarSearchFilter JournalofPublicHealthThisissue PublicHealthandEpidemiologyBooksJournalsOxfordAcademic MobileMicrositeSearchTerm Search SignIn Close NavbarSearchFilter JournalofPublicHealthThisissue PublicHealthandEpidemiologyBooksJournalsOxfordAcademic MicrositeSearchTerm Search AdvancedSearch SearchMenu Abstract BackgroundMaritalstatusinfluenceshealthandthisassociationmightdifferbytimeand/orcountry.DivorcerateshaveincreasedabruptlyinKorea.Weinvestigatedrelationshipsbetweenmaritalstatusandhealthbehaviorsandillnessamongmiddle-agedKoreans.MethodsDatafromthefifthKoreanNationalHealthandNutritionExaminationSurvey2010–12wasused.Participantsweremiddle-aged(40–65years)Koreans(3015maleand4498female)whohadbeenmarried.Healthbehaviorsandphysicalandmentalhealthstatuswereevaluatedseparatelyforeachgenderaccordingtomaritalstatus(currentlymarriedversusseparated,divorcedorwidowed)usinglogisticregressionanalysesadjustedforage,incomelevelandregion.ResultsAbout5.4%ofmenand13.0%ofwomenlivedwithouttheirspouses.Oddratios(ORs)forsmoking,bingedrinking,inadequatesleep,hypertriglyceridemiaanddepressionweresignificantlyhigherinparticipantsnotlivingwiththeirspouses.ORsfornon-participationinregularhealthexaminationsandcancerscreenings,anemia,elevatedalanineaminotransferaseandsuicidalideationweresignificantlyhigherinmennotlivingwiththeirspouses.ConclusionsHealthbehaviorsandillnessweresignificantlyworseinmiddle-agedKoreansnotlivingwiththeirspouses.Menweremoresusceptibletopoorhealthscreening,nutritionaldeficienciesandmentalillness.Preventiveservicesarenecessarytoimprovetheirhealthstatus. gender,healthbehaviors,illness,maritalstatusIntroduction Maritalstatusisanimportantsocialfactorassociatedwithhumanhealthandlongevity.Inmanystudies,marriedadultsshowbetterhealthoutcomesthantheirnon-marriedcounterparts,1–3andmentalhealthisworseinunmarriedversusmarriedadults.4Marriedindividualsmayshowbetterhealthoutcomesforseveralreasons.First,becauseofmaritalselection,healthierpeoplemaybemorelikelytogetmarriedandtostaymarriedlonger,whereaslesshealthypeoplemaybemorelikelytobecomeunmarried,separatedordivorced.Second,themarriageprotectioneffectreferstothefactthatmarriedpeoplehavemoreadvantagesineconomicresources,socialandpsychologicalsupport,andhealthbehaviors.Third,maritalterminationisastressfuleventthataffectshealthstatus.5,6Maritalterminationisapotentialstressorthatchangesimmunological,hormonalandneuralcontrolsystemsindivorcedandwidowedindividuals.7Thesechangesmakethosepeoplemoresusceptibletopoorhealth.8Manystudieshaveshownhighermortalityindivorcedandwidowedversusmarriedpeople.1–3However,apreviousstudyreportedthatmortalitypatternsbasedonmaritalstatusdifferedbetweencountries.9Additionally,anotherstudydemonstratedthatincreasedmortalityforunmarriedmenwasnolongersignificantafteradjustingforotherconfoundingfactors,suggestingthatunmarriedstatusitselfmightnotincreaserisk.10Theeffectsofmaritalstatusonhealthmightdifferaccordingtotimeand/orgeographicalregionassocietychanges.Overthepastfewdecades,ratesofdivorceandsingle-personhouseholdshaveincreasedworldwide.TheOrganizationforEconomicCooperationandDevelopment(OECD)averagecrudedivorcerate(CDR;divorcesper1000people)increasedfrom1.1in1970to1.9in2012,11and,inKorea,almostdoubledfrom1.1in1990to2.3in2012.Inaddition,thenumberofbereavedpeoplewouldbeincreasedfrom1.1millionin1990to2.4millionin2030.12Asmodernsocietyenterstheeraofchronicdegenerativedisease,familymembersplayanimportantroleindiseasepreventionandhealthpromotion.13Intermsofassessingtherelationshipbetweenmaritalstatusandhealth,notonlylongevitybutalsowell-beingisimportantoutcomevariables.Althoughratesofdivorced,separatedandwidowedpeoplearerapidlyincreasinginKorea,healthstatushasnotbeenevaluatedaccordingtomaritalstatus.Theaimsofthisstudyaretoinvestigatetherelationshipsbetweenmaritalstatusandhealthbehaviorsandillnessamongmiddle-agedKoreans,andtotestwhethergenderdifferencesexistinthoserelationships.Materialandmethods Participants DatafromthefifthKoreaNationalHealthandNutritionExaminationSurvey(KNHANES-V,2010–12),anationallyrepresentativepopulation-basedsurveyconductedbytheKoreanCentersforDiseaseControlandPrevention(KCDC),wereused.ThefifthKNHANESwasconductedfor3years(2010–12)andappliedstratified,multistageprobabilitysamplingbasedongeographicalregion,sexandage,whichweredeterminedbyprimarysamplingunits.Inthisstudy,weincluded9213participantsaged40–65years.Weexcluded204subjectswhowerenotmarried,28subjectswhodidnotindicatetheirmaritalstatus,and1468subjectswithmissingdata.Thus,datafrom3015to4498middle-agedmenandwomen,respectively,whohadbeenmarriedatsomepointwereincludedintheanalyses.Demographicvariablesinthestudypopulation