International Journal of Rheumatic Diseases 2015

ORIGINAL ARTICLE

Prevalence of knee osteoarthritis, risk factors, and quality of

life: The Fifth Korean National Health And Nutrition
Examination Survey
Sunggun LEE1 and Seon-Jeong KIM2
1
Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, and 2Department of
Radiology, Myongji Hospital, Goyang, South Korea

Abstract
Aim: Although there have been regional population-based studies on the prevalence of knee osteoarthritis
(KOA) and its risk factors in South Koreans, those studies in common had limited external validity. This study
aims to estimate the national prevalence of KOA and its risk factors using a complex sampling design.
Methods: This was a cross-sectional study including 9512 participants aged ≥ 50 years of The Fifth Korean
National Health and Nutrition Examination Survey, who were selected using two-step stratified clustered equal-
probability systematic sampling. Radiographic KOA (RKOA) was defined as a Kellgren–Lawrence grade of ≥ 2.
Symptoms of KOA were evaluated through a health interview. Obesity was defined as a body mass index
≥ 27.5 kg/m2. Quality of life was measured by the Korean version of European Quality of Life Questionnaire
(EQ-5D).
Results: The prevalence of RKOA was 21.1% (95% CI: 19.6–22.8%) in men, and 43.8% (42.0–45.6%) in
women. The prevalence of symptomatic RKOA (SRKOA) was 4.4% (3.8–5.2%) and 19.2% (17.9–20.6%) in
men and women, respectively. The EQ-5D index was lower in participants with KOA. When plotted against
mean age and prevalence of obesity, regions with a higher mean age and prevalence of obesity had higher preva-
lence of KOA, which was also observed at the individual level. The prevalence of SRKOA was 36.6% (29.7–
44.1%) in women in Jeju province.
Conclusion: The prevalence of SRKOA in women reached 36.6% in high-risk groups accompanied by low qual-
ity of life. The results suggest that the disease burden of KOA is high in South Korea.
Key words: epidemiology, osteoarthritis.

INTRODUCTION remains unresolved, the intangible cost of OA may be

Osteoarthritis (OA) is a highly prevalent disease in the
elderly, and its influence on individuals and society is
large. The disease burden of OA can be considered in
terms of intangible, direct and indirect cost. Because the
mechanism for increased mortality in patients with OA
Correspondence: Assistant Professor Sunggun Lee, Department
of Internal Medicine, Haeundae Paik Hospital, Inje University
College of Medicine, Haeundae-gu Jwa-dong 1435, Busan,
South Korea. Email: sglee.ac@gmail.com
best captured by its influence on quality of life.1 Accord-
ing to the Global Burden of Disease study (GBD) 2010,
OA of the hip and knee combined was the third most
prevalent musculoskeletal disorder, and it was 11th in
the rank of years lived with disability (YLD). Eighty-
three percent of the burden was attributed to knee OA
(KOA)2 and prevalence of KOA was highest in high-
income Asia–Pacific regions of South Korea and Japan.3
Socioeconomic burden is also high; direct cost of OA
comprised 1.7% of the expenses of the French health
insurance program in 2002, which was equivalent to

© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
S. Lee and S.-J. Kim
those caused by coronary artery diseases.4 Another
study showed that the average annual direct and indi-
rect cost of a patient with OA of the hip or knee reached
12 200 US dollars in Canada in 2002, underscoring the
high impact of indirect as well as direct costs on indi-
viduals and society.5
Prevalence of OA and the resultant burden of the dis-
ease is predicted to increase over time. In Sweden,
prevalence of doctor-diagnosed KOA in people aged
≥ 45 years was projected to increase from 13.8% in
2012 to 15.7% in 2032.6 In terms of intangible costs,
OA was one of the diseases that were most rapidly
increasing in YLD ranking in the GBD 2010.2 Direct
cost is also expected to increase rapidly with a projected
increase by six-fold of primary total knee replacements
in the USA by 2030.7 A similar trend for an increase
was reported in South Korea.8
The reason that the disease burden of KOA is rapidly
increasing is that current treatment for KOA is pallia-
tive, consisting mainly of pain control and watchful
waiting, and total joint replacement in the end-stage. A
large portion of the direct cost for KOA originates from
such palliative care, and costs for hospital admission
alone, which is mainly for joint replacement, comprised
about 50% of the direct cost caused by OA.1 Therefore,
in order to decrease the burden of KOA, a paradigm
shift is required toward prevention in high-risk popula-
tions or people in early stages of the disease.9
Despite recent advances in epidemiologic and geno-
mic research on OA, traditional risk factors such as age,
sex and obesity still remain the most important risk fac-
tors for incident KOA.10 Among these, obesity, putting
aside whether it is through biomechanical or metabolic
stress, is the most important modifiable risk factor for
the development and progression of the KOA. In the
USA, in which prevalence of obesity is high, the popula-
tion attributable risk percentage for incident symp-
tomatic KOA reached 50%.11 Although the association
appears to be weaker for progression of KOA,12 it may,
at least in part, be explained by index event bias.13 In
addition, the effect of weight loss on improving symp-
tom and function in established disease is well
known.14 A retrospective study from the Framingham
cohort showed that weight loss could prevent the devel-
opment of symptomatic KOA in women,15 and there
has been emerging evidence that weight loss has struc-
ture-modifying effects on articular cartilage.16 These
studies suggest that by addressing the increasing preva-
lence of obesity, the increase in the burden of KOA may
be delayed or controlled.
2 International Journal of Rheumatic Diseases 2015
The stepping stone for any effort to deal with the dis-
ease burden of KOA would be an accurate assessment
of prevalence of KOA and its risk factors, especially obe-
sity. Although there have been several regional popula-
tion-based studies in South Koreans, those studies in
common had limited external validity. The purpose of
this study was to estimate the national prevalence of
KOA and its risk factors using a complex sampling
design.
METHODS
Participants
This study was a cross-sectional study, using the data of
participants aged ≥ 50 years, who were from The Fifth
Korean National Health and Nutrition Examination
Survey (KNHANES-V: from January 2010 through
December 2012). KNHANES-V is a South Korean
nationwide health and nutrition survey of children,
adolescents and adults that has been conducted regu-
larly since 1998 by the Korean Centers for Disease Con-
trol and Prevention. In KNHANES-V, participants were
selected from South Korean people currently residing in
South Korea except those who are residing in the mili-
tary, prisons and special elderly-care facilities, using
two-step stratified clustered equal-probability sampling.
The population was first stratified into 16 administra-
tive divisions (seven special or metropolitan cities:
Seoul, Busan, Daegu, Incheon, Gwangju, Daejeon and
Ulsan; eight provinces: Gyeonggi, Gangwon, North/
South Chungcheong, North/South Jeolla and North/
South Gyeongsang; and one special autonomous pro-
vince of Jeju), and in the second step, stratified into 26
sub-strata according to age and sex in general residential
areas, or into 24 sub-strata according to average size
and price of houses in apartment areas. Every year, 192
investigation regions (clusters) were selected from the
strata, and 20 households were selected in each investi-
gation region from equal-probability systematic sam-
pling (a total of 11 520 households in 576 regions
during the 3-year survey period). Every family member
of the selected families who was older than 1 year was
invited into the survey. Overall participation rates were
81.9%, 80.4% and 80.8% from 2010 through 2012.
Information on symptoms of KOA, height and weight,
and quality of life measurement was available for
96.8%, 99.9% and 95.8% of the included participants,
respectively. All participants provided written informed
consent for both participation in the survey and use of
their data for research purposes.

