Nutrition Reviews

Miyazawa,, Teruo

doi: 10.1093/nutrit/nuaa066pmid: 33259612

The International Life Science Institute of Japan (ILSI Japan) was established in 1981 as the Japanese branch of the ILSI, whose headquarters are located in Washington DC. Since ILSI Japan organized its first international conference on nutrition and aging in 1991, we have held a series of conferences on the same topic every 4 years in Japan. The 8th International Conference on Nutrition and Aging aimed to explore ways to realize an “extension of healthy life expectancy” through the fields of nutrition and aging, in Japan, a country with a super-aged society. This reflected the “extension of healthy life expectancy and reduction of health disparities” proposed in the “Health Japan 21 (second term) program,” released in 2012 by the Ministry of Health, Labor, and Welfare, as well as the Sustainable Development Goals proposed in the “2030 Agenda for Sustainable Development” and adopted at the United Nations summit in 2015. Through this conference, we hoped to contribute to other Asian countries and ultimately to all other countries around the world. The first session of this conference reviewed research on nutrition and aging over the last 30 years. We also considered the current situation regarding “Health Japan 21,” which has been promoted by the government, and made international comparisons. The second session presented a summary of the findings of 3 ILSI Japan activities: the Healthful Diet Research Committee, the University of Tokyo endowed-chair research project “Functional Food Genomics,” and the Symposium on Sports Science and Nutrition. In the third session, under the theme “Future of healthcare by precision nutrition,” we discussed new technologies such as artificial intelligence and big data, as well as the current research on diet, nutrition, and exercise using data sciences and their social implementation. Investigators using human health big data and artificial intelligence analysis (bioinformatics) also introduced their cutting-edge research on the diversity of human beings and precision nutrition. Originally, the “Nutrition Summit” was to be held in 2020, the same year as the Tokyo Olympics and Paralympics. The timing of this summit, however, is now being reconsidered owing to the postponing of the Tokyo Olympics and Paralympics. According to the Global Monitoring Frame on Noncommunicable Diseases, developed as a follow-up of the Political Declaration on Noncommunicable Diseases, the World Health Organization aims to achieve 3 universal goals by 2025, namely (1) to control the rise of diabetes and obesity, (2) to reduce relative salt intake by 30%, and (3) to reduce the relative prevalence of increased blood pressure by 25%. I am currently serving as the president of the Federation of Asian Nutrition Societies (FANS) and will shift the focus to the upcoming International Union of Nutritional Science-International Congress of Nutrition (the 22nd IUNS-ICN, Tokyo 2021). Having taken part in these conferences, I can clearly see that the nutritionists in Asia are paying close attention to the changes in the Japanese diet during the super-aging of our society. It is expected that this conference will contribute to the development of a nutritional science that can cope with the population increase and aging in Asia, where approximately half of the world population resides, as well as with the food industry by showing possible steps the industry can take toward the future. I sincerely hope that all the discussion during this conference will be fruitful and will lead to solutions for the issues surrounding nutrition and aging in Asia and across the world. Lastly, I would like to express my sincere thanks to Mr. Takuji Yasukawa, the President of ILSI Japan, and Mr. Hideyo Nakamura, the executive director of ILSI Japan, for their strong support for organizing the 8th International Conference on Nutrition and Aging and the Proceedings publication. Chairman of the ILSI Japan, and Chairman of the organizing committee and program committee for the 8th International conference on Nutrition and Aging held on October 1st and 2nd 2019 © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Akiyama,, Hiroko

doi: 10.1093/nutrit/nuaa084pmid: 33259619

Abstract Population aging is a global phenomenon, and Japan is one of the front-runners of rapidly aging societies. In 2030, one-third of the Japanese population will be at least 65 years of age and 20% will be at least 75 years of age. The working age population is shrinking. Healthy aging is a crucial issue for both individual well-being and the sustainability of society. Along with biomedical research, the importance of the living environment and lifestyle has been long recognized and extensively studied. The issues have been identified and now it is time to establish solutions and actions – action-targeted research. The Institute of Gerontology at the University of Tokyo launched a social experiment, redesigning existing communities where people could live for 100 years and remain healthy, active, and connected, while still maintaining a sense of security. This requires co-creation by citizens, researchers, government, and industry. The ultimate goal is to make linkages among longevity, health, and wealth, and to build a sustainable society. action research, co-creation, redesigning community, sustainability Population aging is a global phenomenon, and Japan is one of the front-runners of rapidly aging societies. The average