Demographiccharacteristicsincludingage,sex,maritalstatus,education,occupationandincomelevelwerecollectedinface-to-faceinterviews.Formaritalstatus,allsubjectswereasked,‘Haveyoubeenmarried?’Iftheparticipantsaid‘yes,’thenextquestiongivenwas,‘Whatisyourmaritalstatus?’ThosewhoansweredthattheywerecurrentlymarriedwereincludedintheLivingwithspousegroup,andthosewhoansweredthattheywereseparated,divorcedorwidowedwereincludedintheLivingwithoutspousegroup.Educationlevelwasclassifiedaslessthanhighschool(≤12years)ormorethancollege(>12years).Occupationwasclassifiedasnon-manual,manualorunemployed.Householdincomeswerecalculatedbydividinghouseholdincomebythenumberofhouseholdmembers,andthencategorizedintohigh,middleandlowtertiles.Healthbehaviorvariablesinthestudypopulation Healthbehaviorscollectedviaself-administeredquestionnairesincludedthefollowing:physicalactivity,smokingstatus,alcoholconsumption,sleepdurationandparticipationinperiodichealthexaminations.PhysicalactivitywasassessedusingtheInternationalPhysicalActivityQuestionnaire(IPAQ).Physicalinactivitywasdefinedasnotdoingvigorousactivityforatleast20minperdayforatleast3days,notdoingmoderate-intensityactivityfor5ormoredays,andnotwalkingforatleast30minperday.Participantswhosephysicalactivitywas<600METs-minperweekwerealsodefinedasphysicallyinactive.Participantswhocurrentlysmokedmorethanfivepacksofcigarettesuptodateofthequestionnairewereclassifiedassmokers.14MenandwomenweredefinedasbingedrinkersiftheyreporteddrinkingmorethansevenorfiveglassesofKoreanhardliquor(soju)orfiveorthreecansofbeer,respectively,morethanonceamonth.15Sleepdurationwasassessedusingaself-reportquestion,andinadequatesleepdurationwasdefinedas<7sleepinghours.16Thenutritionsurveywasconductedduringaface-to-faceinterviewusinga24-hrecallmethod.Participantswereaskedtomaintaintheirusualdiet,interviewersinstructedparticipantstorecalleveryfoodandbeverageconsumedduringthepreviousa24-hperiod,andenergydistributionwascalculated.Finally,weaskedaboutparticipationinregularhealthexaminationsandcancerscreeningsthattheKoreanGovernmentperiodicallyprovides.Participantswereaskedwhetherornottheyhadparticipatedinhealthorcancerscreeningsduringthelast2years.Assessmentofphysicalandmentalillnessinthestudypopulation Accordingtostandardizedprotocols,allhealthexaminationprocedureswereperformedbytrainedmedicalpersonnelandallequipmentwasperiodicallycalibrated.Height,weight,bodymassindex(BMI)andwaistcircumference(WC)weremeasured.Trainedinterviewersvisitedeachparticipant’sdwelling.Heightandweightwereobtainedusingstandardizedtechniquesandequipment.Heightwasmeasuredtothenearest0.1cmusingaportableanthropometer(SECA224,Germany).Weightwasmeasuredtothenearest0.1kgonabalancescale(GL-6000–20,Korea)whiletheparticipantworealightweightgown.BMIwascalculatedbydividingweightbyheightsquared(kg/m2).WCwasmeasuredonstandingparticipantswithasofttapemidwaybetweenthelowestribandtheiliaccrest.Systolicbloodpressureanddiastolicbloodpressureweremeasuredbystandardmethodsusingasphygmomanometerwhileparticipantsweresitting.Threemeasurementsweremadeat5-minintervals,andtheaverageofthesecondandthirdmeasurementswasusedintheanalysis.Bloodsampleswerecollectedinthemorningafterfastingforatleast8h.Fastingglucose,totalcholesterol(TC),triglycerides(TG),high-densitylipoproteincholesterol(HDL-C)levels,aspartateaminotransferase(AST)andalanineaminotransferase(ALT)weremeasuredinacentralandcertifiedlaboratory(HitachiAutomaticAnalyzer7600,Japan).HbA1c(HLC-737G7,Japan)andHgb(XE-2100Dhematologyanalyzer,Japan)levelsweremeasuredaccordingtoacceptableprecisionandaccuracystandards.Hypertensionwasidentifiedinparticipantswhotookanti-hypertensivemedicationorwhohadsystolicbloodpressure≥140mmHgordiastolicbloodpressure≥90mmHg.17Diabetesmellituswasidentifiedinsubjectswhowerediagnosedbyaphysician,tookanti-diabeticsdrugs,usedinsulin,orhadfastingglucose≥126mg/dl.18HypercholesterolemiawasidentifiedinparticipantswhotookmedicationtolowercholesterolorwhohadTClevels≥240mg/dl,andhypertriglyceridemiawasidentifiedinparticipantswithserumTG≥200mg/dl.19AnemiawasdefinedasHgb<12and13g/dlinwomenandmen,respectively.ElevatedASTorALTwasdefinedasASTorALTlevel>40IU/l,respectively.20Toassessmentalillness,depressivemoodandsuicidalideationwereinvestigatedusingself-reportedquestionnaires.Depressivemoodwasidentifiedifparticipantsanswered,‘yes’tothequestions,‘Haveyoufeltsadnessordespairthathinderedeverydaylifeconsistentlyfor2weeksormoreduringthelastyear?’Suicidalideationwasidentifiedifparticipantsanswered,‘yes’tothequestion;‘Haveyouwantedtodieduringthelastyear?’Statisticalanalysis