Shared Genetic Etiology of Hwabyung (Anger Syndrome) and Somatization Symptoms in South Korean Adolescent and Young Adult Twins.

Somatization is known to be more prevalent in Asian than in Western populations. Using a South Korean adolescent and young adult twin sample (N = 1754; 367 monozygotic male, 173 dizygotic male, 681 monozygotic female, 274 dizygotic female and 259 opposite-sex dizygotic twins), the present study aimed to estimate heritability of somatization and to determine common genetic and environmental influences on somatization and hwabyung (HB: anger syndrome). Twins completed self-report questionnaires of the HB symptoms scale and the somatization scale via a telephone interview. The results of the general sex-limitation model showed that 43% (95% CI [36, 50]) of the total variance of somatization was attributable to additive genetic factors, with the remaining variance, 57% (95% CI [50, 64]), being due to individual-specific environmental influences, including measurement error. These estimates were not significantly different between the two sexes. The phenotypic correlation between HB and somatization was .53 (p < .001). The bivariate model-fitting analyses revealed that the genetic correlation between the two symptoms was .68 (95% CI [.59, .77]), while the individual-specific environmental correlation, including correlated measurement error, was .41 (95% CI [.34, .48]). Of the additive genetic factors of 43% that influence somatization, approximately half (20%) were associated with those related to HB, with the remainder being due to genes unique to somatization. A substantial part (48%) of individual environmental variance in somatization was unrelated to HB; only 9% of the environmental variance was shared with HB. Our findings suggest that HB and somatization have shared genetic etiology, but environmental factors that precipitate the development of HB and somatization may be largely independent from each other.

Heritability of Age at Menarche in South Korean Female Twins.

Genetic and environmental influences on age at menarche (AAM) have rarely been examined in Asian females. This study aimed to investigate the heritability of AAM in South Korean female twins. The AAM data from 1370 female twins (933 monozygotic [MZ] twins, 294 dizygotic [DZ] twins and 160 female members of opposite-sex DZ twins) born between 1988 and 2001 were analyzed. The age of the sample at the time of the assessment ranged from 16 to 28 years with a mean of 19.3 (SD = 2.2) years. The mean AAM in the total sample was 12.49 (SD = 1.41) years. Although the mean AAM decreased with increasing birth years, it levelled off in birth years 2000-2001. Maximum likelihood MZ and DZ twin correlations were 0.72 [95% CI (0.67, 0.76)] and 0.35 [95% CI (0.19, 0.50)], respectively. The results of model-fitting analysis indicated that the additive genetic and individual-specific environmental effects were 72% [95% CI (67%, 76%)] and 28% [95% CI (24%, 33%)], respectively. Neither nonadditive genetic nor shared environmental effects were significant.

Genetic and Environmental Overlaps Among Sasang Constitution Types: A Multivariate Twin Study.

According to the Sasang theory, humans can be categorized into one of the four Sasang constitution (SC) types. The four SC types are Tae-Yang (TY), Tae-Eum (TE), So-Yang (SY), and So-Eum (SE), which are determined mainly on the basis of anthropometric characteristics, personality, and the balance of the physiological functions of the major organ systems. There is a growing recognition in the complementary and alternative medicine area that SC types have the potential to be a useful scientific tool for the prevention, diagnosis, and treatment of diseases (Cooper, Evidence Based Complementary and Alternative Medicine, Vol. 6 (Suppl. 1), 2009, pp. 1-3). The main purposes of the present study are to estimate genetic and environmental influences on SC types, and to explore genetic and environmental correlations that affect phenotypic associations among the SC types. In total, 1,742 (365 monozygotic male, 173 dizygotic male, 675 monozygotic female, 271 dizygotic female, and 258 opposite-sex dizygotic) twins (mean age = 19.1 ± 3.1 year) completed a Sasang questionnaire. Univariate and multivariate model-fitting analyses were performed. Total (additive and non-additive) genetic influences were 71% for males and 81% for females in TE, 70% for males and 71% for females in SE, and 47% for both sexes in SY. Non-additive genetic effects were substantial, and shared environmental influences were negligible in most SC types. Multivariate model-fitting analysis revealed that non-additive genetic and individual-specific environmental correlations between TE and SE were -0.92 (95% CI [-0.89, -0.93]) and -0.62 (95% CI [-0.57, -0.68]), respectively. The corresponding estimates were -0.55 (95% CI [-0.48, -0.61]) and -0.44 (95% CI [-0.37, -0.51]) between TE and SY and 0.19 (95% CI [0.09, 0.29]) and -0.40 (95% CI [-0.32, -0.47]) between SE and SY. These results suggest that the phenotypic associations among SC types may be mediated by pleiotropic mechanism of genes.

