RESEARCH

Original Research

Trends in Fast-Food and Sugar-Sweetened

Beverage Consumption and Their Association
with Social Environmental Status in South Korea
Hyunjung Lim, PhD; Hae Jeoung Lee, PhD; Ryowon Choue, PhD; Youfa Wang, MD, PhD

ARTICLE INFORMATION ABSTRACT

Article history: Background As South Korea has enjoyed rapid economic development, Koreans’ diet,
Submitted 23 March 2016 particularly consumption of fast food (FF) and sugar-sweetened beverages (SSBs), has
Accepted 31 July 2017 changed.
Available online 5 October 2017
Objective To examine time trends in FF and SSB consumption and their associations
Keywords: with social environmental status (SEnS) in South Korea.
Fast food Design Korean National Health and Nutrition Examination Surveys (KNHANES) were a
Sugar-sweetened beverages
series of population-based cross-sectional surveys.
Social environmental status
Korean National Health and Nutrition Examination Participants Data from the KNHANES conducted in 1998, 2001, 2005, and 2007-2009
Survey for 49,826 Koreans aged
1 year were used.
South Korea Main outcome measures Consumption of FF and SSBs were assessed by a 24-hour
Supplementary materials: recall. We defined two FF categories (Western-style and Korean-style) and one SSB
The Figure is available at www.jandonline.org category. Sex, age, household income, and residence regions were investigated.
Statistical analyses performed The primary sampling units, strata, and sampling
weights were taken into account using SAS survey-related procedures. Logistic
2212-2672/Copyright ª 2018 by the Academy of
Nutrition and Dietetics. regression models were used to test associations between SEnS and FF consumption.
http://dx.doi.org/10.1016/j.jand.2017.08.001 Results Over an 11-year period, the proportion of participants’ who consumed Western
FF and SSBs on the surveyed day doubled (P<0.05). Per capita energy contribution from
Western FF also increased in adults, men, and low-income groups. SSB consumption
doubled (per capita: 32 to 82 kcal/day, only consumers: 123 to 166 kcal/day), but
consumption of Korean-style FF decreased (P<0.05). Compared with the low-income
rural resident group, the high-income urban resident group was much more likely to
consume Western FF (OR¼26.7[3.7, 193.4]) and SSBs (odds ratio [OR]¼3.1 [2.4, 4.1]) in
1998. However, in recent years, the patterns changed; the high-income urban resident
group was more likely to consume Korean-style FF (OR¼2.0[1.3, 2.9]) and SSBs (OR¼1.7
[1.3, 2.1]).
Conclusions In South Korea, people who reported consuming Western FF and SSBs on
the surveyed day almost doubled during 1998-2009, whereas those who consumed
Korean FF decreased. SEnS was related to FF and SSB consumption.
J Acad Nutr Diet. 2018;118(7):1228-1236.

P
EOPLE’S LIFESTYLES HAVE CHANGED AS A RESULT OF
rapid economic development in many countries.
These changes, particularly changes in dietary pat-
terns and activity levels, may be contributing to in-
creases in noncommunicable diseases such as obesity,
hypertension, and diabetes.1-5 For example, the proportion of
energy obtained from dietary fat increased from 19.3% in
1989 to 27.5% in 2004 in China,6 with similar increases re-
ported in other countries, such as the Philippines1 and
Thailand.2 In addition, traditional diets of cereals, soy prod-
ucts, fish, and vegetables, suggested to prevent cardiovascular
disease and lower blood cholesterol levels, are gradually
being replaced with higher-sugar and higher-fat diets.2,3
In the past 2 decades, South Korea has enjoyed rapid eco-
nomic development, which may have led to changes in
individuals’ dietary and disease patterns. The accelerated
shifts began in the 1970s. Major dietary changes included a
large increase in animal foods consumption and a decrease in
total cereal intake.7,8 The Korean diet also has diversified
because of the development of processed foods, the growth
of the foodservice industry, and a massive influx of Western
foods.9 The most representative examples are fast foods (FF)
and sugar-sweetened beverages (SSBs).
Some research indicates that increased consumption of FF
and SSBs is associated with increased obesity risk10,11 and risk
of other diseases such as metabolic syndrome and type 2
diabetes.12,13 Many developing countries have their own
traditional FF and SSBs (eg, street foods) in addition to related
Western products. Western FF restaurants not only directly
affect the kind of food local residents consume, but they also

1228 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2018 by the Academy of Nutrition and Dietetics.