StatisticalanalysiswereconductedusingSPSSver.21.0forWindowsandtwo-tailedP-values<0.05wereconsideredstatisticallysignificant.Allanalyseswereevaluatedafteraccountingforsampleweightsandcomplexsampledesign.PopulationweightsprovidedbyKNHANESwereappliedtoproduceestimatesrepresentativeoftheKoreanpopulation.Baselineparticipantcharacteristicsforeachgenderareshownasmeansorpercentageswithstandarderror(SE).Linearregressionforcontinuousvariablesandchi-squaretestsforcategoricalvariableswereusedtoexaminedifferencesbetweenthetwogroups.Therelationshipsbetweenmaritalstatusandhealthbehaviors,physicalillnessandmentalillnesswereassessedwithmultivariatelogisticregressionanalyses.Oddsratios(ORs)and95%confidenceintervals(CIs)wereestimatedafteradjustingforpotentialconfounds,includingage,incomelevelandgeographicalregion.Results Demographicparticipantcharacteristics Atotalof7502adults(3015menand4498women)wereincludedinthisstudy,andtheirdemographiccharacteristicsarepresentedinTable1.Ofthetotalsample,5.4%ofmenand13.0%ofwomenwerecategorizedasLivingwithoutspouse.About63.0%ofmenand51.0%ofwomenhadmorethanacollegeeducation.About27.5%ofmenand10.7%ofwomenhadnon-manualoccupations.Table1Demographicparticipantcharacteristics . Men(n=3015) . Women(n=4498) . n . % . n . % . Age  40–49years 1048 46.0 1659 45.6  50–59years 1215 39.7 1849 39.1  60–65years 752 14.2 990 15.3 Maritalstatus  Livingwithoutspouse 165 6.5 13.2 13.2  Livingwithspouse 2850 93.5 86.8 86.8 Education  >12years 2012 70.4 2411 56.8  ≤12years 923 29.6 2000 43.2 Occupation  Non-manual 859 29.2 513 12.5  Manual 1671 59.2 1874 45.7  Unemployed 394 11.6 2025 41.9 Householdincomelevel  High 1047 33.1 1430 30.4  Middle 1646 57.4 2389 56.2  Low 289 9.5 631 13.4  . Men(n=3015) . Women(n=4498) . n . % . n . % . Age  40–49years 1048 46.0 1659 45.6  50–59years 1215 39.7 1849 39.1  60–65years 752 14.2 990 15.3 Maritalstatus  Livingwithoutspouse 165 6.5 13.2 13.2  Livingwithspouse 2850 93.5 86.8 86.8 Education  >12years 2012 70.4 2411 56.8  ≤12years 923 29.6 2000 43.2 Occupation  Non-manual 859 29.2 513 12.5  Manual 1671 59.2 1874 45.7  Unemployed 394 11.6 2025 41.9 Householdincomelevel  High 1047 33.1 1430 30.4  Middle 1646 57.4 2389 56.2  Low 289 9.5 631 13.4  Openinnewtab Table1Demographicparticipantcharacteristics . Men(n=3015) . Women(n=4498) . n . % . n . % . Age  40–49years 1048 46.0 1659 45.6  50–59years 1215 39.7 1849 39.1  60–65years 752 14.2 990 15.3 Maritalstatus  Livingwithoutspouse 165 6.5 13.2 13.2  Livingwithspouse 2850 93.5 86.8 86.8 Education  >12years 2012 70.4 2411 56.8  ≤12years 923 29.6 2000 43.2 Occupation  Non-manual 859 29.2 513 12.5  Manual 1671 59.2 1874 45.7  Unemployed 394 11.6 2025 41.9 Householdincomelevel  High 1047 33.1 1430 30.4  Middle 1646 57.4 2389 56.2  Low 289 9.5 631 13.4  . Men(n=3015) . Women(n=4498) . n . % . n . % . Age  40–49years 1048 46.0 1659 45.6  50–59years 1215 39.7 1849 39.1  60–65years 752 14.2 990 15.3 Maritalstatus  Livingwithoutspouse 165 6.5 13.2 13.2  Livingwithspouse 2850 93.5 86.8 86.8 Education  >12years 2012 70.4 2411 56.8  ≤12years 923 29.6 2000 43.2 Occupation  Non-manual 859 29.2 513 12.5  Manual 1671 59.2 1874 45.7  Unemployed 394 11.6 2025 41.9 Householdincomelevel  High 1047 33.1 1430 30.4  Middle 1646 57.4 2389 56.2  Low 289 9.5 631 13.4  Openinnewtab Nutritionalstatusandcardio-metabolicriskfactorsaccordingtomaritalstatusinmenandwomen Table2showsmeanvaluesfordietaryintakeandcardio-metabolicparametersaccordingtomaritalstatusinbothgenders.Totalenergyintakewassignificantlylowerinthemenandwomenlivingwithoutversuswiththeirspouses.SerumTGwassignificantlyhigherinmenlivingwithoutversuswiththeirspouses.Systolicbloodpressure,fastingglucoseandHbA1Cweresignificantlyhigherinwomenlivingwithoutversuswiththeirspouses.Table2Nutritionalstatusandcardio-metabolicriskfactorsaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . Mean(SE) . Mean(SE) . Mean(SE) . Mean(SE) . Age(years) 50.9(0.2) 51.8(0.5) 0.102 50.6(0.2) 53.8(0.4) <0.001 Energyintake(kcal) 2475.0(22.1) 