Health interview and health examination
Data on age and KOA symptoms were obtained
through health interview. Presence of KOA symptoms
was defined as presence of knee arthralgia for more
than 30 days during the last 3 months. Height and
weight were measured during a health examination.
Body mass index (BMI: kg/m2) was calculated using the
body weight and height measured during the health
examination. Obesity was defined as a BMI ≥ 27.5.17
Quality of life was measured by the Korean version of
the European Quality of Life Questionnaire (EQ-5D).18
The EQ-5D is a composite measure of health outcomes
that consists of five domains (mobility, self-care, daily
activity, pain/discomfort and anxiety/depression) with
each domain having three levels of health state. The
EQ-5D index is a quality-adjusted life year (QALY),
which was calculated using weights from a Korean valu-
ation study using time trade-off methods.19 In the
study, a linear transformation was used for health states
worse than death, and the index ranges from 1 to 1,
values smaller than 0 meaning a life worse than death
and 1 representing a perfect health state. The mean
absolute error (MAE), the average value of the differ-
ence between observed values and estimated values was
0.029 in the study. EQ-5D visual analogue scale (VAS)
is of ‘today’s health state’ ranging from 0 through 100,
0 representing the worst imaginable and 100 the best
imaginable health state.
Radiographic examination of the knee
Bilateral anteroposterior, lateral (30° flexion), and
weight-bearing anteroposterior plain radiographs of the
knees were taken using an SD3000 Synchro Stand
(SYFM, Namyangju, South Korea). Radiographic fea-
tures of OA were assessed using the Kellgren–Lawrence
grade,20 a grade for each case representing the highest
concordant grade in both knees. In 2010 and 2011, the
radiographic digital images were graded by two radiolo-
gists. Concordant grades were accepted. When there
was a difference of one grade between the two radiolo-
gists, the higher grade was accepted. If the discrepancy
was greater than one grade, a third radiologist was con-
sulted, and the grade concordant with the third grade
was accepted. Inter-rater agreement between the two
radiologists was 57.4%, and unweighted Cohen‘s kappa
coefficient was 0.43 in 2010. Those were 64.0% and
0.44 in 2011, respectively. In 2012, one of the two radi-
ologists read all images, and 5% of images were read by
another radiologist. Inter-rater agreement was 67.0%
and linear-weight kappa was 0.74. Radiographic KOA
International Journal of Rheumatic Diseases 2015
Knee OA and risk factors
(RKOA) was defined as a Kellgren–Lawrence grade of
≥ 2.20 Symptomatic RKOA (SRKOA) was defined as
RKOA accompanied by symptoms of KOA as defined
above.
Statistical analysis
Prevalence estimates and 95% confidence intervals
(CIs), and mean values and standard errors (SEs) are
presented for categorical and continuous variables,
respectively. SEs were estimated using weights that
accounted for proportion of selection, proportion of
response, and post-hoc correction for age and sex-specific
population structure. Because the sampling fraction was
small, SEs were estimated using sampling with replace-
ment design. Mean values and mean differences of con-
tinuous variables between groups were obtained from
complex sample general linear models, statistical signif-
icance of parameter estimates being tested by t-test. The
prevalence of RKOA and SRKOA in each administrative
division was plotted in bubble plots against mean age
and prevalence of BMI with areas of circles being pro-
portional to the prevalence of KOA. The ecologic associ-
ations between KOA, age and obesity were verified
using logistic regression at the individual level. Models
were built for the presence of RKOA or SRKOA using
age (as a continuous variable with a unit increase of
10 years), sex (men as the reference) and presence of
obesity (BMI ≥ 27.5 kg/m2 compared to < 27.5 kg/m2)
as independent variables. Statistical analyses were per-
formed using SPSS 21.0 software (IBM, New York, NY,
USA).
RESULTS
Characteristics of participants and prevalence
of KOA
In KNHANES-V, a total of 24173 people participated in
the survey. Among the participants, 9734 people aged
50 or older, for whom radiographic examination was
indicated, were eligible for this study. A total of 9512
participants (men, 4064; women, 5448, a male-to-
female ratio of 0.75) who underwent the radiographic
examination with viable results were included in this
study, which was 97.7% of the eligible participants. The
number of participants from each administrative divi-
sion is shown in Table 1.
The mean age (SE) of the participants was 61.5
(0.18) years in men and 63.3 years (0.18) in women.
The mean BMI and prevalence of obesity (95% CI) was
23.8 (0.06) kg/m2 and 9.7% (8.6–10.9%) in men, and
24.3 (0.06) kg/m2 and 14.7% (13.5–15.9%) in women.
3
S. Lee and S.-J. Kim