affect local food restaurants, including local FF supplies and
consumption. FF and SSB consumption has been studied in
various populations,10,14-18 but it has rarely been studied in
transition societies such as South Korea. In addition, much of
the literature regarding FF and beverage consumption has
focused on Western-style FF and specific drink types.19,20 A
distinct difference exists in the consumption and eating
patterns of Western-style FF and SSBs between developed
and developing countries. Unlike in the United States,18 FF
and SSB intake in China was higher in high socioeconomic
status (SES) groups than in their counterparts.21 Few studies
have attempted to determine the association between SES
and FF and SSB intake in South Korea.
This study examined time trends in contributions from FF
and SSB consumption to total energy intake (TEI) using na-
tionally representative data collected in South Korea. In
addition, we examined the association between social envi-
ronmental status (SEnS), which was indicated by using
household income level and urban-rural residency, as well as
FF and SSB consumption.
MATERIALS AND METHODS
Study Population and Database
Data from the Korean National Health and Nutrition Exami-
nation Surveys (KNHANES) conducted in 1998 (KNHANES I),
2001 (KNHANES II), 2005 (KNHANES III), and 2007-2009
(KNHANES IV) were used. KNHANES were a series of
population-based, cross-sectional surveys that selected a
representative group using a stratified, multistage sampling
design according to geographic area, age, and sex. Since 2007,
the KNHANES has become a year-round investigation with
rolling survey sampling. Stratification was conducted based
on the country’s 29 areas, including 11 metropolitan cities
and provinces, the administrative unit, and dwelling type.
The KNHANES included a health interview survey, a health
examination survey, and a nutrition survey. The response rate
of each KNHANES was 86.1% in KNHANES I, 84.7% in
KNHANES II, 89.9% in KNHANES III, and 78.4% in KNHANES IV,
respectively. Detailed descriptions of the study design and
data collection have been published previously.22 This study
was approved by the Korea Centers for Disease Control and
Prevention Institutional Review Board, and informed written
consent was obtained from each subject.
We focused on subjects aged 1 year or older; a sample of
135,954 (39,060 in KNHANES I; 37,878 in KNHANES II; 34,145
in KNHANES III; and 24,871 in KNHANES IV) had complete
demographic data. All nonpregnant respondents who
completed the 24-hour dietary recall and self-reported
household income were included in our study sample. We
excluded 1,585 participants (72 from KNHANES I; 654 from
KNHANES II; 150 from KNHANES III; and 709 from KNHANES
IV) because of implausible energy intake (<500 or >5,000
kcal per day). Our final analysis included 49,826 respondents
(10,328 from KNHANES I; 9,314 from KNHANES II; 8,780 from
KNHANES II; and 21,404 from KNHANES IV).
Study Variables and Measures
Dietary Assessment. Dietary intake, including beverage
consumption, was assessed by using a single 24-hour recall
administered by trained dietary interviewers. Subjects re-
ported all food and beverage consumed over the last 24-hour
July 2018 Volume 118 Number 7
RESEARCH
period (midnight to midnight). After the dietary interview, all
reported food and beverage items were coded using the
Korean Nutrient Database.23
Outcome Variables: FF and SSBs. We defined two FF
categories and one SSB category based on a total of 18,404
dish items (3,909 dish items in KNHANES I; 3,585 dish items
in KNHANES II; 5,290 dish items in KNHANES III; and 5,620
dish items in KNHANES IV):
a) Western-style FF (102 items; eg, hamburgers, pizza,
hot dogs, sandwiches, french fries, onion rings,
chicken nuggets)
b) Korean-style FF (245 items; eg, Korean street foods,
instant food products, quick delivery foods)
c) SSBs (243 items; nonalcoholic drinks containing
added sugars, see the Figure [available at www.
jandonline.org]).
Exposure Variables and Covariates. These included sex,
age, household income, and urban/rural residence. House-
hold income was family income adjusted for number of
family members. The quartiles of average household monthly
income were defined by KNHANES (average monthly
household income¼monthly household income/number of
family members).22 Urban/rural residence was classified
based on the South Korean administrative units, primarily
according to population size (urban
50,000). Rural areas
(and associated populations) are those dominated by primary
or secondary industries such as agriculture and
manufacturing. Tertiary service-related industries dominate
in urban areas.
SEnS was defined based on a combination of household per
capita income and resident region. We defined eight income-
resident groups; however, because of space limitations, we
only present the results for four combinations to highlight
the differences in SEnS: (1) low-income and rural residence;
(2) high-income and rural residence; (3) low-income and
urban residence; and (4) high-income and urban residence.
Statistical Analysis
The primary sampling units, strata, and sampling weights
were taken into account, using SAS version 9.2 (SAS Institute)
survey-related procedures, which gave us nationally repre-
sentative estimates and a correct estimate of the related
variances for each KNHANES. P<0.05 was considered statis-
tically significant.
First, we compared the proportion of consumers who
consumed the main types of FF and their sociodemographic
characteristics. Second, we described the sociodemographic
and socioeconomic differences in the consumption of FF and
SSBs and the energy distribution from FF and SSBs, which
were shown as least squares adjusted means adjusted for age
and sex. We also tested the time trends across the four
KNHANES. Third, we compared the percentage of energy
from FF and SSBs among daily TEI (KNHANES IV compared
with KNHANES I), using t tests. Then, we fit logistic regression
models to examine the association between combinations of
SEnS (different levels of income plus region of residence) and
FF or SSB consumption (outcome variables; consumer vs
nonconsumer). All models included age and sex. The low-
income and rural resident group was the reference group.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1229
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RESULTS Western-style FF consumption increased (P<0.0001); how-