2291.2(77.7) 0.023 1727.4(14.0) 1655.2(35.1) 0.045 Carbohydrate(%) 66.4(0.3) 70.0(1.1) 0.595 69.6(0.2) 69.9(0.6) 0.642 Protein(%) 30.5(0.1) 30.9(0.6) 0.583 29.4(0.1) 29.6(0.3) 0.626 Fat(%) 18.2(0.2) 17.6(0.9) 0.493 16.3(0.2) 15.9(0.4) 0.397 Hemoglobin(g/dl) 15.3(0.0) 15.3(0.1) 0.997 13.1(0.0) 13.2(0.1) 0.088 Bodymassindex(kg/m2) 24.3(0.1) 23.9(0.3) 0.195 24.0(0.1) 24.2(0.3) 0.496 WC(cm) 85.3(0.2) 84.3(0.7) 0.188 79.8(0.2) 80.8(0.6) 0.093 Systolicbloodpressure(mmHg) 122.7(0.4) 123.3(1.5) 0.660 118.6(0.4) 120.9(1.0) 0.019 Diastolicbloodpressure(mmHg) 81.8(0.3) 81.9(1.1) 0.932 76.4(0.3) 77.3(0.5) 0.106 Fastingglucose(mg/dl) 103.1(0.6) 102.3(1.9) 0.684 96.8(0.5) 101.1(1.6) 0.007 HbA1c(%) 5.9(0.0) 5.9(0.1) 0.375 5.8(0.0) 6.0(0.1) 0.005 TC(mg/dl) 192.5(0.8) 195.8(4.0) 0.410 196.9(0.7) 199.7(1.7) 0.135 TG(mg/dl) 168.8(2.9) 226.8(25.8) 0.027 121.0(2.0) 130.8(4.9) 0.051 AST(IU/l) 25.8(0.5) 27.5(1.7) 0.327 21.3(0.2) 21.8(0.5) 0.383 ALT(IU/l) 27.5(0.8) 28.4(1.9) 0.651 19.6(0.4) 19.7(0.5) 0.853 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . Mean(SE) . Mean(SE) . Mean(SE) . Mean(SE) . Age(years) 50.9(0.2) 51.8(0.5) 0.102 50.6(0.2) 53.8(0.4) <0.001 Energyintake(kcal) 2475.0(22.1) 2291.2(77.7) 0.023 1727.4(14.0) 1655.2(35.1) 0.045 Carbohydrate(%) 66.4(0.3) 70.0(1.1) 0.595 69.6(0.2) 69.9(0.6) 0.642 Protein(%) 30.5(0.1) 30.9(0.6) 0.583 29.4(0.1) 29.6(0.3) 0.626 Fat(%) 18.2(0.2) 17.6(0.9) 0.493 16.3(0.2) 15.9(0.4) 0.397 Hemoglobin(g/dl) 15.3(0.0) 15.3(0.1) 0.997 13.1(0.0) 13.2(0.1) 0.088 Bodymassindex(kg/m2) 24.3(0.1) 23.9(0.3) 0.195 24.0(0.1) 24.2(0.3) 0.496 WC(cm) 85.3(0.2) 84.3(0.7) 0.188 79.8(0.2) 80.8(0.6) 0.093 Systolicbloodpressure(mmHg) 122.7(0.4) 123.3(1.5) 0.660 118.6(0.4) 120.9(1.0) 0.019 Diastolicbloodpressure(mmHg) 81.8(0.3) 81.9(1.1) 0.932 76.4(0.3) 77.3(0.5) 0.106 Fastingglucose(mg/dl) 103.1(0.6) 102.3(1.9) 0.684 96.8(0.5) 101.1(1.6) 0.007 HbA1c(%) 5.9(0.0) 5.9(0.1) 0.375 5.8(0.0) 6.0(0.1) 0.005 TC(mg/dl) 192.5(0.8) 195.8(4.0) 0.410 196.9(0.7) 199.7(1.7) 0.135 TG(mg/dl) 168.8(2.9) 226.8(25.8) 0.027 121.0(2.0) 130.8(4.9) 0.051 AST(IU/l) 25.8(0.5) 27.5(1.7) 0.327 21.3(0.2) 21.8(0.5) 0.383 ALT(IU/l) 27.5(0.8) 28.4(1.9) 0.651 19.6(0.4) 19.7(0.5) 0.853 P-valuefromlinearregressionofcontinuousvariables.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab Table2Nutritionalstatusandcardio-metabolicriskfactorsaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . Mean(SE) . Mean(SE) . Mean(SE) . Mean(SE) . Age(years) 50.9(0.2) 51.8(0.5) 0.102 50.6(0.2) 53.8(0.4) <0.001 Energyintake(kcal) 2475.0(22.1) 2291.2(77.7) 0.023 1727.4(14.0) 1655.2(35.1) 0.045 Carbohydrate(%) 66.4(0.3) 70.0(1.1) 0.595 69.6(0.2) 69.9(0.6) 0.642 Protein(%) 30.5(0.1) 30.9(0.6) 0.583 29.4(0.1) 29.6(0.3) 0.626 Fat(%) 18.2(0.2) 17.6(0.9) 0.493 16.3(0.2) 15.9(0.4) 0.397 Hemoglobin(g/dl) 15.3(0.0) 15.3(0.1) 0.997 13.1(0.0) 13.2(0.1) 0.088 Bodymassindex(kg/m2) 24.3(0.1) 23.9(0.3) 0.195 24.0(0.1) 24.2(0.3) 0.496 WC(cm) 85.3(0.2) 84.3(0.7) 0.188 79.8(0.2) 80.8(0.6) 0.093 Systolicbloodpressure(mmHg) 122.7(0.4) 123.3(1.5) 0.660 118.6(0.4) 120.9(1.0) 0.019 Diastolicbloodpressure(mmHg) 81.8(0.3) 81.9(1.1) 0.932 76.4(0.3) 77.3(0.5) 0.106 Fastingglucose(mg/dl) 103.1(0.6) 102.3(1.9) 0.684 96.8(0.5) 101.1(1.6) 0.007 HbA1c(%) 5.9(0.0) 5.9(0.1) 0.375 5.8(0.0) 6.0(0.1) 0.005 TC(mg/dl) 192.5(0.8) 195.8(4.0) 0.410 196.9(0.7) 199.7(1.7) 0.135 TG(mg/dl) 168.8(2.9) 226.8(25.8) 0.027 121.0(2.0) 130.8(4.9) 0.051 AST(IU/l) 25.8(0.5) 27.5(1.7) 0.327 21.3(0.2) 21.8(0.5) 0.383 ALT(IU/l) 27.5(0.8) 28.4(1.9) 0.651 19.6(0.4) 19.7(0.5) 0.853 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . Mean(SE) . Mean(SE) . Mean(SE) . Mean(SE) . Age(years) 50.9(0.2) 51.8(0.5) 0.102 50.6(0.2) 53.8(0.4) <0.001 Energyintake(kcal) 2475.0(22.1) 2291.2(77.7) 0.023 1727.4(14.0) 1655.2(35.1) 0.045 Carbohydrate(%) 66.4(0.3) 70.0(1.1) 0.595 69.6(0.2) 69.9(0.6) 0.642 Protein(%) 30.5(0.1) 30.9(0.6) 0.583 29.4(0.1) 29.6(0.3) 0.626 Fat(%) 18.2(0.2) 17.6(0.9) 0.493 16.3(0.2) 15.9(0.4) 0.397 Hemoglobin(g/dl) 15.3(0.0) 15.3(0.1) 0.997 13.1(0.0) 13.2(0.1) 0.088 Bodymassindex(kg/m2) 24.3(0.1) 23.9(0.3) 0.195 24.0(0.1) 24.2(0.3) 0.496 WC(cm) 85.3(0.2) 84.3(0.7) 0.188 79.8(0.2) 80.8(0.6) 0.093 Systolicbloodpressure(mmHg) 122.7(0.4) 123.3(1.5) 0.660 118.6(0.4) 120.9(1.0) 0.019 Diastolicbloodpressure(mmHg) 81.8(0.3) 81.9(1.1) 0.932 76.4(0.3) 77.3(0.5) 0.106 Fastingglucose(mg/dl) 103.1(0.6) 102.3(1.9) 0.684 96.8(0.5) 101.1(1.6) 0.007 HbA1c(%) 5.9(0.0) 5.9(0.1) 0.375 5.8(0.0) 6.0(0.1) 0.005 TC(mg/dl) 192.5(0.8) 195.8(4.0) 0.410 196.9(0.7) 199.7(1.7) 0.135 TG(mg/dl) 168.8(2.9) 226.8(25.8) 0.027 121.0(2.0) 130.8(4.9) 0.051 AST(IU/l) 25.8(0.5) 27.5(1.7) 0.327 21.3(0.2) 21.8(0.5) 0.383 ALT(IU/l) 27.5(0.8) 28.4(1.9) 0.651 19.6(0.4) 19.7(0.5) 0.853 P-valuefromlinearregressionofcontinuousvariables.