Table 1 Unweighted sample sizes by sex and administrative

regions
Men Women All
Seoul 769 1020 1789
Busan 251 341 592
Daegu 217 291 508
Incheon 220 310 530
Gwangju 106 128 234
Daejeon 133 146 279
Ulsan 84 139 223
Gyeonggi 723 998 1721
Gangwon 154 200 354
North Chungcheong 149 180 329
South Chungcheong 193 250 443
North Jeolla 205 251 456
South Jeolla 213 303 516 Figure 1 The prevalence of each Kellgren–Lawrence grade.
North Gyeongsang 290 389 679 Error bars represent upper limits of 95% confidence intervals.
South Gyeongsang 253 359 612
Jeju 104 143 247
Total 4064 5448 9512 The quality of life measured by EQ-5D index and EQ-
5D VAS was significantly lower in participants with
RKOA than in those without it. The estimated mean dif-
The prevalence of RKOA was 21.1% (19.6–22.8%) in ferences and 95% CIs of EQ-5D index were 0.04 (0.02–
men, and 43.8% (42.0–45.6%) in women. Among the 0.05) for men and 0.07 (0.06–0.09) for women. The
participants with RKOA, 20.9% (18.2–23.9%) of men corresponding estimates for EQ-5D VAS were 2.6 (0.9–
and 44.6% (42.0–47.2%) of women had KOA symp- 4.3) and 5.4 (4.0–6.9) for men and women, respec-
toms, and the prevalence of SRKOA was 4.4% (3.8– tively. The difference was larger when RKOA was
5.2%) and 19.2% (17.9–20.6%) in men and women, accompanied by symptoms. The estimated mean differ-
respectively. The proportion of participants in the pop- ences and 95% CIs of EQ-5D index between partici-
ulation who had RKOA without KOA symptoms was pants with SRKOA and those without it were 0.16
16.8% (15.3–18.3%) in men and 23.9% (22.4–25.5%) (0.13–0.19) for men and 0.17 (0.15–0.19) for women.
in women. When men and women were combined, the The corresponding estimates for EQ-5D VAS were 12.8
prevalence of RKOA was 33.3%, and the prevalence of (9.4–16.2) and 12.0 (9.9–14.1) for men and women,
SRKOA was 12.4%. The proportion of participants with respectively (Table 3).
non-symptomatic RKOA was 20.6% (19.5–21.8%).
The prevalence of each Kellgren–Lawrence grade is KOA in each administrative division in South
shown in Figure 1. The prevalence of high grades of 3 Korea
or 4, which correspond to the presence of definite joint The mean age of the participants was higher in rural
space narrowing,21 was about 9% in men and 30% in areas than in urban cities. It was 59 in men in Ulsan city
women. In the participants with SRKOA, the propor- and 64 in men in South Jeolla province (Table 4). The
tion of Kellgren–Lawrence grades 3 and grade 4 was prevalence of obesity was higher in regions with a
13.6% (12.3–15.0%) and 3.4% (2.8–4.2%), respec- higher mean age, except in Daejeon, in which the
tively, in men; these were 43.4% (39.9–46.9%) and prevalence of obesity reached 25% in women. The
38.7% (35.4–42.2%) in women. prevalence of RKOA was higher in regions with a higher
The prevalence of RKOA was higher in women than mean age and prevalence of obesity, and it was 57.9%
in men, in participants with obesity than in those with- and 55.9% in women in South Choongcheong and in
out obesity, and increased with age (Table 2). The Jeju provinces, respectively (Fig. 2a,b). In the case of
prevalence of SRKOA showed similar trends with age SRKOA, the trend of higher prevalence in regions with a
and prevalence of obesity, but there was a bigger differ- higher mean age and prevalence of obesity was more
ence between men and women; the prevalence of prominent. It reached 36.6% in women in Jeju pro-
SRKOA was about 10% in men and about 40% in vince, which had the highest mean age and prevalence
women in age of 60s through 70s. of obesity (Fig. 2c,d).