Sociodemographic Characteristics of Consumers of
FF and SSBs
The distribution of sex, age, household income levels, and
residence region of the respondents was similar across the
four surveys (Table 1). The percentages of subjects aged 19 to
39 years and 40 to 65 years (approximately 30% for each)
were greater than those for other age groups. Approximately
80% of participants lived in urban areas.
Sociodemographic characteristics of consumers of FF and
SSBs, on the surveyed day, which increased from 2.5% in 1998
to 4.8% in 2007-2009 for Western-style FF among South Ko-
reans excluding those aged 65 years and older (Table 2),
whereas consumer proportions of Korean-style FF decreased
in all subgroups. Consumer rates of SSBs approximately
doubled during those periods.
Per Capita Energy Contribution from FF and SSB
Consumption
Per capita energy consumption from FF and SSBs by de-
mographic and socioeconomic groups are presented in
Table 3. Western-style FF consumption was inconsistent
across SEnS, and its consumption increased over time in men,
but not in women. Among adults aged 19 to 65 years,
ever, the absolute Western-style FF-derived calories, regard-
less of survey period, was the highest among adolescents
aged 12 to 18 years. In the KNHANES IV (2007-2009), mean
Western-style FF consumption was 53 kcal/day among ado-
lescents, whereas the mean consumptions were lower in
other age groups: 19 kcal/day in children aged 6-11 years and
31 kcal/day in young adults aged 19 to 39 years. We also
found that the high-income group consumed more Western-
style FF than did the low-income group; however, the
amounts consumed by the low-income group increased over
time from 5 kcal/day in 1998 to 18 kcal/day in 2007-2009
(P<0.001).
Conversely, overall energy consumption from Korean-style
FF declined by approximately one-third from 115 kcal/day to
40 kcal/day over time, whereas SSB consumption has more
than doubled over time (32 kcal/day to 82 kcal/day, trend test
P<0.0001). Little difference was seen in Korean-style FF
intake by age, income level, and residence.
Energy Contribution of FF and SSB Consumption
and among Consumers
Table 4 presented the energy contributions of Western-style
FF, Korean-style FF, and SSBs among consumers. As the

Table 1. Distribution (n and %) of study population aged
1 years: four Korean National Health and Nutrition Examination
Surveys (KNHANES; I: 1998, II: 2001, III: 2005, IV: 2007-2009)

KNHANES IV
KNHANES I KNHANES II KNHANES III 2007-2009
1998 (n[10,328) 2001 (n[9,314) 2005 (n[8,748) (n[20,187)
n Weighted %a n Weighted %a n Weighted %a n Weighted %a

Sex
Male 4,976 48.3 4,465 47.9 4,099 49.2 8,794 48.1
Female 5,352 51.7 4,849 52.1 4,649 50.8 11,393 51.9
Age, y
1-5 810 8.3 713 7.4 616 6.8 1,539 5.5
6-11 953 9.6 1,058 11.3 880 9.5 2,189 8.4
12-18 1,132 11.2 932 10.1 879 9.9 1,815 10.0
19-39 3,361 34.5 2,968 31.8 2,420 32.5 4,634 31.2
40-65 3,103 28.6 2,791 30.3 2,958 32.0 6,532 34.0
65þ 969 7.9 852 9.1 995 9.4 3,478 10.9
Household incomeb
Low (Q1) 2,079 17.5 1,843 20.2 1,752 18.9 3,783 15.1
Low-middle (Q2) 2,485 23.2 2,373 24.9 2,352 27.5 5,062 25.3
Middle-high (Q3) 3,050 31.2 2,364 25.2 2,400 27.9 5,769 30.0
High (Q4) 2,714 28.0 2,734 29.7 2,244 25.7 5,573 29.5
Residence
Urban 6,557 77.2 7,306 80.1 7,044 81.3 15,116 80.1
Rural 3,771 22.8 2,008 19.9 1,704 18.7 5,071 19.9
a
Weighted percentages have been adjusted to be nationally representative.
b
The quartiles of average household monthly income (monthly household incomes/number of family members).