Etiologies of the Relationships Among Body Mass Index and Cold-Heat Patterns: A Twin Study.

The phenotypic relationships between body mass index (BMI) and cold-heat patterns have been frequently reported, but the etiology of these relationships remains unknown. We previously demonstrated that the cold pattern (CP) and the heat pattern (HP) were heritable traits. In the present study, we explored underlying genetic and environmental structures of the relationships among BMI and the CP and the HP. Twins (N = 1,752) drawn from the South Korean twin registry completed a cold-heat pattern questionnaire via a telephone interview. The phenotypic correlations among the three phenotypes were moderate but significant. Cross-twin, cross-trait correlations among BMI and the CP and the HP were consistently greater in monozygotic than in dizygotic twins, suggesting the presence of genetic effects on the relationships between BMI and the two patterns. A trivariate Cholesky model was applied to the raw data. The results indicated that the phenotypic relationship between the HP and BMI was completely determined by common genetic influences, while the relationship between the CP and BMI was explained by both common genetic and common individual-specific environmental influences. The genetic correlation between the HP and the CP was not significant, suggesting that the two patterns may be genetically independent from each other. Genetic correlations were 0.31 between the HP and BMI, and -0.22 between the CP and BMI. The individual-specific environmental correlation was -0.22 between HP and CP, and between CP and BMI.

Heritability of Cold and Heat Patterns: A Twin Study.

In traditional East Asian medicine, cold-heat patterns have been widely used in the diagnosis and treatment of patients suffering from various diseases. The present study aimed to estimate the heritability of cold-heat patterns. Trained interviewers administered a cold-heat pattern questionnaire to 1,753 twins (mean age = 19.1 ± 3.1 years) recruited throughout South Korea. Correlations for the cold pattern (CP) were 0.42 (95% CI [0.28, 0.54]) for monozygotic (MZ) males, 0.16 (95% CI [-0.08, 0.39]) for dizygotic (DZ) males, 0.40 (95% CI [0.30, 0.49]) for MZ females, 0.30 (95% CI [0.12, 0.45]) for DZ females, and 0.07 (95% CI [-0.11, 0.25]) for opposite-sex DZ twins. The corresponding twin correlations for the heat pattern (HP) were 0.38 (95% CI [0.24, 0.51]), -0.22 (95% CI [-0.43, 0.02]), 0.34 (95% CI [0.24, 0.43]), 0.21 (95% CI [0.03, 0.37]), and 0.08 (95% CI [-0.10, 0.26]), respectively. These patterns of twin correlations suggested significant genetic effects on the HP and the CP. Model-fitting analysis revealed that heritability estimates in both sexes were 40% (95% CI [38, 42]) for the CP and 33% (95% CI [25, 42]) for the HP, with the remaining variances attributable to unique environmental variances. These estimates did not vary significantly with age during adolescence and young adulthood.

Heritability of Hwabyung Symptoms in South Korean Adolescent and Young Adult Twins.

The present study aimed to estimate heritability of Hwabyung (HB) symptoms in adolescent and young adult twins in South Korea. The sample included 1,601 twins consisting of 143 pairs of monozygotic male (MZM), 67 pairs of dizygotic male (DZM), 295 pairs of monozygotic female (MZF), 114 pairs of dizygotic female (DZF), and 117 pairs of opposite-sex dizygotic (OSDZ) twins and 129 twins with non-participating co-twins (mean age = 19.1 ± 3.1 years; range: 12-29 years). An HB symptom questionnaire was given to twins via a telephone interview. Consistent with the literature of HB, the mean level of HB was significantly higher in females than in males. Maximum likelihood twin correlations for HB were 0.31 (95% CI [0.16, 0.45]) for MZM, 0.19 (95% CI [-0.05, 0.41]) for DZM, 0.50 (95% CI [0.41, 0.58]) for MZF, 0.28 (95% CI [0.11, 0.44]) for DZF, and 0.23 (95% CI [0.05, 0.40]) for OSDZ twins. These patterns of twin correlations suggested the presence of additive genetic influences on HB. Model-fitting analysis showed that additive genetic and individual-specific environmental influences on HB were 44% (95% CI [37, 51]) and 56% (95% CI [49, 63]), respectively. Shared environmental influences were not significant. These parameter estimates were not significantly different between two sexes, and did not change significantly with age in the present sample, suggesting that genetic and environmental influences on HB in both sexes are stable across adolescence and young adulthood.