life expectancy of Japanese men and women is now 81 years and 87 years, respectively. The current total fertility rate is 1.43. As a result, 28% of the Japanese population – 1 in 4 persons in Japan – is aged 65 years or older. In 2030, one-third of the Japanese population will be at least 65 years of age. The number of people aged 75 years or older is expected to increase drastically. This segment of the population will double in the next 11 years and account for 20% of the total population in 2030 (Figure 1).1–3 By 2055, this segment of the population will account for 27% of the total population. Figure 1 Open in new tabDownload slide Projected drastic increase of older-old subjects (age 75+) in Japan. Figure 1 Open in new tabDownload slide Projected drastic increase of older-old subjects (age 75+) in Japan. The working age population is shrinking. In 1965, >50 years ago, there were 9.1 persons to support 1 older person. Now, the ratio is 2.4:1, and this is expected to approach 1:1 in 2050. Obviously, the social security system cannot be sustained. In 2030, it is predicted that 20% of the population aged 65 years or older will have dementia and 45% will be living alone (Figure 2). This is a new phenomenon in Japan and in Asia in general. Figure 2 Open in new tabDownload slide Demographic shift and new needs (2030). Figure 2 Open in new tabDownload slide Demographic shift and new needs (2030). On the basis of limitations in activities of daily living (ADLs) and independent activities of daily living (IADLs), changes in independent living were tracked with increasing age, termed functional independence, a key concept of the World Health Organization definition of healthy aging. The scoring ranged from 3 to 0, as follows: 3 = no ADL and IADL limitations; 2 = no ADL limitations, but requiring assistance for IADL; 1 = assistance required for both ADL and IADL; 0 = death (Figure 3). Figure 3 Open in new tabDownload slide Measures of independent living. Abbreviations: ADL, activities of daily living; IADL, independent activities of daily living Figure 3 Open in new tabDownload slide Measures of independent living. Abbreviations: ADL, activities of daily living; IADL, independent activities of daily living One latent class analysis model revealed 3 typical health change patterns among men (Figure 4).4 Particular attention should be paid to the gradual decline line in Figure 4. The majority of men (70%) remained functionally independent until their mid-70s and then their health gradually declined and they began to require some assistance. There is a similar graph for women. Approximately 70% of men and 90% of women – altogether, 80% of Japanese older persons – begin to lose their physical independence in their mid-70s. This segment of the population will double over the next 11 years. So, these trajectories pose a serious problem. Figure 4 Open in new tabDownload slide Trajectories of independent living. Figure 4 Open in new tabDownload slide Trajectories of independent living. The academic community can make contributions mainly in 3 areas: biomedical research, improving the living environment, and improving each individual’s lifestyle. Universities and other research institutions are the main force in biomedical research. Biomedical research is obviously a very important and rapidly evolving field, but additionally, a great deal of research on the living environment and individual lifestyles has accumulated. Current success in actually improving the living environment and individual lifestyles, however, remains limited. For example, the annual health checkup rate of nonworking women in Japan is less than 20%. Although smoking prevalence is declining, sitting has emerged as an independent risk factor for health, and this risk factor is increasing steeply. Problems with diet and sleep are widespread and show little sign of improving. The specific issues that need to be addressed to improve the living environment and individual lifestyles have been identified. Now solutions and actions must be established. Action-targeted research from the academic community is one viable approach. The purpose of action-targeted research is to solve a particular problem and to produce guidelines for best practices. It is a participatory research in collaboration involving multiple stakeholders, such as the government, industry, various organizations (eg, nonprofit organizations), physicians’ associations, and certainly citizens. It requires a spiral of steps, each step comprising a PDCA (“plan, do, check, and adjust”) cycle – in this case, planning, action, evaluation of the results of the action, and adjustment. Universities can offer a platform for action-targeted research. The collaboration of multiple stakeholders who jointly seek solutions to a particular issue will provide a platform for open innovations. Action-targeted research is a promising method, but it is still in the formative stage. Additional work is needed to further develop action-targeted research as a rigorous scientific research method. To address various issues in the living environment, the Institute of Gerontology at the University of Tokyo launched a social experiment within a community (https://www.u-tokyo.ac.jp/focus/en/features/f_00048.html). As the existing community infrastructure was built when the population was much younger, both the hard and soft community infrastructures must now be redesigned to meet the needs of a highly aged society. In other words, communities should be built in