4 International Journal of Rheumatic Diseases 2015

 Knee OA and risk factors

Table 2 Prevalence of radiographic knee osteoarthritis, by symptom status, age group, obesity and sex
Age Men Non-obesity Obesity Women Non-obesity Obesity
n n
Prevalence of radiographic knee osteoarthritis
50–59 1431 10.4 (8.5–12.6) 18.8 (12.6–27.1) 2019 18.9 (16.7–21.4) 42.2 (34.9–49.8)
60–69 1383 23.0 (20.1–26.1) 38.9 (29.8–48.8) 1705 46.4 (43.1–49.7) 69.1 (62.0–75.5)
70–79 1051 37.5 (33.8–41.3) 46.9 (33.6–60.7) 1367 66.9 (63.4–70.2) 72.0 (64.7–78.3)
80+ 191 49.5 (40.3–58.7) 70.6 (27.8–93.8) 352 80.2 (75.0–84.5) 94.0 (81.8–98.2)
Total 4056 5443
Prevalence of symptomatic and radiographic knee osteoarthritis
50–59 1391 0.9 (0.5–1.7) 3.7 (1.5–8.4) 1985 5.1 (3.9–6.7) 16.1 (11.5–22.0)
60–69 1351 6.0 (4.5–7.9) 9.0 (4.9–15.9) 1671 18.4 (15.9–21.1) 41.9 (34.5–49.7)
70–79 1012 9.3 (7.4–11.5) 10.9 (5.5–20.6) 1303 33.6 (30.1–37.2) 40.0 (32.7–47.6)
80+ 167 12.6 (8.1–19.2) 19.5 (2.4–70.8) 312 41.3 (34.7–48.1) 63.2 (39.8–81.7)
Total 3921 5271
Data represent the numbers of participants and prevalence estimates with 95% confidence intervals.

Table 3 Quality of life by knee osteoarthritis and sex

Men Knee OA Normal P-value Women Knee OA Normal P-value
n n
Radiographic knee osteoarthritis
EQ-5D index 3926 0.91 (0.89–0.92) 0.94 (0.94–0.95) < 0.001 5265 0.84 (0.83–0.85) 0.91 (0.90–0.92) < 0.001
EQ-VAS 3908 71 (69–72) 73 (72–74) 0.003 5208 66 (64–67) 71 (70–72) < 0.001
Symptomatic radiographic knee osteoarthritis
EQ-5D index 3925 0.78 (0.75–0.81) 0.94 (0.94–0.95) < 0.001 5264 0.74 (0.72–0.76) 0.91 (0.91–0.92) < 0.001
EQ-VAS 3907 60 (57–64) 73 (72–74) < 0.001 5207 59 (57–61) 71 (70–72) < 0.001
EQ-5D index ranges from –1 through 1, 1 representing the perfect health state. EQ-5D VAS ranges from 0 through 100, 100 representing the best
imaginable today’s health state. EQ-5D, European Quality of Life Questionnaire; VAS, visual analog scale.

The ecological associations between RKOA, age and
obesity was also observed at the individual level. The
odds ratios (ORs) and 95% CIs for RKOA were 2.54
(2.38–2.70) for a unit (10 years) increase in age and
2.33 (1.97–2.75) for obesity, when adjusted for sex.
The corresponding ORs and 95% CIs for SRKOA were
2.45 (2.26–2.66) for age and 2.44 (1.99–2.99) for
obesity.
DISCUSSIONS
In this study, the prevalence of KOA in people aged
≥ 50 in South Korea was 33.3% for RKOA and 12.4%
for SRKOA. The prevalence of SRKOA in Kellgren–Lawr-
ence grades 3 or 4, which is considered as an entry crite-
ria for total knee joint replacement,21 was high; about
80% of SRKOA was of high grade in women. The qual-
ity of life was lower in people with KOA than in those
without it, especially when it was accompanied by
symptoms. The prevalence of RKOA and SRKOA was
higher in regions with a higher mean age and preva-
lence estimate of obesity, which was also observed at
the individual level.
There were two regional population-based studies on
the prevalence of KOA in South Korea. The Hallym
Aging Study, which was conducted in the Chooncheon
area in 2007, was similar to this study in the inclusion
criteria for age and the definition of KOA.22 In the
study, the prevalence of RKOA was 37.3%, and given
that the mean age of subjects was higher than in this
study, the results of the two studies are considered con-
sistent. However, the study reported SRKOA prevalence
of 24.2%, higher than 20.1% in Gangwon province
(which includes Chooncheon) in this study. Differences
in the definition of KOA symptoms and the modest par-
ticipation proportion of 61% in the study may explain
the difference. Another study conducted in Seongnam
area in 2011 included an older population aged ≥ 65,
and reported RKOA prevalence of 38.1%.23 In terms of
RKOA, these three studies appear to show consistent