Constitutional multicenter bank linked to Sasang constitutional phenotypic data.

BACKGROUND: Biobanks are more important in medical area because they can give researchers data for demonstrating and validating their research. In this study, we developed a biobank called the Korea Constitutional Multicenter Bank (KCMB) based on Sasang Constitutional Medicine (SCM). The aim of the KCMB was a foundation to providing the scientific basis of SCM. METHODS: The KCMB has been constructed since 2006 in 24 Korean medical clinics with collection of questionnaire data, physical measurements and biological information comprised the results from blood test and DNA analyses. All participants were prescribed Sasang Constitution (SC)-specific herbal remedies for the treatment, and showed improvement of original symptoms as confirmed by Korean medicine doctor. Collected data went through de-identification process using the electronic case report form system. For calculation of several SC type specific tendencies, we used the direct standardization and Chi-square tests. RESULTS: The KCMB collected clinical information from 3,711 study participants (1,353 men and 2,358 women) aged more than 10 years. The mean age (± standard deviation) was 47.1 (±16.6) and 47.7 (±15.8) years for men and women respectively. After applying the direct standardization, the estimated constitutional distributions for the SC types were as follows: 39.2% for Tae-eumin(TE), 27.1% for Soeumin(SE), 33.7% for Soyangyin(SY), and non-zero but below 0.1% for Taeyangyin(TY). The estimated distribution of TE was about 10% less, while that of SY and SE were slightly more than the distribution reported by Jema Lee established the SCM. Based on the participants' medical history within the KCMB, each SC type had notably different frequencies for some diseases such as hypertension, diabetes, hyperlipidemia, stroke, and obesity (P < 0.001). CONCLUSIONS: The KCMB may serve to verify and validate SCM theories and practices. It may also provide new insights into SCM mechanisms. The results from many studies using the KCMB data are of great importance and value for making decisions in healthcare policy and developing novel therapies.

Exploring Stroke Risk through Mendelian Randomization: A Comprehensive Study Integrating Genetics and Metabolic Traits in the Korean Population.

Numerous risk factors play a role in the causation of stroke, and the cardiometabolic condition is a one of the most important. In Korea, various treatment methods are employed based on the constitutional type, which is known to differ significantly in cardiometabolic disease. In this study, we compared the estimates obtained for different groups by applying the Mendelian randomization method to investigate the causal effects of genetic characteristics on stroke, according to constitutional type. In clinical analysis, the subtypes differ significantly in diabetes or dyslipidemia. The genetic association estimates for the stroke subtype risk were obtained from MEGASTROKE, the International Stroke Genetics Consortium (ISGC), UKbiobank, and BioBank Japan (BBJ), using group-related SNPs as instrumental variables. The TE subtypes with higher risk of metabolic disease were associated with increased risk (beta = 4.190; s.e. = 1.807; p = 0.035) of cardioembolic stroke (CES), and the SE subtypes were associated with decreased risk (beta = -9.336, s.e. = 1.753; p = 3.87 × 10-5) of CES. The findings highlight the importance of personalized medicine in assessing disease risk based on an individual's constitutional type.

Gut microbiome and metabolic pathways linked to sleep quality.

Sleep quality is a vital determinant of human health as sleep disorders are associated with cognitive deficits, and chronic sleep deprivation is associated with a broad range of health complications. Previous studies on the association between the gut microbiome and sleep quality have been constrained by small sample sizes or have focused on specific sleep disorders, thus yielding inconsistent results. Herein, we investigated the relationship between microbial composition and sleep quality in a cohort of 159 Koreans. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), determined through a self-administered questionnaire. Gut microbiome analyses were performed using 16S rRNA amplicons. We found no direct correlation between microbial alpha diversity metrics and sleep; however, we identified differences in beta diversity among sleep quality groups (with a PSQI score > 5 indicating poor sleep quality and PSQI ≤5 indicating good sleep quality). We also found differential microbial signatures (Bacteroides, Prevotella 9, and Faecalibacterium) among the groups. Furthermore, functional metabolic pathway profiles revealed significant linear correlations of the L-arginine and L-tryptophan biosynthetic pathways as well as 4-aminobutanoate degradation with sleep status. In particular, Faecalibacterium prausnitzii, which harbors these metabolic pathways, showed differences between sleep quality groups and a linear association with sleep quality scores and was thus identified as the species most strongly associated with sleep status. This study provides a significant advance in our understanding of the relationship between gut microbiota and sleep regulation. The current findings provide a basis for further research into potential therapeutic strategies for sleep disorders targeting the gut microbiome.