which people can live for 100 years and remain healthy, active, and connected, while still maintaining a sense of security. This is not a retirement community, but rather, an ordinary community for people of all ages. As this was a social experiment, it was envisaged that the effects and costs of the interventions would be evaluated at both the individual and community level and that the policy should then be recommended based on scientific evidence. Many scientific and social innovations were required. A metropolitan area 30 km from Tokyo and a rural area were selected as the experimental sites. Two quite ordinary communities were chosen to serve as examples upon which other areas could redesign their communities. Here, several projects in an urban community in Kashiwa are introduced. The first project was to design workplaces for those in the Second Life. “Live longer, Work longer” is the title of the report by the Organisation for Economic Co-operation and Development (OECD) published in 2006. People not only live longer now, but also more healthily. Figure 5 compares the usual walking speed of people in the same age groups, between 1992 and 2002. It shows that older persons in 2002 were 11 years younger, in terms of walking speed, than their counterparts in 1992 (Figure 5).5 In other words, a 75-year-old person in 2002 was found to walk at the same speed as a 64-year-old person did in 1992. Three years ago, the Japan Gerontological Society made an official pronouncement to raise the definition of old age from 65 to 75 years old.6 Figure 5 Open in new tabDownload slide Change in walking speed between 1992 and 2002. Figure 5 Open in new tabDownload slide Change in walking speed between 1992 and 2002. Two years ago, a survey was conducted that asked 5000 people aged 50–64 years what they wanted to do after age 65 (Figure 6).7 First, over half of the respondents indicated that they would like to continue working full-time or part-time. Second, more than half the respondents indicated that they would like to continue learning. Figure 7 shows a graph from a report published by the Ministry of Health, Labour and Welfare. It shows a moderate correlation between the labor participation rate of seniors (65+ years) and their medical care expenditure.8 Figure 6 Open in new tabDownload slide Survey of act7. Figure 6 Open in new tabDownload slide Survey of act7. Figure 7 Open in new tabDownload slide Labor force participation rate and health expenditure by prefecture (age 65+). Data from the Ministry of Health, Labour and Welfare; Statistics Bureau1 Figure 7 Open in new tabDownload slide Labor force participation rate and health expenditure by prefecture (age 65+). Data from the Ministry of Health, Labour and Welfare; Statistics Bureau1 People wish to work even after age 65 and work is good for health. Therefore, a project called “Work place for the second life” was initiated. Kashiwa City is a typical bedroom community of Tokyo. A huge number of baby boomers who commuted to work in Tokyo retired and returned to this community. This project aimed to create age-friendly workplaces and flexible employment schemes suitable for the second half of life. To date, 9 workplaces have been created: 3 in agriculture, 2 that are food related, and the remainder in the fields of education and personal care. All workplaces are operated by business owners in the private sector. The wage varies depending on the nature of the work, but the minimum wage is guaranteed for all jobs. Using work-sharing, a flexible employment scheme for both the employers and senior workers was developed. Older persons decide when and for how long they work. As this is a social experiment, the effects and costs of the interventions were evaluated at both the individual level and community level. The project gathered scientific evidence on the effect of working in the second half of life on physical, cognitive, and social health, and made policy recommendations with evidence to the national government. In March 2016, the legislation was passed at the National Diet of Japan to institutionalize the program. Now, implementation of this program has begun to spread throughout the country. The next project concerned frailty prevention. In a highly aged society, frailty is the dominant cause of disability. This project promoted frailty prevention in the community and aimed to raise awareness about physical frailty, cognitive frailty, and social frailty (Figure 8) (Prof. Katsuya Iijima, The University of Tokyo, personal communication). Figure 8 Open in new tabDownload slide The trinity for health and longevity. Figure 8 Open in new tabDownload slide The trinity for health and longevity. This was a large-scale longitudinal cohort study. Trained active seniors participated as staff members in the frailty check-up. Preliminary analysis of the data indicated that social frailty often precedes physical frailty and cognitive frailty. Therefore, social engagement is an important factor in the prevention of frailty. To remain safe and active, transportation is a big issue for older persons. In collaboration with several companies, such as Toyota, the project is working toward providing alternative means of transportation in the community. The project will maximally utilize the existing information and communication technology to reach out to people to help them stay healthy, safe, and connected. It is also pursuing technological innovations and testing new technology in the community. This kind of social