International Journal of Rheumatic Diseases 2015 5

International Journal of Rheumatic Diseases 2015

ORIGINAL ARTICLE

Prevalence of knee osteoarthritis, risk factors, and quality of

life: The Fifth Korean National Health And Nutrition
Examination Survey
Sunggun LEE1 and Seon-Jeong KIM2
1
Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, and 2Department of
Radiology, Myongji Hospital, Goyang, South Korea

Abstract
Aim: Although there have been regional population-based studies on the prevalence of knee osteoarthritis
(KOA) and its risk factors in South Koreans, those studies in common had limited external validity. This study
aims to estimate the national prevalence of KOA and its risk factors using a complex sampling design.
Methods: This was a cross-sectional study including 9512 participants aged ≥ 50 years of The Fifth Korean
National Health and Nutrition Examination Survey, who were selected using two-step stratified clustered equal-
probability systematic sampling. Radiographic KOA (RKOA) was defined as a Kellgren–Lawrence grade of ≥ 2.
Symptoms of KOA were evaluated through a health interview. Obesity was defined as a body mass index
≥ 27.5 kg/m2. Quality of life was measured by the Korean version of European Quality of Life Questionnaire
(EQ-5D).
Results: The prevalence of RKOA was 21.1% (95% CI: 19.6–22.8%) in men, and 43.8% (42.0–45.6%) in
women. The prevalence of symptomatic RKOA (SRKOA) was 4.4% (3.8–5.2%) and 19.2% (17.9–20.6%) in
men and women, respectively. The EQ-5D index was lower in participants with KOA. When plotted against
mean age and prevalence of obesity, regions with a higher mean age and prevalence of obesity had higher preva-
lence of KOA, which was also observed at the individual level. The prevalence of SRKOA was 36.6% (29.7–
44.1%) in women in Jeju province.
Conclusion: The prevalence of SRKOA in women reached 36.6% in high-risk groups accompanied by low qual-
ity of life. The results suggest that the disease burden of KOA is high in South Korea.
Key words: epidemiology, osteoarthritis.

INTRODUCTION remains unresolved, the intangible cost of OA may be

Osteoarthritis (OA) is a highly prevalent disease in the
elderly, and its influence on individuals and society is
large. The disease burden of OA can be considered in
terms of intangible, direct and indirect cost. Because the
mechanism for increased mortality in patients with OA
Correspondence: Assistant Professor Sunggun Lee, Department
of Internal Medicine, Haeundae Paik Hospital, Inje University
College of Medicine, Haeundae-gu Jwa-dong 1435, Busan,
South Korea. Email: sglee.ac@gmail.com
best captured by its influence on quality of life.1 Accord-
ing to the Global Burden of Disease study (GBD) 2010,
OA of the hip and knee combined was the third most
prevalent musculoskeletal disorder, and it was 11th in
the rank of years lived with disability (YLD). Eighty-
three percent of the burden was attributed to knee OA
(KOA)2 and prevalence of KOA was highest in high-
income Asia–Pacific regions of South Korea and Japan.3
Socioeconomic burden is also high; direct cost of OA
comprised 1.7% of the expenses of the French health
insurance program in 2002, which was equivalent to

© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
 Knee OA and risk factors

(a) (b)

(c) (d)

Figure 2 The prevalence of radiographic knee osteoarthritis (a and b) and the prevalence of symptomatic radiographic knee
osteoarthritis (c and d) in 16 administrative regions in South Korea is shown in bubble plots against prevalence of obesity and
mean ages. The area of bubbles is proportional to the prevalence of knee osteoarthritis.

estimates, the prevalence of about mid-30% in people
older than 50 years in South Korea.
In the case of studies in the United States, a study
conducted in Johnston County in North Carolina
reported RKOA prevalence of 27.8% in a population
aged ≥ 45 years,24 and NHANES III showed a preva-
lence of 42.1% in a population aged ≥ 60 years.25
Prevalence of SRKOA was 16.7% and 12.1%, respec-
tively. If the difference in the age of subjects are
accounted for, these two studies and this study appear
to show similar prevalences of RKOA and SRKOA.
The lower quality of life in people with KOA,
especially symptomatic KOA, is supported by a com-
munity-based study in an elderly population in
South Korea. In the study, the quality of life mea-
sured by Short Form-12 was significantly lower in
people with knee pain, which was significantly asso-
ciated with KOA.26 Together with data showing that
the direct and indirect economic costs of muscu-
loskeletal disorders are also high,27 the results sug-
gest that the disease burden of KOA is high in South
Korea.