Elevated prevalence and treatment of sleep disorders from 2011 to 2020: a nationwide population-based retrospective cohort study in Korea.

OBJECTIVES: This study used National Health Insurance claims data from Korea to report the prevalence of sleep disorders and treatment status, including traditional Korean medicine, in the last 10 years. METHODS: This is a retrospective cohort study in Korea. All diagnosis and prescription data, including herbal medicine claims, from the Health Insurance Review and Assessment Service from 2011 to 2020 were reviewed. Prevalence estimation, direct medical expenses and prescribed amounts for sleep disorders were recorded. RESULTS: The prevalence of sleep disorders increased from 3 867 975 (7.62%) in 2011 to 7 446 846 (14.41%) in 2020, nearly doubling over 10 years. Insomnia was observed in 91.44% (n=9 011 692) of the patients. The mean number of hospital visits per patient for sleep disorders was 11.5 (±26.62). Benzodiazepines are the most commonly prescribed medications for sleep disorders, and gamma-isoyosan is the most frequently prescribed herbal medicine. CONCLUSIONS: Sleep disorders are continuously increasing, as is the use of medical services-personal and social medical expenses are also increasing accordingly. Sleep disorders should be recognised as a significant health problem that needs to be actively addressed to improve quality of life.

Characteristics of insulin resistance in Korean adults from the perspective of circadian and metabolic sensing genes.

BACKGROUND: The biological clock allows an organism to anticipate periodic environmental changes and adjust its physiology and behavior accordingly. OBJECTIVE: This retrospective cross-sectional study examined circadian gene polymorphisms and clinical characteristics associated with insulin resistance (IR). METHODS: We analyzed data from 1,404 Korean adults aged 30 to 55 with no history of cancer and cardio-cerebrovascular disease. The population was classified according to sex and homeostasis model assessment of insulin resistance (HOMA-IR) values. Demographics, anthropometric and clinical characteristics, and single nucleotide polymorphisms (SNPs) were analyzed with respect to sex, age, and HOMA-IR values. We used association rule mining to identify sets of SNPs from circadian and metabolic sensing genes that may be associated with IR. RESULTS: Among the subjects, 15.0% of 960 women and 24.3% of 444 men had HOMA-IR values above 2. Most of the parameters differed significantly between men and women, as well as between the groups with high and low insulin sensitivity. Body fat mass of the trunk, which was significantly higher in insulin-resistant groups, had a higher correlation with high sensitivity C-reactive protein and hemoglobin levels in women, and alanine aminotransferase and aspartate aminotransferase levels in men. Homozygous minor allele genotype sets of SNPs rs17031578 and rs228669 in the PER3 gene could be more frequently found among women with HOMA-IR values above 2 (p = .014). CONCLUSION: Oxidative stress enhanced by adiposity and iron overload, which may also be linked to NRF2 and PER3-related pathways, is related to IR in adulthood. However, due to the small population size in this study, more research is needed.

Supplementary data for genome-wide DNA methylation and gene expression analysis of PBMCs in patients with metabolic syndrome.

This supplementary data supports the research article 'Genome-wide DNA methylation profiling reveals candidate biomarkers and probable molecular mechanism of metabolic syndrome' (Baek et al., in press). To obtain these data, 32 participants with metabolic syndrome (MetS) were enrolled in the associated study. We collected peripheral blood mononuclear cells (PBMCs) from 11 patients with MetS and nine controls and compared genome-wide gene expression and DNA methylation signatures. The remaining 12 participants were used for the experimental validation of the candidate groups. We provide the raw, analyzed, and filtered genome-wide DNA methylation data, obtained using the Infinium Human MethylationEPIC BeadChIP array, and whole transcriptome sequencing data (accession number GSE181647). We list the differentially expressed and differentially methylated genes and their biological functions. These data can serve as a basis for screening appropriate epigenetic biomarkers for MetS.