experiment requires not only the collaboration of researchers from different disciplines but also full collaboration with local governments, healthcare institutions, nonprofit organizations, business communities, and residents. Action-targeted research is a promising research method in gerontology, but, as described previously, it is still in the formative stage. Action-targeted research must be further developed as a scientific research method. Two years ago, an introductory book in Japanese about action-targeted research in an aging society was published.9 It is hoped that action-targeted research will gain acceptance in gerontological research and will contribute to solutions for formidable challenges in our rapidly aging society. The University-Industry Consortium on Gerontology was formed in 2009. This consortium provides a platform for the merging of academic ideas and business ideas in order to develop new values and solutions for the formidable challenges facing society in the next 11 years. To date, 91 Japanese and 7 international enterprises have participated in the consortium. The author is a social psychologist by training and does not consider market research or business in general to be an area of expertise. After tracking the lives of 6000 older persons for 30 years, however, the author has concluded that the needs of a large portion of the older population are not being met. It seems that the industry is targeted at 2 relatively small segments of the older population: the frail and the wealthy. A large majority of the older population lies somewhere in between these two categories (Figure 9). Figure 9 Open in new tabDownload slide Life stages and needs (market). Abbreviations: ADL, activities of daily living; IADL, independent activities of daily living. Figure 9 Open in new tabDownload slide Life stages and needs (market). Abbreviations: ADL, activities of daily living; IADL, independent activities of daily living. Persons aged 65 years and older comprise a diverse group. Those in their 60 s are quite different from those in their 90 s and thus people over the age of 65 years cannot be treated as a single entity. It appears there are roughly 3 phases of life after age 65 (Figure 10). In the first phase, seniors wish to explore a new life and new opportunities after retiring. In particular, baby boomers are the first generation to recognize that they have 20 or 30 more years and to make plans for the second half of life. They wish to explore many options. The business community should not wait until seniors express their needs and wants, but rather should propose various new life designs/lifestyles with attractive products and services. The business community needs to be proactive. This is certainly a challenge. Figure 10 Open in new tabDownload slide The untapped silver market. Figure 10 Open in new tabDownload slide The untapped silver market. Unlike 2-year-olds, the older population is diverse in health and economic status, values, and lifestyle. Therefore, it is not easy to figure out the large variety of needs in the silver market. Nevertheless, given the huge proportion of the population aged 65 years and older, even a small fraction of older people would create a good market. In the second phase, the main goal of seniors is to stay healthy and independent, and maintain their ADLs. This is particularly true for people aged 75 years and older. They would like to continue doing what they are doing today, such as taking a walk after dinner, driving to the grocery store, and going to a hot spring with friends, 1 month later, 1 year later, and hopefully 10 years later as well. They do not want to give up a favorite food because it is too tough to chew. The baby boomers who are now in the first phase are the first generation to make plans for their second and third phases. To maintain their independence and their lifestyles, they are willing to invest and spend money. As described previously, the main target of industry has been to meet the healthcare and long-term care needs for seniors in their third phase. Seniors, however, want to be able to enjoy life throughout all 3 phases. Meeting these needs of seniors requires technological and social innovations. A 100-year life society represents a gold mine of innovation. There are many issues that need to be solved. One strategy is to create a platform for open innovation and for co-creation by multiple stakeholders, such as users, industry, academia, and government. The Institute of Gerontology, along with partners, recently launched a living lab in Kamakura – a city located 50 km from Tokyo – called the Kamakura Living Lab. A living lab is a user-centered, open-innovation platform within a public-private-people partnership. It goes through the process of co-creation, exploration, experimentation, and evaluation of innovative ideas, concepts, and related technological artifacts in real-life use cases. Such use cases involve user communities, not only as observed subjects, but also as a source of creation. This is a crucially important infrastructure for the promotion of technological and social innovations. The goals for 2017–2018 were as follows: consolidating a quadruple helix eco-system for open innovation, developing a living lab scheme suitable for the Japanese context, building a sustainable business model, and forming a transnational living lab. The Kamakura Living Lab started as a transnational living lab with the Swedish Network of Living Lab, whose ultimate goal is to make linkages among longevity, health, and wealth, which is the utmost challenge in this rapidly aging world. Population aging is a global phenomenon. By taking up this enormous challenge and exploring new opportunities in our aging society, the global goal is to build a sustainable society together. Acknowledgments Author contributions. The author wrote, revised, and approved the manuscript. Funding. None Declaration of interest. The author has no conflict of interest to declare. References 1 Population Census. Japan: Statistics Bureau; 2010 . Available at: https://www.stat.go.jp/data/kokusei/2010/final/pdf/01-03.pdf. Accessed May 26, 2020. 