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Table 2. Sociodemographic characteristics of consumers of fast foods (FF) and sugar-sweetened beverages (SSBs) among total population aged
1 years: four Korean
National Health and Nutrition Examination Surveys (KNHANES; I: 1998, II: 2001, III: 2005, IV: 2007-2009)a

Western FFb Korean FFc SSBd

I II III IV P for trend I II III IV P for trend I II III IV P for trend

All 2.5 3.0 3.3 4.8 <0.0001f 23.4 21.7 21.5 13.2 <0.0001 25.9 42.6 44.2 48.1 <0.0001
Sex
Male 2.0 2.6 3.3 4.8 <0.0001 25.5 21.9 23.3 13.7 <0.0001 26.4 46.2 42.7 52.3 <0.0001
Female 3.0 3.4 3.3 4.8 <0.0001 21.4 21.6 19.8 12.8 <0.0001 25.4 39.4 45.6 44.4 <0.0001
Age, y
1-5 2.5 3.2 3.5 3.9 0.0249 25.3 23.5 9.0 11.3 <0.0001 44.2 41.9 51.3 63.9 <0.0001
6-11 4.2 4.6 5.6 5.7 0.0047 27.8 30.1 15.6 15.5 <0.0001 35.5 30.6 43.8 60.2 <0.0001
12-18 6.4 8.9 7.1 12.0 0.0001 36.5 35.5 16.8 22.7 <0.0001 29.5 34.1 46.4 46.7 <0.0001
19-39 3.0 3.9 4.5 7.2 <0.0001 29.0 26.8 57.6 19.6 <0.0001 26.8 54.6 50.2 54.0 <0.0001
40-65 0.5 0.3 1.2 1.8 <0.0001 13.6 12.6 27.0 7.4 <0.0001 18.1 44.4 41.4 43.7 <0.0001
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

65þ 0.0 0.1 0.0 0.2 0.2656 8.3 7.5 3.6 3.4 <0.0001 13.7 19.8 25.5 29.1 <0.0001
Household incomee
Low (Q1) 1.2 1.5 2.4 4.0 <0.0001 19.3 17.7 18.5 9.1 <0.0001 16.1 31.6 36.1 36.8 <0.0001
Low-middle (Q2) 2.2 3.2 3.0 4.1 <0.0001 24.4 22.7 22.5 12.7 <0.0001 22.7 40.5 43.2 47.2 <0.0001
Middle-high (Q3) 2.9 3.1 3.4 4.5 0.0001 24.9 22.7 22.3 15.1 <0.0001 29.1 44.6 47.5 51.0 <0.0001
High (Q4) 3.1 3.7 4.2 6.1 <0.0001 23.4 22.8 21.9 13.9 <0.0001 30.9 50.2 47.7 51.7 <0.0001
Residence
Urban 3.0 3.3 3.6 5.3 <0.0001 24.6 22.7 22.7 14.0 <0.0001 28.1 44.9 44.5 49.0 <0.0001
Rural 0.7 1.6 1.9 2.7 <0.0001 19.2 17.7 16.7 10.0 <0.0001 18.1 33.3 44.0 44.5 <0.0001
a
Values are proportion (%) of consumers based on a single 24-hour dietary recall from each study participant.
b
The most common, Westernized FF, top-sellers at specific FF chains.
c
Korean street foods, instant food products, quick delivery foods.

RESEARCH
d
Nonalcoholic drinks containing added sugars.
e
Quartiles of average household monthly income (monthly household income/number of family members).
f
Boldface P values indicate statistical significance.
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Table 3. Energy contribution (as kcal) of fast foods (FF) and sugar-sweetened beverages (SSBs) to total energy intake among total population aged
1 years: Korean
National Health and Nutrition Examination Surveys (KNHANES; I: 1998, II: 2001, III: 2005, IV: 2007-2009)

Western FFa Korean FFb SSBc

P for P for P for
1998 2001 2005 2007-09 trend 1998 2001 2005 2007-09 trend 1998 2001 2005 2007-09 trend

ƒƒƒmeanstandard errorƒƒƒ! ƒƒƒƒƒƒmeanstandard errorƒƒƒƒƒƒ! ƒƒƒmeanstandard errorƒƒƒ!

All 142 121 152 191 0.0345 1154 843 1125 402 <0.0001 321 612 562 822 <0.0001
Sex
Male 122 111 173 212 0.0007 1396 944 1448 483 <0.0001 332 712 602 962 <0.0001
Female 162 142 121 171 0.6577 924 743 815 322 <0.0001 312 522 522 672 <0.0001
Age, y
1-5 93 82 83 61 0.1389 697 455 486 142 <0.0001 484 464 624 1206 <0.0001
6-11 195 204 245 193 0.6296 11911 908 11612 343 <0.0001 363 333 574 1044 <0.0001
12-18 358 365 305 536 0.2033 19813 16110 15411 737 <0.0001 353 514 684 904 <0.0001
19-39 214 182 233 313 0.0001 1507 1136 17411 634 <0.0001 362 843 693 993 <0.0001
40-65 21 10 42 61 0.0003 715 504 695 232 <0.0001 242 652 462 652 <0.0001
65þ 00 00 00 00 0.3581 355 325 295 112 <0.0001 152 243 232 392 <0.0001
d
Household income
Low (Q1) 52 51 134 183 0.0005 1119 726 10713 324 <0.0001 222 463 433 624 <0.0001
Low-middle (Q2) 102 112 112 172 0.0005 1207 896 1169 393 <0.0001 282 573 522 783 <0.0001
Middle-high (Q3) 184 153 184 192 0.6093 1187 896 1178 443 <0.0001 352 613 593 883 <0.0001
High (Q4) 204 162 163 232 0.9432 1117 836 1078 423 <0.0001 393 753 663 893 <0.0001
Residence
Urban 172 141 162 211 0.6238 1175 864 1176 422 <0.0001 342 652 572 842 <0.0001
July 2018 Volume 118 Number 7