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab Prevalenceofpoorhealthbehaviors,physicalillnessandmentalillnessaccordingtomaritalstatusinmenandwomen AsshowninTable3,thereweresignificantlyhigherratesofsmokingandbingedrinkinginbothmenandwomen,andworsesleepdurationinwomen,livingwithoutversuswiththeirspouses.Menlivingwithouttheirspousesshowedhigherratesofnon-participationinregularhealthexaminationsandcancerscreenings.Inaddition,menlivingwithouttheirspouseshadhigherratesofanemia,hypertriglyceridemia,AST≥40IU/l,depressivemood,andsuicidalideation.Womenlivingwithouttheirspousesshowedhigherratesofhypertension,diabetes,hypercholesterolemia,hypertriglyceridemia,depressivemoodandsuicidalideation.Table3Prevalenceofpoorhealthbehaviors,physicalillness,andmentalillnessaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . % . % . % . % . Physicalinactivity 52.2 49.0 0.514 54.7 56.6 0.503 Currentsmoking 42.1 59.5 <0.001 3.2 10.4 <0.001 Bingedrinking(≥1/month) 53.0 64.9 0.016 15.3 21.1 0.007 Inadequatesleepduration 40.0 48.2 0.059 43.4 55.0 <0.001 Non-participationinregularhealthexaminations 29.5 47.6 <0.001 32.6 30.0 0.345 Non-participationincancerscreenings 41.2 57.7 <0.001 28.7 27.8 0.712 Anemia 2.0 5.9 0.017 11.8 11.8 0.974 Obesity 39.0 37.2 0.685 33.4 34.7 0.615 Hypertension 38.2 46.0 0.100 26.3 36.3 <0.001 Diabetesmellitus 13.4 8.5 0.107 7.2 12.8 <0.001 Hypercholesterolemia 14.2 18.8 0.193 17.8 22.4 0.034 Hypertriglyceridemia 25.8 38.6 0.008 10.8 17.5 0.001 AST≥40IU/l 6.9 12.0 0.040 3.5 2.8 0.371 ALT≥40IU/l 13.6 20.2 0.052 5.7 4.8 0.466 Depressivemood 8.9 17.3 0.002 15.9 26.2 <0.001 Suicidalideation 9.4 20.9 <0.001 15.2 19.4 0.023 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . % . % . % . % . Physicalinactivity 52.2 49.0 0.514 54.7 56.6 0.503 Currentsmoking 42.1 59.5 <0.001 3.2 10.4 <0.001 Bingedrinking(≥1/month) 53.0 64.9 0.016 15.3 21.1 0.007 Inadequatesleepduration 40.0 48.2 0.059 43.4 55.0 <0.001 Non-participationinregularhealthexaminations 29.5 47.6 <0.001 32.6 30.0 0.345 Non-participationincancerscreenings 41.2 57.7 <0.001 28.7 27.8 0.712 Anemia 2.0 5.9 0.017 11.8 11.8 0.974 Obesity 39.0 37.2 0.685 33.4 34.7 0.615 Hypertension 38.2 46.0 0.100 26.3 36.3 <0.001 Diabetesmellitus 13.4 8.5 0.107 7.2 12.8 <0.001 Hypercholesterolemia 14.2 18.8 0.193 17.8 22.4 0.034 Hypertriglyceridemia 25.8 38.6 0.008 10.8 17.5 0.001 AST≥40IU/l 6.9 12.0 0.040 3.5 2.8 0.371 ALT≥40IU/l 13.6 20.2 0.052 5.7 4.8 0.466 Depressivemood 8.9 17.3 0.002 15.9 26.2 <0.001 Suicidalideation 9.4 20.9 <0.001 15.2 19.4 0.023 P-valuefromchi-squaretestforcategoricalvariables.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab Table3Prevalenceofpoorhealthbehaviors,physicalillness,andmentalillnessaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . % . % . % . % . Physicalinactivity 52.2 49.0 0.514 54.7 56.6 0.503 Currentsmoking 42.1 59.5 <0.001 3.2 10.4 <0.001 Bingedrinking(≥1/month) 53.0 64.9 0.016 15.3 21.1 0.007 Inadequatesleepduration 40.0 48.2 0.059 43.4 55.0 <0.001 Non-participationinregularhealthexaminations 29.5 47.6 <0.001 32.6 30.0 0.345 Non-participationincancerscreenings 41.2 57.7 <0.001 28.7 27.8 0.712 Anemia 2.0 5.9 0.017 11.8 11.8 0.974 Obesity 39.0 37.2 0.685 33.4 34.7 0.615 Hypertension 38.2 46.0 0.100 26.3 36.3 <0.001 Diabetesmellitus 13.4 8.5 0.107 7.2 12.8 <0.001 Hypercholesterolemia 14.2 18.8 0.193 17.8 22.4 0.034 Hypertriglyceridemia 25.8 38.6 0.008 10.8 17.5 0.001 AST≥40IU/l 6.9 12.0 0.040 3.5 2.8 0.371 ALT≥40IU/l 13.6 20.2 0.052 5.7 4.8 0.466 Depressivemood 8.9 17.3 0.002 15.9 26.2 <0.001 Suicidalideation 9.4 20.9 <0.001 15.2 19.4 0.023 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . % . % . % . % . Physicalinactivity 52.2 49.0 0.514 54.7 56.6 0.503 Currentsmoking 42.1 59.5 <0.001 3.2 10.4 <0.001 Bingedrinking(≥1/month) 53.0 64.9 0.016 15.3 21.1 0.007 Inadequatesleepduration 40.0 48.2 0.059 43.4 55.0 <0.001 Non-participationinregularhealthexaminations 29.5 47.6 <0.001 32.6 30.0 0.345 Non-participationincancerscreenings 41.2 57.7 <0.001 28.7 27.8 0.712 Anemia 2.0 5.9 0.017 11.8 11.8 0.974 Obesity 39.0 37.2 0.685 33.4 34.7 0.615 Hypertension 38.2 46.0 0.100 26.3 36.3 <0.001 Diabetesmellitus 13.4 8.5 0.107 7.2 12.8 <0.001 Hypercholesterolemia 14.2 18.8 0.193 17.8 22.4 0.034 Hypertriglyceridemia 25.8 38.6 0.008 10.8 17.5 0.001 AST≥40IU/l 6.9 12.0 0.040 3.5 2.8 0.371 ALT≥40IU/l 13.6 20.2 0.052 5.7 4.8 0.466 Depressivemood 8.9 17.3 0.002 15.9 26.2 <0.001 Suicidalideation 9.4 20.9 <0.001 15.2 19.4 0.023 P-valuefromchi-squaretestforcategoricalvariables.