2 Ministry of Internal Affairs and Communications; 2010 . Available at: https://www.mhlw.go.jp/stf/shingi/2r98520000021dhc-att/2r98520000021dit.pdf. Accessed on May 26, 2020. 3 National Institute of Population and Social Security Research (IPSS). Tokyo. Population projections for Japan (January 2012 ). Japan: IPSS. 4 Akiyama H. Concept of science and society in the age of longevity . Kagaku (Iwanami) . 2010 ; 80 : 59 – 64 . Google Scholar OpenURL Placeholder Text WorldCat 5 Suzuki T , Kwang J. Research for the change of vertical and horizontal physical function and in Japanese elderly . Index Welfare . 2006 ; 53 : 1 – 10 . Google Scholar OpenURL Placeholder Text WorldCat 6 The official pronouncement of the Japan Gerontological Society https://www.jpn-geriat-soc.or.jp/info/topics/pdf/20170410_01_01.pdf Accessed on November 15th 2020. 7 Development of social participation promotion measures based on the actual situation and needs of elderly people's social participation - Research project report on demonstration of social participation effect http://www.iog.u-tokyo.ac.jp/wp-content/uploads/2014/05/556984f2bbf71217e5c092b690579fb8.pdf accessed on November 15th 2020. 8 Ministry of Health, Labour and Welfare of Japan. Report on the interim evaluation of Health Japan 21. Available at: https://www.mhlw.go.jp/content/000378318.pdf. Accessed on April 09, 2020. 9 Akiyama H. Action research - redesigning communities for aged society. Tokyo, University of Tokyo press. 2015. © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Shobayashi,, Tokuaki

doi: 10.1093/nutrit/nuaa078pmid: 33259615

Abstract Why has Japan become the longest-lived country in the world? The longevity is often attributed to Japan’s economic growth, but Japan experienced an extended life expectancy prior to achieving such economic growth. During and after the Second World War when the General Headquarters of the Supreme Commander for the Allied Powers was occupying Japan, the welfare administration system was drastically reformed, resulting in dramatic improvements in the hygiene status, which led to an increase in the average life expectancy in Japan. Here, this background is reviewed, along with an explanation of how Japan has become the world's longest-lived country. average life expectancy, healthy life expectancy, history of nutrition policy, infectious disease, public health According to the theme of the 8th International Conference on Nutrition and Aging “Realization of a Society where Healthy Life Expectancy Approximates Overall Life Expectancy,” how Japan became the world's longest-lived country will be considered from a mainly nutritional point of view. In 1945, shortly after the war, Japan suffered serious damage to its infrastructure as a result of air strikes, massive unemployment, severe inflation, food shortages, and the spread of infectious diseases. The General Headquarters of the Supreme Commander for the Allied Powers occupied Japan for 7 years after the war, and various reforms were carried out, including re-establishment of the constitution, fiscal reform, education reform, and healthcare and medical system reform. In addition, at the same time, woman’s suffrage was established and community activities were initiated. The literacy rate at that time, according to the Ministry of Education, Science, and Culture,1 was 98%, and this very high literacy rate was extremely useful for the penetration of future policies to rebuild the nation. After the war, the average life expectancy in Japan increased dramatically. Although the average life expectancy before the war was less than 50 years, it continued to grow after the war and as of 2017 was 81.09 years for men and 87.26 years for women.2 The increased longevity is often said to be the result of Japan's economic growth. The economic growth brought about by the plan of the Ikeda Cabinet (to double the national income) took place from 1955 to the 1970s; however, life expectancy had already improved by this time, being comparable to that in the world's top countries.3 Policies that seem to have been the most effective toward improving life expectancy in the short period after the war include organizational reform of the Ministry of Health and Welfare, strengthening of public health centers, measures against infectious diseases, community participation activities, human resource development, medical system reform (enactment of the legal requirement for universal health insurance), pharmaceutical system reform, data collection and analysis, maternal and child health, and nutrition improvement as an overall reformation. According to the 50-year history of the Ministry of Health, Labor, and Welfare,4 30 health-related laws were enacted and amended in 1947 and 1948, and these efforts led to a rapid reduction in mortality due to tuberculosis (Figure 1).5 Figure 1 Open in new tabDownload slide