International Journal of Rheumatic Diseases 2015 7

S. Lee and S.-J. Kim
The prevalence of KOA was higher in regions with
higher prevalence of obesity, especially in women,
which was also observed at the individual level. The
association showed a trend for a closer association with
SRKOA. Although obesity is a well-established risk fac-
tor for KOA, the association found in this study needs
to be interpreted with caution. KOA is associated with
impairment in mobility, which may lead to low energy
expenditure and obesity. Therefore, temporal bias (re-
verse causation) is a concern and the cross-sectional
design of this study cannot exclude the bias. Assuming
a prospective association between obesity and KOA,
increased mechanical loading on the knee joints from
increased body weight would be an important cause.28
However, there are studies that showed weight-inde-
pendent association between KOA and obesity and
other obesity-related factors such as metabolic abnor-
malities.29 The beneficial effects of weight reduction in
KOA are likely to be mediated through the positive
effect on these factors, and the exact cause of the associ-
ation between KOA and obesity remains to be eluci-
dated in the future. Nevertheless, the association found
in this study is important because no country has suc-
ceeded yet in decreasing the prevalence of obesity30 and
prevalence of obesity is expected to increase in South
Korea, leading to an increase in the disease burden of
KOA. As evidence is emerging that weight reduction
may have disease-modifying effects for KOA,31,32 it is
crucial to know the prevalence of KOA and obesity in
South Korean populations.
Close national population-level surveillance is
required for signals of KOA ‘epidemics’ and this study
provides the steppingstone for this. Eligible participants
were selected systematically, and exposures such as BMI
were calculated using directly measured height and
weight rather than self-report, providing reliable esti-
mates for the prevalence of KOA and obesity. However,
this study also has limitations. First, this study used a
composite measure of Kellgren–Lawrence grade as the
outcome, which is known to be insensitive to changes
in articular cartilage. It is believed that patients with
radiographic changes are in a late stage of the disease.33
Although Kellgren–Lawrence grades of 2 or higher are
defined as RKOA, early radiographic changes of grade 1
are known to be predictors for future development of
radiographic KOA.10 Therefore, studies defining RKOA
as a Kellgren–Lawrence grade ≥ 2 may underestimate
the prevalence of KOA.3 Second, the Inter-rater agree-
ment between readings by radiologists was of modest
quality, and it leaves the potential for overestimation of
prevalence. However, limited inter-rater reliability is
8 International Journal of Rheumatic Diseases 2015
inherent to semi-quantitative Kellgren–Lawrence grad-
ing. Even in well-established prospective cohorts such
as the Osteoarthritis Initiative (OAI) and Cohort Hip
and Cohort Knee (CHECK), inter-rater reliability shows
kappa values of 0.6, which correspond to a high level of
agreement, only when the value is weighted (which is
appropriate given the ordinary nature of the scale)21,34
or when binary agreement between the presence or
absence of KOA was assessed.35 It was reported that
quantitative measurement of minimum joint space
width had more reliable results.36 Lastly, low participa-
tion of men is also a limitation: a male-to-female ratio
of 0.75 in the included participants in contrast to the
ratio of 0.98 (in the all age group) according to the Kor-
ean census of 2010. Although this limitation was
addressed by adjusting weights in post hoc correction, it
may compromise representativeness of the data.
In conclusion, in South Korean people aged 50 years
or older, the prevalences of RKOA and SRKOA were
33.3% and 12.4%, respectively. The prevalence of KOA,
especially symptomatic RKOA in women, was higher in
regions with high prevalence of obesity. Following stud-
ies on projected prevalence and disease burden of KOA
is expected in the future.
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