Rural 52 72 93 122 0.1154 1107 747 9313 323 <0.0001 253 442 514 734 <0.0001
a
The most common, Westernized FF, top-sellers at specific FF chains.
b
Korean street foods, instant food products, quick delivery foods.
c
Nonalcoholic drinks containing added sugars.
d
Quartiles of average household monthly income (monthly household income/number of family members).
July 2018 Volume 118 Number 7

Table 4. Energy contribution (as kcal) of fast foods (FF) and sugar-sweetened beverages (SSBs) to total energy intake among those who consume each food/beverage:
Korean National Health and Nutrition Examination Surveys (KNHANES; I: 1998, II: 2001, III: 2005, IV: 2007-2009)

Western FFa Korean FFb SSBc

P for P for P for
1998 2001 2005 2007-09 trend 1998 2001 2005 2007-09 trend 1998 2001 2005 2007-09 trend

ƒƒƒƒƒƒmeanstandard errorƒƒƒƒƒƒ! ƒƒƒƒƒmeanstandard errorƒƒƒƒƒ! ƒƒƒƒmeanstandard errorƒƒƒƒ!

All 56645 40017 43331 38517 <0.0001 48611 3818 51915 2998 <0.0001 1231 1412 1263 1662 <0.0001
Sex
Male 60956 42226 53952 43027 <0.0001 54314 42311 61021 35313 <0.0001 1264 1523 1404 1803 <0.0001
Female 53848 38519 33620 34016 <0.0001 42112 34210 41015 2437 <0.0001 1205 1303 1132 1492 <0.0001
Age, y
1-5 35588 24223 19739 15216 0.0526 27116 18713 21915 1248 <0.0001 1089 1096 1226 1907 <0.0001
6-11 43144 42749 41652 32425 0.5340 42824 29117 42128 22413 <0.0001 1036 1086 1305 1694 <0.0001
12-18 56678 39227 41233 43831 0.5770 53824 44917 55730 34222 <0.0001 1205 1409 1497 1886 <0.0001
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19-39 68484 42724 51442 41726 0.0923 51515 42213 58723 31112 <0.0001 1345 1534 1385 1774 <0.0001
40-65 34460 37337 332111 29029 0.0552 50726 38217 48721 30116 <0.0001 13210 1434 1093 1463 0.0338
65þ 00 1590 00 13740 0.4897 42533 42239 47352 31030 0.0008 10811 1247 924 1324 0.8291
d
Household income
Low (Q1) 42472 37450 52972 38638 0.0072 54732 40619 56444 33030 <0.0001 13313 1427 1175 1596 0.4283
Low-middle (Q2) 43848 35025 36826 38434 0.9630 49718 38217 52227 30116 <0.0001 1227 1404 1204 1624 <0.0001
Middle-high (Q3) 59685 42832 53864 41338 0.2907 46716 38314 51622 29314 <0.0001 1205 1353 1274 1714 <0.0001
High (Q4) 63887 42030 35633 36621 0.0711 46718 36516 49225 29313 <0.0001 1266 1464 1355 1673 <0.0001
Residence
Urban 55847 39819 43334 38217 0.0682 47012 3759 51715 2979 <0.0001 1214 1433 1273 1672 <0.0001
Rural 687122 42338 43769 41057 0.7042 55522 41615 53542 31418 <0.0001 1337 1283 1207 1625 0.0138
a
The most common, Westernized FF, top-sellers at specific FF chains.