Regulation of CIRP by genetic factors of SP1 related to cold sensitivity.

Cold-inducible RNA-binding-protein (CIRP) is a cold shock protein that plays a protective role in genotoxic stress response. CIRP modulates inflammation in human diseases, inhibits cell proliferation, and protects cells from genotoxic damage during cellular stress. The mild cold responsive element and specificity protein 1 (SP1) play a role in Cirp expression at low temperatures. Although previous studies have provided insights into the immune functions of SP1 or CIRP, the mechanisms by which CIRP and SP1 me diate inflammatory responses remain largely unknown. Therefore, in the current study, we examined whether Cirp expression is affected by genetic factors related to temperature sensitivity as well as under low temperature. We performed a genome-wide association study on cold sensitivity in 2,000 participants. Fifty-six genome-wide significant trait-locus pairs were identified (p<1×10-5, false discovery rate < 0.05). Among these variants, rs1117050 and rs11170510 had a strong linkage disequilibrium (r2 > 0.8) relationship and expression quantitative trait locus-associated signals with the nearest Sp1 gene. We confirmed that the minor alleles of rs11170510 and rs58123204 were associated with increased Sp1 expression. Additionally, Sp1 overexpression led to CIRP translocation from the nucleus to the cytoplasm. CIRP protein levels increased in serum samples that had minor alleles of rs11170510 and rs58123204. Levels of various pro-inflammatory cytokines were also significantly increased in human peripheral blood mononuclear cells with minor alleles of rs11170510 and rs58123204. These results suggest that genetic factors related to cold sensitivity regulate CIRP expression and function and provide valuable insights into prediction of potential diseases through analysis of inherent genetic factors in humans.

Systematic Analysis of the Molecular Mechanisms of Cold and Hot Properties of Herbal Medicines.

Effective treatments for patients experiencing temperature-related symptoms are limited. The hot and cold effects of traditional herbal medicines have been utilized to treat and manage these symptoms, but their molecular mechanisms are not fully understood. Previous studies with arbitrarily selected herbs and ingredients may have produced biased results. Here, we aim to systematically elucidate the molecular mechanisms of the hot and cold properties of herbal medicines through an unbiased large-scale investigation of herbal ingredients, their target genes, and the transcriptome signatures induced by them. Using data regarding 243 herbs retrieved from two herbal medicine databases, we statistically identify (R)-Linalool, (-)-alpha-pinene, peruviol, (L)-alpha-terpineol, and cymol as five new hot-specific ingredients that share a common target, a norepinephrine transporter. However, no significant ingredients are cold-specific. We also statistically identify 14 hot- and 8 cold-specific new target genes. Pathway enrichment analysis of hot-specific target genes reveals the associated pathways including neurotransmitter reuptake, cold-induced thermogenesis, blood pressure regulation, adrenergic receptor signaling, and cation symporter activity. Cold-specific target genes are associated with the steroid pathway. Transcriptome analysis also shows that hot herbs are more strongly associated with coagulation and synaptic transmission than cold herbs. Our results, obtained from novel connections between herbal ingredients, target genes, and pathways, may contribute to the development of pharmacological treatment strategies for temperature-related pain using medicinal plants.

Feasibility and Effectiveness of Assessing Subhealth Using a Mobile Health Management App (MibyeongBogam) in Early Middle-Aged Koreans: Randomized Controlled Trial.