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab ORsand95%CIforpoorhealthbehaviors,physicalillnessandmentalillnessaccordingtomaritalstatusinmenandwomen AccordingtothemultivariateanalysisshowninTable4,ORsforsmoking,bingedrinking,inadequatesleepduration,non-participationofregularhealthexaminationandnon-participationofcancerscreeninginmenlivingwithouttheirspouseswere2.08(95%CI,1.41–3.07),1.63(95%CI,1.09–2.45),1.47(95%CI,1.03–2.08),2.08(95%CI,1.41–3.07)and1.91(95%CI,1.31–2.78)comparedwithmenlivingwithspouse,respectively.Table4Adjustedoddsratiosand95%CIsforpoorhealthbehaviors,physicalillnessandmentalillnessaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . OR . OR(95%CI) . OR . OR(95%CI) . Physicalinactivity 1.0 0.88(0.60–1.29) 0.506 1.0 1.13(0.88–1.43) 0.327 Currentsmoking 1.0 2.08(1.41–3.07) <0.001 1.0 3.58(2.27–5.65) <0.001 Bingedrinking(≥1/month) 1.0 1.63(1.09–2.45) 0.018 1.0 1.66(1.24–2.25) 0.001 Inadequatesleepduration 1.0 1.47(1.03–2.08) 0.032 1.0 1.50(1.20–1.86) <0.001 Non-participationinperiodichealthexaminations 1.0 2.08(1.41–3.07) <0.001 1.0 0.93(0.71–1.21) 0.595 Non-participationincancerscreenings 1.0 1.91(1.31–2.78) 0.001 1.0 0.93(0.71–1.20) 0.555 Anemia 1.0 2.84(1.27–6.39) 0.012 1.0 1.17(0.92–1.49) 0.199 Obesity 1.0 0.97(0.66–1.43) 0.866 1.0 1.03(0.82–1.20) 0.806 Hypertension 1.0 1.35(0.90–2.01) 0.146 1.0 1.17(0.92–1.49) 0.205 Diabetesmellitus 1.0 0.58(0.31–1.11) 0.098 1.0 1.46(1.00–2.13) 0.049 Hypercholesterolemia 1.0 1.38(0.83–2.29) 0.219 1.0 1.03(0.77–1.38) 0.828 Hypertriglyceridemia 1.0 1.72(1.10–2.69) 0.018 1.0 1.51(1.06–2.15) 0.021 AST≥40IU/l 1.0 1.75(0.95–3.22) 0.072 1.0 0.70(0.42–1.18) 0.182 ALT≥40IU/l 1.0 1.69(1.02–2.78) 0.041 1.0 0.80(0.49–1.31) 0.382 Depressivemood 1.0 2.20(1.34–3.55) 0.002 1.0 1.76(1.32–2.35) <0.001 Suicidalideation 1.0 2.55(1.56–4.11) <0.001 1.0 1.18(0.90–1.55) 0.233 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . OR . OR(95%CI) . OR . OR(95%CI) . Physicalinactivity 1.0 0.88(0.60–1.29) 0.506 1.0 1.13(0.88–1.43) 0.327 Currentsmoking 1.0 2.08(1.41–3.07) <0.001 1.0 3.58(2.27–5.65) <0.001 Bingedrinking(≥1/month) 1.0 1.63(1.09–2.45) 0.018 1.0 1.66(1.24–2.25) 0.001 Inadequatesleepduration 1.0 1.47(1.03–2.08) 0.032 1.0 1.50(1.20–1.86) <0.001 Non-participationinperiodichealthexaminations 1.0 2.08(1.41–3.07) <0.001 1.0 0.93(0.71–1.21) 0.595 Non-participationincancerscreenings 1.0 1.91(1.31–2.78) 0.001 1.0 0.93(0.71–1.20) 0.555 Anemia 1.0 2.84(1.27–6.39) 0.012 1.0 1.17(0.92–1.49) 0.199 Obesity 1.0 0.97(0.66–1.43) 0.866 1.0 1.03(0.82–1.20) 0.806 Hypertension 1.0 1.35(0.90–2.01) 0.146 1.0 1.17(0.92–1.49) 0.205 Diabetesmellitus 1.0 0.58(0.31–1.11) 0.098 1.0 1.46(1.00–2.13) 0.049 Hypercholesterolemia 1.0 1.38(0.83–2.29) 0.219 1.0 1.03(0.77–1.38) 0.828 Hypertriglyceridemia 1.0 1.72(1.10–2.69) 0.018 1.0 1.51(1.06–2.15) 0.021 AST≥40IU/l 1.0 1.75(0.95–3.22) 0.072 1.0 0.70(0.42–1.18) 0.182 ALT≥40IU/l 1.0 1.69(1.02–2.78) 0.041 1.0 0.80(0.49–1.31) 0.382 Depressivemood 1.0 2.20(1.34–3.55) 0.002 1.0 1.76(1.32–2.35) <0.001 Suicidalideation 1.0 2.55(1.56–4.11) <0.001 1.0 1.18(0.90–1.55) 0.233 ORsand95%CIadjustedforage,incomelevelandgeographicalregion.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab Table4Adjustedoddsratiosand95%CIsforpoorhealthbehaviors,physicalillnessandmentalillnessaccordingtomaritalstatusinmenandwomenVariables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . OR . OR(95%CI) . OR . OR(95%CI) . Physicalinactivity 1.0 0.88(0.60–1.29) 0.506 1.0 1.13(0.88–1.43) 0.327 Currentsmoking 1.0 2.08(1.41–3.07) <0.001 1.0 3.58(2.27–5.65) <0.001 Bingedrinking(≥1/month) 1.0 1.63(1.09–2.45) 0.018 1.0 1.66(1.24–2.25) 0.001 Inadequatesleepduration 1.0 1.47(1.03–2.08) 0.032 1.0 1.50(1.20–1.86) <0.001 Non-participationinperiodichealthexaminations 1.0 2.08(1.41–3.07) <0.001 1.0 0.93(0.71–1.21) 0.595 Non-participationincancerscreenings 1.0 1.91(1.31–2.78) 