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b
Korean street foods, instant food products, quick delivery foods.
c
Nonalcoholic drinks containing added sugars.
d
Quartiles of average household monthly income (monthly household income/number of family members).
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amount of FF and SSBs consumed has changed, the energy
contribution from Korean-style FF has decreased from 486
kcal/day to 299 kcal/day, and SSB-derived calories have
increased from 123 kcal/day to 166 kcal/day (trend test
P<0.0001). However, the energy contribution from Western-
style FF has slightly decreased from 566 kcal/day to 385 kcal/
day (P<0.0001), although the proportion of consumers and
per capita energy consumption have increased significantly.
Association between SEnS and FF and SSB
Consumption
Table 5 presents the associations between joint income and
residence region (eg, high income and urban residence) and
FF and SSB consumption for KNHANES I (1998) and KNHANES
IV (2007-09). After controlling for age, sex, and TEI, SSB
consumption was strongly related to SEnS level in both 1998
and 2007-09. Compared with the low-income and rural
residence group (reference group), the other three SEnS
groups were more likely to consume SSBs (high-income and
urban residence group: odds ratio [OR]¼3.1 [2.4, 4.1] in 1998;
OR¼1.7 [1.3, 2.1] in 2007-9). However, the association be-
tween SEnS group and consumption of Western-style FF and
Korean-style FF were different at different times (1998 vs
2007-09). The high-income and urban residence group was
much more likely to consume Western FF (OR¼26.7 [3.7,
193.4]) than were the low-income and rural residence group
in 1998, whereas the consumption of income and residence
groups did not differ from the low-income and rural resi-
dence reference group in 2007-09. In addition, urban resi-
dents were more likely to consume Korean-style FF
regardless of income level, especially in recent years (low
income and urban residence OR¼2.0 [1.3, 3.0] and high in-
come and urban residence OR¼2.0 [1.3, 2.9] in 2007-09).
DISCUSSION
Our analysis of national representative data from South Korea
shows that, between 1998 and 2007-2009, Western-style FF
consumption increased among adults (ie, aged 19 to 65 y),
men, and low-income groups, and SSB consumption at least
doubled, but the overall consumption of Korean-style FF
declined by half. Compared with the low-income and rural
resident group, the high-income and urban resident group
was much more likely to consume Western FF in 1998, but
not in 2007-09. Regardless of income levels, urban residents
were more likely to drink SSBs than were rural residents (by
1.3-3.1 times).
Our findings provide insights for future interventions that
promote healthy eating (eg, which food groups and popula-
tion groups to target) and for future research to examine
differences in local vs Western FF consumption. Most previ-
ous studies, especially US and European studies, have defined
a “fast-food restaurant” as a food service outlet that quickly
serves inexpensive foods with minimal preparation and table
service.20 Some studies have used population-specific defi-
nitions or criteria for FF10,14,24; however, they included only a
few specific foods (eg, beef and mutton soup) as Chinese FF,24
and Kalbas (a kind of sausage) as Iranian FF.14
Korean-local FF is much more popular, less expensive, and
easier to access than Western-style FF in South Korea. We
reaffirmed that Korean FF intakes were not much different
across income levels and residence regions. However, in the
last decade, Korean-style FF consumption has consistently
decreased in proportion of consumers, amount, and energy
intakes. The results may be related to transitions in the
overall Korean diet and eating patterns. Previous Korean
studies showed that intake trends for major food groups (eg,
grains) fell dramatically over the last few decades, whereas a
significant rise in total animal food product intake was
seen.7,8 Korean-style FF comprises high-carbohydrate foods
such as white flour, white rice, and corn starch.
Individuals of different generations may respond differ-
ently to social and economic changes, with the younger
generation adopting new dietary patterns more quickly,
whereas elderly people continue to eat in more traditional
ways.5 Thus, we must rethink and consider strengthening

Table 5. Association between social environmental factors and fast foods (FF) and sugar-sweetened beverage (SSB)
consumption among total population of South Koreans aged
1 years: Korean National Health and Nutrition Examination
Survey (KNHANES) I (1998) and IV (2007-2009)a

Sugar-Sweetened
Western FFb Korean FFc Beveraged
1998 2007-09 1998 2007-09 1998 2007-09
ORe (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Low incomef and rural residence (refg)

High incomef and rural residence 10.1 (1.1, 91.7) 0.8 (0.4, 1.7) 1.1 (0.8, 1.6) 1.6 (1.0, 2.6) 2.0 (1.4, 2.7) 2.0 (1.5, 2.6)
Low incomef and urban residence 17.2 (2.3, 131.7) 1.3 (0.7, 2.4) 1.5 (1.1, 2.0) 2.0 (1.3, 3.0) 1.8 (1.3, 2.5) 1.3 (1.0, 1.7)
High incomef and urban residence 26.7 (3.7, 193.4) 1.2 (0.7, 2.1) 1.3 (1.0, 1.7) 2.0 (1.3, 2.9) 3.1 (2.4, 4.1) 1.7 (1.3, 2.1)
a
Logistic regression models controlled for age, sex, and total energy intake. Low-family income and rural residence was the reference group.
b
The most common, Westernized FF, top sellers at specific FF chains.
c
Korean street foods, instant food products, quick delivery foods.
d
Nonalcoholic drinks containing added sugars.
e
OR¼odds ratio.
f
Quartiles of average household monthly income (monthly household income/number of family members). High income: first quartile; low income: fourth quartile.
g
ref¼reference.