BACKGROUND: Mobile health (mHealth) is a major source of health management systems. Moreover, the demand for mHealth, which is in need of change due to the COVID-19 pandemic, is increasing worldwide. Accordingly, interest in health care in everyday life and the importance of mHealth are growing. OBJECTIVE: We developed the MibyeongBogam (MBBG) app that evaluates the user's subhealth status via a smartphone and provides a health management method based on that user's subhealth status for use in everyday life. Subhealth is defined as a state in which the capacity to recover to a healthy state is diminished, but without the presence of clinical disease. The objective of this study was to compare the awareness and status of subhealth after the use of the MBBG app between intervention and control groups, and to evaluate the app's practicality. METHODS: This study was a prospective, open-label, parallel group, randomized controlled trial. The study was conducted at two hospitals in Korea with 150 healthy people in their 30s and 40s, at a 1:1 allocation ratio. Participants visited the hospital three times as follows: preintervention, intermediate visit 6 weeks after the intervention, and final visit 12 weeks after the intervention. Key endpoints were measured at the first visit before the intervention and at 12 weeks after the intervention. The primary outcome was the awareness of subhealth, and the secondary outcomes were subhealth status, health-promoting behaviors, and motivation to engage in healthy behaviors. RESULTS: The primary outcome, subhealth awareness, tended to slightly increase for both groups after the uncompensated intervention, but there was no significant difference in the score between the two groups (intervention group: mean 23.69, SD 0.25 vs control group: mean 23.1, SD 0.25; P=.09). In the case of secondary outcomes, only some variables of the subhealth status showed significant differences between the two groups after the intervention, and the intervention group showed an improvement in the total scores of subhealth (P=.03), sleep disturbance (P=.02), depression (P=.003), anger (P=.01), and anxiety symptoms (P=.009) compared with the control group. CONCLUSIONS: In this study, the MBBG app showed potential for improving the health, especially with regard to sleep disturbance and depression, of individuals without particular health problems. However, the effects of the app on subhealth awareness and health-promoting behaviors were not clearly evaluated. Therefore, further studies to assess improvements in health after the use of personalized health management programs provided by the MBBG app are needed. The MBBG app may be useful for members of the general public, who are not diagnosed with a disease but are unable to lead an optimal daily life due to discomfort, to seek strategies that can improve their health. TRIAL REGISTRATION: Clinical Research Information Service KCT0003488; https://cris.nih.go.kr/cris/search/search_result_st01.jsp?seq=14379.

Perception on genetic testing in Korean medicine doctors: A mobile-based survey.

BACKGROUND: Currently, genetic testing is widely used to understand individual characteristics. In Korea, genetic testing has been in use, but not actively in Korean Medicine (KM). To examine the perceptions of genetic testing, we performed online survey to Korean Medicine doctors (KMDs). METHODS: The survey was a mobile-based study that was developed by 6 survey specialists based on electronic database search results. The questionnaire consisted of 6 categories: general characteristics of respondents, understanding of genetic testing, demand for using genetic testing, application field and utilization level of genetic testing, limitations of genetic testing, and plans and necessary efforts to begin using genetic testing based on an 11-point Likert scale. RESULTS: With the response rate of 27.2% (n = 544), 46.9% of respondents answered that they understood the definition and mechanism of genetic testing. About 80% of KMDs responded that they would be willing to use genetic testing results; a notable reason for this was the need for more objective and evidence-based test results. KMDs recognized that genetic testing could not only provide personalized treatment and care, but also help communicate with patients. CONCLUSIONS: This study observed KMDs' perceptions of the potential clinical benefits of genetic testing. We confirmed that development of genetic testing technology, knowledge of their use, and new technology-friendly policies are essential for expanding the genetic testing technology in Korean medicine.

Corrigendum to "Physiological indices for the categorization of Mibyeong severity" [Integr. Med. Res. 2017; 6: 88-92].

[This corrects the article DOI: 10.1016/j.imr.2017.01.005.].

Factors Affecting Health-promoting Behavior of Nurses in Small and Medium-sized Hospitals based on the IMB Model / 재활간호학회지

Purpose@#The purpose of this study is to identify e-health literacy, job-esteem, self-efficacy and health promoting behaviors and to identify affecting the health promoting behaviors among of nurses in small and medium-sized hospital based on the IMB Model. @*Methods@#The research design for this study was a descriptive survey using convenience sampling. Data collection was done using online questionnaires completed by 121 nurses in small and medium-sized hospital in D,C and S cities. The data were analyzed using percentage, mean, standard deviation, t-test, ANOVA, Scheffé ́ test, Pearson correlation analysis and hierarchical multiple regression with the SPSS/WIN 23.0 Program. @*Results@#The mean score of health promoting behaviors was 3.65±0.55 out of a possible 5. Health promoting behaviors showed a significantly positive correlation with e-health literacy (r=.39, p<.001), job-esteem (r=.62, p<.001) and self-efficacy (r=.31, p=.001). In the hierarchical multiple regression analysis, job-esteem (β=.47, p<.001), self-efficacy (β=.18, p=.010) and e-health literacy (β=.15, p=.049) were significant predictors and explained 44% of health promoting behaiviors. @*Conclusion@#The results of the study showed factors that influence health promoting behaviors in nurses in small and medium-sized hospital. Based on the results of the study, health promoting behaviors improvement program need to include factors that e-health literacy, job-esteem and self-efficacy.