0.001 1.0 0.93(0.71–1.20) 0.555 Anemia 1.0 2.84(1.27–6.39) 0.012 1.0 1.17(0.92–1.49) 0.199 Obesity 1.0 0.97(0.66–1.43) 0.866 1.0 1.03(0.82–1.20) 0.806 Hypertension 1.0 1.35(0.90–2.01) 0.146 1.0 1.17(0.92–1.49) 0.205 Diabetesmellitus 1.0 0.58(0.31–1.11) 0.098 1.0 1.46(1.00–2.13) 0.049 Hypercholesterolemia 1.0 1.38(0.83–2.29) 0.219 1.0 1.03(0.77–1.38) 0.828 Hypertriglyceridemia 1.0 1.72(1.10–2.69) 0.018 1.0 1.51(1.06–2.15) 0.021 AST≥40IU/l 1.0 1.75(0.95–3.22) 0.072 1.0 0.70(0.42–1.18) 0.182 ALT≥40IU/l 1.0 1.69(1.02–2.78) 0.041 1.0 0.80(0.49–1.31) 0.382 Depressivemood 1.0 2.20(1.34–3.55) 0.002 1.0 1.76(1.32–2.35) <0.001 Suicidalideation 1.0 2.55(1.56–4.11) <0.001 1.0 1.18(0.90–1.55) 0.233 Variables . Men . Women . Livingwithspouse . Livingwithoutspouse . P-value . Livingwithspouse . Livingwithoutspouse . P-value . OR . OR(95%CI) . OR . OR(95%CI) . Physicalinactivity 1.0 0.88(0.60–1.29) 0.506 1.0 1.13(0.88–1.43) 0.327 Currentsmoking 1.0 2.08(1.41–3.07) <0.001 1.0 3.58(2.27–5.65) <0.001 Bingedrinking(≥1/month) 1.0 1.63(1.09–2.45) 0.018 1.0 1.66(1.24–2.25) 0.001 Inadequatesleepduration 1.0 1.47(1.03–2.08) 0.032 1.0 1.50(1.20–1.86) <0.001 Non-participationinperiodichealthexaminations 1.0 2.08(1.41–3.07) <0.001 1.0 0.93(0.71–1.21) 0.595 Non-participationincancerscreenings 1.0 1.91(1.31–2.78) 0.001 1.0 0.93(0.71–1.20) 0.555 Anemia 1.0 2.84(1.27–6.39) 0.012 1.0 1.17(0.92–1.49) 0.199 Obesity 1.0 0.97(0.66–1.43) 0.866 1.0 1.03(0.82–1.20) 0.806 Hypertension 1.0 1.35(0.90–2.01) 0.146 1.0 1.17(0.92–1.49) 0.205 Diabetesmellitus 1.0 0.58(0.31–1.11) 0.098 1.0 1.46(1.00–2.13) 0.049 Hypercholesterolemia 1.0 1.38(0.83–2.29) 0.219 1.0 1.03(0.77–1.38) 0.828 Hypertriglyceridemia 1.0 1.72(1.10–2.69) 0.018 1.0 1.51(1.06–2.15) 0.021 AST≥40IU/l 1.0 1.75(0.95–3.22) 0.072 1.0 0.70(0.42–1.18) 0.182 ALT≥40IU/l 1.0 1.69(1.02–2.78) 0.041 1.0 0.80(0.49–1.31) 0.382 Depressivemood 1.0 2.20(1.34–3.55) 0.002 1.0 1.76(1.32–2.35) <0.001 Suicidalideation 1.0 2.55(1.56–4.11) <0.001 1.0 1.18(0.90–1.55) 0.233 ORsand95%CIadjustedforage,incomelevelandgeographicalregion.P-values<0.05wereconsideredstatisticallysignificant. Openinnewtab Inwomenlivingwithoutspouses,ORsforsmoking,bingedrinkingandinadequatesleepdurationwere3.58(95%CI,2.27–5.65),1.66(95%CI,1.24–2.25)and1.50(95%CI,1.20–1.86)comparedwithwomenlivingwithspouse,respectively.ORsforanemia,hypertriglyceridemia,ALT(IU/l)≥40,depressivemoodandsuicidalideationinmenlivingwithoutversuswiththeirspouseswere2.84(95%CI,1.27–6.39),1.72(95%CI,1.10–2.69),1.69(95%CI,1.02–2.78),2.20(95%CI,1.34–3.55)and2.55(95%CI,1.67–4.11),respectively.ORsfordiabetes,hypertriglyceridemiaanddepressivemoodinwomenlivingwithoutversuswiththeirspouseswere1.46(95%CI,1.00–2.13),1.51(95%CI,1.06–2.15)and1.76(95%CI,1.32–2.35),respectively.Discussion Thisstudydemonstratedthatmiddle-agedmenandwomenlivingwithouttheirspouseshadhigherrisksforpoorhealthbehaviorsandillnessincludingsmoking,bingedrinking,inadequatesleepduration,hypertriglyceridemiaanddepressivemoodcomparedtothoselivingwiththeirspouses.Moreover,therisksfornon-participationinperiodichealthexaminationandcancerscreeningprograms,anemia,andsuicidalideationweresignificantlyhigherinmenlivingwithoutversuswiththeirspouses.Previousstudiesshowedthathealthbehaviorssuchassmoking,alcoholconsumptionanddietdifferedbasedonmaritalstatusinadults.Divorceandbereavementleadtoanincreaseinalcoholconsumptioninmiddle-agedmen,6andsmokingrelapseinmiddle-agedwomen.21Accordingtothe1999–02NationalHealthInterviewSurveysintheUSA,ratesofsmokingandheavydrinkingwereapproximatelytwiceashighformiddle-agedmenwhoweredivorcedorseparatedversusmarried.22Singlemenhavealow-qualitydietcomparedtomarriedmen.4However,onestudyreportedthatsmokingandhigh-riskalcoholconsumptiondidnotdifferbetweenmenlivingwithversuswithoutapartner,andmenlivingwithoutapartnerengagedinmoreregularexercise.23Inthatstudy,includingmenwhowerenevermarriedintheLivingwithoutpartnergroupeliminatedorreversedrelationshipsbetweenmaritalstatusandhealthbehaviors.Ouranalysesonlyincludedmarriedadultstoremovesuchabias,andwefoundthatORsforsmokingandbingedrinkingwerehigher,andtotalenergyintakewaslower,inseparated,divorced,andwidowedversusmarriedmenandwomen,consistentwithmostpreviousstudies.Furthermore,weinvestigatedinadequatesleepdurationasapoorhealthbehavioranddemonstratedthattheriskforsleeping<7hanightwassignificantlyhigherinseparated,divorcedandwidowedversusmarriedmenandwomen.Sleepdisturbanceisrecognizedasahealthriskfactorthatisassociatedwithmentaldisorders,likedepressionoranxiety,andcardio-metabolicdiseases,suchasobesity24ortypetwodiabetes25duetoimpairedinsulinsensitivity.TheKoreangovernmentprovideshealthcareservicesforKoreanadultstopreventdiseaseandpromotehealth,includingregularhealthexaminationsandcancerscreenings.Thisstudyshowedgenderdifferencesinhealthriskappraisalorhealth-seekingbehaviors.Non-participationinregularhealthexaminationsandcancerscreeningswereabouttwiceashighformenlivingwithoutversuswiththeirspouses,althoughtherewasnodifferencebasedonmaritalstatusinwomen.Generally,marriedpeoplehaveadvantagesbecausetheyhavesomeonetoremindthemtoundergoscreeningexams,drivethemtodoctorappointments,orhelpwithphysicalcare.26However,ourresultsindicatethatmiddle-agedKoreanmenmightbemoresusceptiblethanwomentorisksassociatedwithnotmanagingtheirhealth.Koreanwomentendtobemoreconcernedabouttheirhealthstatusandusethehealthcaresystemregardlessofwhethertheyexperiencedmaritaldissolutionorbereavement.Thisgenderdifferenceinparticipationinhealthcareservicesaccordingtomaritalstatusmaybeduetodifferencesbetweenmenandwomeninthedistributionsofsubgroupslivingwithouttheirspouses.Theproportionofparticipantswhowereseparatedordivorcedpersonswassimilarbetweengenders(~1.0and5.0%,respectively),butthepercentageofwidowedparticipantswasmuchhigherinwomen(7.1%)thaninmen(0.8%).Intermsofphysicalandmentalillness,theriskforanemiainmenlivingwithouttheirspouseswasapproximatelythreetimesgreatercomparedtothoselivingwiththeirspouses.Widowhoodhasbeenassociatedwithpoorerenergyintakeandnutritionalstatus,andwidowsaremorelikelytoreportpoorerappetite,skippingmealsandlowerfruit,vegetableandredmeatintake.27Inthisstudy,meantotalenergyintakewassignificantlylowerinseparated,divorcedandwidowedversusmarriedmenandwomen.However,menlivingwithouttheirspousesmighthaveahigherriskforpoornutritionandinadequatedietaryintakebecausetheytendtoskipmealsfrequentlyduetotheabsenceofwivestopreparemealsforthem.ORsforhypertriglyceridemiainbothgenders,anddiabetesmellitusinwomenweresignificantlyhigherinthoselivingwithoutspouses.Poorhealthbehaviorslikesmoking,bingedrinkingandsleepproblemscouldincreasetheriskofsuchcardio-metabolicdiseases.28OurresultsshowedthatORsfordepressivemoodwerehigherinbothmenandwomenlivingwithoutversuswithspouses.Maritalbreak-uplowersself-esteemandfeelingsoffailureinmen,deficienciesincaringrelationshipsandinterpersonallossinwomen,andleadstodepression.29,30Theriskforsuicidalideationwas~2.5timesgreaterinseparated,divorced,andwidowedversusmarriedmen,althoughtherewasnodifferencebasedonmaritalstatusinwomen.SuicidehasbecomeaserioussocialandpublichealthissueinKorea.31In2014,SouthKorearankedfirstamongotherOECDcountrieswithasuiciderateof28.7per100000comparedtotheaveragerateof12.0per100000,32andthereisarapidincreaseinsuicideamongtheyoungandmiddle-aged.31Inparticular,thesuiciderateformenintheir40–70yearsoldis2.5–3.5timeshigherthanthatinwomen.31Sociallyisolatedpeopleareatahigherriskfordeathfromsuicidecomparedwithwell-integratedmen.33Afewlimitationsshouldbeconsideredwheninterpretingourresults.First,wecouldnotanalyzethecharacteristicsofeachLivingwithoutspousesubgroup(separated,divorcedandwidowed)separatelybecausetherewerenotenoughparticipantsineachsubgroup.Besides,wecouldnotexcludethepossibilitythatpeoplewhowereremarriedwereincludedintheLivingwithspousegroup.However,weonlyincludeddatafrompeoplewhogotmarried,therefore,ourresultscanexcludeamarriageselectionbiasinwhichlesshealthypeoplearelesslikelytogetmarried.Second,recallbiasmighthaveinfluencedthequalityofinformationprovidedbyparticipants.Theremaybeintra-individualdailyvariationinthesurveysforassessinglifestylefactors,includingthesingle24-hrecall.Althoughdailyvariationinlifestylefactorsmightbeunder-orover-estimated,singlerecallisusefulforestimatingpopulationmeans.Third,theKNHANESisacross-sectionalsurvey,andthuscausalityintherelationshipsbetweenmaritalstatusandhealthoutcomescannotbedetermined.Ourstudysuggeststhathealthbehaviorsandillnessweresignificantlyworseinmiddle-agedKoreanswhowerenotlivingwiththeirspouses.Inparticular,menseemedtobemoresusceptibletorisksforpoorhealthscreening,nutritionaldeficienciesandmentalillness.Publiceducationandpreventiveservicesareneededfortheseindividualstopromotehealthriskappraisalandimprovetheirhealthstatus.Conflictofinterest 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