Mortality rate trends of the 10 major killers. Data from the Ministry of Health, Labour, and Welfare (Vital Statistics).5 Figure 1 Open in new tabDownload slide Mortality rate trends of the 10 major killers. Data from the Ministry of Health, Labour, and Welfare (Vital Statistics).5 Infectious diseases, such as Salmonella infections, paratyphoid fever, and diphtheria were also dramatically reduced compared with the period before the war (Figure 2).5 Figure 2 Open in new tabDownload slide Mortality rate from (A) Salmonella typhi, (B) Salmonella paratyphi, and (C) Diphtheria. Data from the Ministry of Health, Labour, and Welfare (Vital Statistics).5 Figure 2 Open in new tabDownload slide Mortality rate from (A) Salmonella typhi, (B) Salmonella paratyphi, and (C) Diphtheria. Data from the Ministry of Health, Labour, and Welfare (Vital Statistics).5 Other factors include (1) improvement in hygiene after the war by various medical system reforms, such as reduced spread of infectious diseases, and (2) training of nutritionists, dissemination and awareness of nutritional education, and distribution of food supplied by the United States, along with nutritional measures such as the provision of school lunches. At that time, in addition to a severe food shortage, Japan was hit by severe inflation. According to the results of a national survey of the nutritional status of Japanese subjects, the amount of energy intake in 1946 was approximately 1500 kcal, and in 1947 it was 1800 kcal in urban areas and approximately 2000 kcal in rural areas.6 Thus, the energy intake was considerably lower than that of the present diet, and food shortage was quite serious, particularly in urban areas. In terms of the price of food, if the average price of food in1945 is set as the basis, costs were 4 times higher in 1946 and 13 times higher in 1947. Further, prices rose sharply to 70 times higher in the 1950s,7 and many people were unable to afford food, leading to starvation. Under such circumstances, the General Headquarters in 1945 issued a directive to carry out a nutrition survey of citizens to help establish emergency food measures. Dieticians very successfully carried out the survey. This was the beginning of the National Health and Nutrition Survey, and this nutrition survey has been conducted on a nationwide scale 4 times a year since 1946, and is used as the basic data for national nutrition improvement measures and guidance to improve dietary habits. Implementation and analysis of this survey have contributed to the improvement of national physical standards and health and food production measures, as well as import measures. In particular, the distribution of food for school lunches began and contributed greatly to improving the nutrition of the people by the provision of food supplies from LARA (Licensed Agencies for Relief in Asia) organized by the American Council of Voluntary Agencies for Foreign Service, which mainly involved various religious organizations from the United States.4,8 The rapid realization of nutritional improvement is attributed to Dr. Tadasu Saeki, who recognized the need for nutrition administration in the early days and laid the foundation. Dr. Saeki, the founder and father of nutrition in Japan, established and ran a nutrition school from the Taisho era to the prewar era, established a nutrition research department at the national sanitation laboratory, contributed to establishing public health centers, established a nutrition section in the Public Health Bureau of the Ministry of Health and Welfare, and helped to enact the Nutrition Improvement Act in 1952. The establishment of the Ministry of Agriculture, Forestry, and Fisheries was also considered very important for nutritional improvement. Since the end of the war, various laws and enactments of new laws have been carried out, such as the implementation of the Livestock Health Center Act and the Domestic Animal Infectious Diseases Control Act for farmers.9As a result, the increased intake of meat and milk has been remarkable. The nutrition policies developed after the war contributed to overcoming the spread of infectious diseases through various health and medical reforms and to improving poor hygiene, thereby playing an important role in the improved health of the Japanese population. The nutrition policies also helped to control infectious diseases to some extent by fostering nutritionists, who worked very hard to develop nutritional guidance programs for the citizens, and the food supply from the United States, which westernized dietary habits, led to an extension of the average life expectancy. On the other hand, the westernized dietary style contributed to the changes in the leading cause of death from tuberculosis and stroke to cancer and heart disease (Figure 3).5Dementia, lifestyle-related diseases, and frailty are currently increasing, and tackling these conditions is a social issue. Figure 3 Open in new tabDownload slide Annual change in crude mortality rates by major cause of death. Data from the Ministry of Health, Labour, and Welfare(Vital Statistics).5 Figure 3 Open in new tabDownload slide Annual change in crude mortality rates by major cause of death. Data from the Ministry of Health, Labour, and Welfare(Vital Statistics).5 The major issue for the future is to continue developing measures to improve health, such as Health Japan 21, and to decrease the gap between a healthy life expectancy and overall life expectancy. Healthcare reform after the war helped to overcome