1234 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS July 2018 Volume 118 Number 7

government policies by considering children and adolescents
as a vulnerable group.
Western FF intake has increased in Korean men and adults
aged 19 to 65 years. The consumption among Korean ado-
lescents (aged 12 to 18 years) is the highest among all age
groups. This may be caused by recent changes in Korean
sociocultural environments that lend themselves to more
convenience foods. Young adults and men consumed more FF
than women because they perceived FF as “inexpensive and
economical” and “time-saving,” and they “enjoy the taste.”25
Previously the patterns of FF and soft drink consumption
seen in the United States were predicted to become global
trends.26,27 Our findings support this contention. However,
our findings for South Korea may differ from those for other
Asian countries. For example, FF chains are rapidly expanding
in Chinese cities, but the expansion of these FF chains into
the broader population is still limited.4,28 In 2000, Chinese
children aged 2 to 18 years obtained less than 0.1% of their
energy from FF and soft drinks compared with children in
other countries such as Pilipino children, who obtained
approximately 3% of their energy from FF and soft drinks in
2002.26
A US study based on the 1994-1996 and 1998 Continuing
Survey of Food Intakes by Individuals data showed that 42.2%
of Americans aged 2 years or older reported eating FF on the
survey day.29 In comparison, the rate of eating Western FF on
the survey day was only 4.8% in South Korea in 2007-2009,
but the consumer rate had increased twofold from 1998.
However, energy derived from Western FF has decreased.
Potential explanations include changes in the diets of con-
sumers on the survey day because of high-calorie FF. Further
research is needed to better understand the underlying rea-
sons for this discrepancy.
In our study, SSB intake among South Koreans aged
1 year
significantly increased over a 10þ-year period, a trend that is
similar to findings for many countries.17,30-32 In particular, the
consumption of SSBs has increased greatly in developing
countries, such as India33 and Mexico,17 as they experience
rapid socioeconomic progress. Moreover, India and China
now represent the largest growth markets for soft drink
producers.34 Consumption of SSBs in the United States has
more than doubled since the 1970s; for example, is increased
from 64.4 kcal/day/person in the late 1970s to 141.7 kcal/day/
person in 2006.35 Our results show that energy intakes from
SSBs remain much lower than in the United States (32.0 kcal/
day in 1998 to 81.9 kcal/day in 2007-2009). However, SSB
consumption rates are rising rapidly among South Koreans
regardless of sex, age, and income levels.
Regarding the relationship between SES factors and FF ac-
cess, FF consumption was negatively associated with higher
SES in developed countries such as the United States,18 the
United Kingdom,15 and Canada.16 In developing Asian coun-
tries, however, high-income groups were more likely to
consume Western FF,21 which is consistent with our findings
for 1998. However, we did not find any significant association
in 2007-09, which could be attributable to variations in study
samples, dietary assessment, and data analysis methods. In
addition, it may be because Western FF has become more
common, with increased regional accessibility in rural areas
of South Korea. The regional accessibility of FF restaurants
was associated with a higher body mass index percentile,
which indicates that the presence of nearby FF restaurants is
July 2018 Volume 118 Number 7
RESEARCH
related to increased FF intake.36 Unlike rural residents, urban
residents consumed more Korean-style FF, although the
overall consumption of this FF type has decreased in recent
years. The subjects who live in urban areas can easily pur-
chase or access various street or delivery foods. Many people,
particularly the young working class who live and work in
major urban or metropolitan areas, consume high-calorie
beverages after meals. Therefore, high income and urban
residence should be considered in targeting education pro-
grams to encourage healthful beverage consumption in South
Korea.
Our study has several important strengths. First, we stud-
ied trends in FF and SSB consumption, including Korean-type
FF items, and their association with SEnS. Second, our study
was based on a nationally representative sample in South
Korea, with data ranging over a decade, from 1998 to 2009. In
addition, our analysis took into account the complex sam-
pling design to provide representative estimates. This study
also had several limitations. First, dietary intake was assessed
using a single 24-hour recall, which may not be an accurate
reflection of typical intake. This study calculated as 0 g intake
for those who did not consume FF and SSBs on the surveyed
day. Also, exclusive reliance on self-report data could intro-
duce bias, such as memory bias, or demand characteristics
may have biased our findings because of underreporting,
unreliability, and conversion errors. Second, results may
differ because of FF and SSB definitions. Additional research
should explore whether use of different definitions of FF and
SSBs influence study findings. Moreover, our cross-sectional
study precludes inferences as to causation.
In summary, the proportion of consumers of Western FF
and SSBs on the surveyed day increased regardless of sex, age
groups, and SEnS. Per capita energy consumption from
Western-style FF has increased, especially in men, adults, and
low-income groups. Family income and residence were
strongly associated with consumption of FF and SSBs.
Compared with low-income and rural residents, high-income
urban dwellers were more likely to consume Western FF and
SSBs. Our findings provide useful insights into formulating
intervention strategies and policies to promote healthy eating
and to target high-risk populations in South Korea. In addi-
tion, future longitudinal studies are needed to test direction
of causality between SEnS and consumption of FF and SSBs.
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AUTHOR INFORMATION
H. Lim is an associate professor and R. Choue is a professor, Department of Medical Nutrition, Graduate School of East-West Medical Science,
Kyung Hee University, Republic of Korea, and Research Institute of Medical Nutrition, Kyung Hee University, Republic of Korea. H. J. Lee is an
associate professor, Department of Food and Nutrition, Gachon University, Republic of Korea. Y. Wang is an associate director, Fisher Institute of
Health and Well-being, professor, Department of Nutrition and Health Sciences, and director, Systems-Oriented Global Childhood Obesity
Intervention Program, Fisher Institute of Health and Well-being, Department of Nutrition and Health Sciences, College of Health, Ball State
University, Muncie, IN.
Address correspondence to: Hyunjung Lim, PhD, Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee
University, 1732 Deogyeong-daero, Giheung-gu, Yongin 17104, Republic of Korea. E-mail: hjlim@khu.ac.kr
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
The study was supported in part by Korea Centers for Disease Control & Prevention (No. 2011E3501000) and the US Eunice Kennedy Shriver
National Institute of Child Health & Human Development (NICHD), National Institute of Health (NIH, U54HD070725). The U54 project is co-funded
by the NICHD and the Office of Behavioral and Social Sciences Research (OBSSR).
ACKNOWLEDGEMENTS
We thank the staff at the Korea Centers for Disease Control and Prevention for their assistance and the anonymous reviewers for their comments
and suggestions to improve the study. I thank Hansongyi Lee, PhD, for her great assistance in reviewing the final paper draft.

1236 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS July 2018 Volume 118 Number 7
 RESEARCH

Coding definitions for fast foods and sugar-sweetened beverage categories, KNHANES I to IV: As key outcome variables, two
types of fast foods (FF) and sugar-sweetened beverages (SSBs) are defined as follows:
1) FF type I includes all kinds of hamburgers, pizza, hot dogs, sandwiches, french fries, onion rings, typical chicken nuggets,
and top sellers at specific fast-food chains: McDonald’s, Burger King, Kentucky Fried Chicken, Lotteria (the biggest FF
chain restaurant in Korea), Pizza Hut, and Domino’s Pizza. This comprised 20 items in KNHANES I, 18 items in KNHANES II,
28 items in KNHANES III, and 36 items in KNHANES IV.
2) FF type II includes Korean street foods, instant food products, and quick delivery foods.
a) Street food includes fried foods, spicy rice cakes, fish cakes, and pork blood sausage, and comprised 17 items in
KNHANES I, 29 items in KNHANES II, 14 items in KNHANES III, and 25 items in KNHANES IV.
b) Instant food products include frozen foods, instant noodles, or retort pouch foods, and comprised 27 items in
KNHANES I, 32 items in KNHANES II, 23 items in KNHANES III, and 22 items in KNHANES IV.
c) Quick delivery foods include fried chicken and jajangmyeon (Korean black-bean-sauce noodles) and comprised
eight items in KNHANES I, 12 items in KNHANES II, 12 items in KNHANES III, and 14 items in KNHANES IV.
3) SSBs includes all sodas, fruit drinks, sport drinks, traditional Korean sweetened beverages, sugar-added dairy products,
instant coffee drinks, and other sugar-added beverages (eg, sweetened tea, cocoa, flavored waters).
a) Soda includes all carbonated beverages with added sugar, which comprised 4 items in KNHANES I, 1 item in
KNHANES II, 6 items in KNHANES III, and 7 items in KNHANES IV.
b) Fruit drinks include all fruit drinks, fruit juices, fruit nectar, and fruit punch with added sugar. This comprised 16
items in KNHANES I, 16 items in KNHANES II, 23 items in KNHANES III, and 27 items in KNHANES IV.
c) Sport drinks and mineral water include all drinks labeled Gatoradea, Pocari Sweatb, Poweradec, or thirst quencher.
This comprised 1 item in KNHANES I, 7 items in KNHANES II, 7 items in KNHANES III, and 5 items in KNHANES IV.
d) Traditional Korean sweetened beverages include beverages made with rice, roasted grain powders, or oriental herb
extracts. This comprised 8 items in KNHANES I, 10 items in KNHANES II, 15 items in KNHANES III, and 9 items in
KNHANES IV.
e) Sugar-added dairy products include flavored milk, yogurt, or soymilk and consisted of 5 items in KNHANES I, 5
items in KNHANES II, 3 items in KNHANES III, and 6 items in KNHANES IV.
f) Instant coffee drinks include coffee mix and canned coffee and exclude brewed coffee. This comprised 6 items in
KNHANES I, 4 items in KNHANES II, 8 items in KNHANES III, and 5 items in KNHANES IV.
g) Other sugar-added beverages include sweetened tea, cocoa, and flavored waters, which comprised 7 items in
KNHANES I, 7 items in KNHANES II, 16 items in KNHANES III, and 9 items in KNHANES IV.
a
PepsiCo.
b
Otsuka Pharmaceutical.
c
The Coca-Cola Company.
Figure. Coding definitions for fast foods and sugar-sweetened beverage categories, Korean National Health and Nutrition Exam-
ination Surveys (KNHANES) I to IV.

July 2018 Volume 118 Number 7 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1236.e1