the spread of infectious diseases. In addition, the enthusiastic promotion of nutritional education to the people, along with the provision of food supplied by the United States, has changed the traditional Japanese dietary habits to a westernized diet, which was one reason for the extended average life expectancy. The leading cause of death has now changed from tuberculosis and stroke to cancer and heart disease, and dementia, lifestyle-related diseases, and frailty have increased. The current major challenges are to continue measures for health promotion and to close the gap between the healthy life expectancy and average life expectancy. Acknowledgments Author contributions. The author wrote, revised, and approved the manuscript. Funding. No external funding was received to support this work. Declaration of interest. The author has no conflict of interests to declare. References 1 Education and Training Institute, Japanese Ministry of Education. 1948 Survey of Japanese Reading and Writing Ability . Tokyo, Japan : Tokyo University Press ; 1951 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2 Ministry of Health, Welfare and Labour of Japan. Abridged Life Tables for Japan 2017. Available at: https://www.mhlw.go.jp/toukei/saikin/hw/life/life17/dl/life17-15.pdf. Accessed April 16, 2020 . 3 United Nations. United Nations Demographic Yearbook 1955. 1955. Available at: https://unstats.un.org/unsd/demographic-social/products/dyb/dybsets/1955%20DYB.pdf. Accessed July 15, 2020. 4 Ministry of Health, Labor and Welfare of Japan. The History of the Ministry of Health and Welfare for 50 Years . Tokyo, Japan : Chuohoki Publishing ; 1988 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5 Division of Health and Welfare Statistics, Welfare minster’s Secretariat. Vital Statistics. Ministry of Health, Labour and Welfare of Japan . Source . PortalSite of Official Statistics of Japan website (https://www.e-stat.go.jp/). Available at: https://www.e-stat.go.jp/stat-search/files?page=1&layout=datalist&toukei=00450011&tstat=000001028897&cycle=7&tclass1=000001053058&tclass2=000001131643&tclass3=000001131644. Accessed July 15, 2020. 6 Ministry of Health, Labor and Welfare of Japan. Nutrition Trends in the Postwar Showa Era . Tokyo, Japan : Dai-Ichi Shuppan ; 1998 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7 Japanese Ministry of Finance. The History of Finance in Showa Era. Tokyo , Japan : Okura Zaimu Kyokai ; 1978 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 8 Oiso T. Nutrition Essays . Tokyo, Japan : Ishiyaku Publishers, Inc .; 1959 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 9 The ministry of Agriculture, Forestry and Fisheries of Japan. 100 Years of Agriculture Forestry and Fisheries . Tokyo : Publication Society ; 1981 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Tsuji,, Ichiro

doi: 10.1093/nutrit/nuaa079pmid: 33259610

Abstract The national health promotion program, Health Japan 21 (second term), began in 2013. This program has set 5 basic goals: to extend healthy life expectancy and reduce health disparity, to prevent noncommunicable disease, to improve function for social life, to establish a social environment for health, and to improve lifestyle. To achieve these goals, Health Japan 21 (second term) set 53 targets for the period between 2013 and 2022. At the interim evaluation in 2018, only 21 of the 53 targets were judged likely to be achieved by 2022. In addition, 18 targets were judged as unchanged, and 1 target was judged to be deteriorating. Thus, to achieve the goals of Health Japan 21 (second term), further efforts to strengthen health promotion programs across Japan are needed. Health Japan 21, healthy life expectancy, health promotion programs, noncommunicable disease INTRODUCTION In 2000, the Ministry of Health, Labour and Welfare of Japan started a national health promotion program named “Health Japan 21.” The main goals of this program were to prevent premature death and to extend healthy life expectancy. Health Japan 21 set 79 targets for 2010 in 9 areas (nutrition and diet, physical activity and exercise, rest and promotion of mental health, tobacco, alcohol, dental health, diabetes, circulatory disease, and cancer). This program was conducted by national and local governments, health-related professionals, industries, schools, organizations, and individuals. The final evaluation in 2012 indicated that 17% of the targets had been achieved, 42% had improved, 24% had remained unchanged, and 15% had worsened. The Ministry of Health, Labour and Welfare initiated Health Japan 21 (second term) in 2013. This program aimed to ensure that all citizens – from infants to the elderly – have hope and live a meaningful life while supporting each other, and to achieve a vibrant society that embraces healthy and spiritually rich lives according to life stage (ie, at each stage of human life, such as infancy, childhood, adolescence, adulthood, and older ages), along with a sustainable social security system. Health Japan 21 (second term) set 5 basic goals for the period between 2013 and 2022: (1) to extend healthy life expectancy and reduce health disparities, (2) to prevent onset and progression of lifestyle-related diseases (“Noncommunicable disease prevention”), (3) to maintain and improve the functions necessary for engaging in social life (“Improving function for social life”), (4) to establish a social environment where the health of individuals is protected and supported (“Establishment of a social environment”), and (5) to improve the social environment and lifestyle factors, including nutrition and dietary habits, physical activity and exercise, rest, drinking alcohol, smoking tobacco, and oral health (“Lifestyle improvement”). The concept of Health Japan 21 (second term) is illustrated in Figure 1. To achieve these goals, Health Japan 21 (second term) set 53 targets. Of these, extension of healthy life expectancy and reduction in health disparities were considered the most important. Figure 1 Open in new tabDownload slide Concept of Health Japan 21 (second term). Abbreviation: NCD, noncommunicable disease. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 Figure 1 Open in new tabDownload slide Concept of Health Japan 21 (second term). Abbreviation: NCD, noncommunicable disease. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 Health Japan 21 (second term) began in 2013 and will end in 2022. An interim evaluation was performed in 2018.1 In this paper, the results of the interim evaluation are reviewed. EXTENSION OF HEALTHY LIFE EXPECTANCY AND REDUCTION IN HEALTH DISPARITIES In this program, healthy life expectancy is defined as the average period of time spent, without limitation, engaged in daily activities, such as activities of daily living, going out, work-housework-study, and sports activities. Healthy life expectancy is measured every 3 years by a Comprehensive Survey of Living Conditions administered by the Ministry of Health, Labour and Welfare, which randomly samples over 700 000 men and women of all ages from all over Japan. Healthy life expectancy in 2010 in Japan was found to be 70.42 years for men and 73.63 years for women. Total life expectancy in 2010 was 79.55 years for men and 85.99 years for women. Accordingly, the gap between total life expectancy and healthy life expectancy (ie, the life-years spent in an unhealthy state) was 9.13 years for men and 12.36 years for women. There is a wide difference in the healthy life expectancy among Japan’s 47 prefectures. In 2010, the difference between prefectures with the longest and shortest healthy life expectancies was 2.79 years for men and 2.95 years for women. The first target of Health Japan 21 (second term) is to extend healthy life expectancy beyond the increase in the life expectancy. The achievement of this target would result in a reduction of the life-years spent in an unhealthy state, hence enhancing the quality of life among the people and decreasing social security expenditure. The interim evaluation indicated that this target has been achieved (Figure 2). Between 2010 and 2016, life expectancy increased by 1.43 years (from 79.55 to 80.98) in men, and by 0.84 years (from 86.30 to 87.14) in women. Meanwhile, healthy life expectancy increased by 1.72 years (from 70.42 to 72.14) in men, and by 1.17 years (from 73.62 to 74.79) in women. Thus, the gap between healthy life expectancy and the increase in life expectancy was narrowed, with the number of life-years to be spent in an unhealthy state decreasing by 0.29 years in men and by 0.33 years in women. Therefore, it is concluded that the first target of Health Japan 21 (second term) has been achieved. Figure 2 Open in new tabDownload slide Trends in life expectancy and healthy life expectancy in Japan. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 Figure 2 Open in new tabDownload slide Trends in life expectancy and healthy life expectancy in Japan. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 The second target of Health Japan 21 (second term) is to reduce the disparity in healthy life expectancy among prefectures. The interim evaluation indicated that the difference between prefectures with the longest healthy life expectancy and the shortest healthy life expectancy decreased by 0.79 years (from 2.79 in 2010 to 2.00 in 2016) in men and by 0.22 years (from 2.95 to 2.70) in women. Figure 3 shows that the prefectural disparities in the normalized score of healthy life expectancy decreased in the period between 2010 and 2013 for men and between 2010 and 2016 for women. Figure 3 Open in new tabDownload slide Trends in disparity among prefectures concerning healthy life expectancy. Abbreviation: SD, standard deviation among all 47 prefectures in Japan. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 Figure 3 Open in new tabDownload slide Trends in disparity among prefectures concerning healthy life expectancy. Abbreviation: SD, standard deviation among all 47 prefectures in Japan. Reproduced from the Ministry of Health, Labour and Welfare with permission.1 INTERIM EVALUATION OF ACHIEVEMENT OF OTHER TARGETS Table 1 shows the evaluation results of the interim evaluation performed in 2018. Of the 53 targets, 21 were judged to be improving and likely to be achieved by 2022 (on target), 12 were judged to be improving but unlikely to be achieved by 2022 if the current trend continues (better), 18 were judged to be unchanged, and only 1 was judged to be worse than before the start of the initiative. Table 1 Summary of the 2018 interim evaluation1 Target . Goals . On Target . Better . Unchanged . Worse . Healthy life expectancy 2 2 0 0 0 NCD prevention 12 3 3 6 0 Social life function 12 4 3 4 Social environment 5 4 0 1 Lifestyle improvement  Nutrition 5 1 1 3 0  Exercise 3 1 0 2 0  Rest 2 1 1 0 0  Alcohol 3 1 1 1 0  Tobacco 4 1 3 0 0  Oral health 5 3 0 1 1 Total 53 21 12 18 1 Target . Goals . On Target . Better . Unchanged . Worse . Healthy life expectancy 2 2 0 0 0 NCD prevention 12 3 3 6 0 Social life function 12 4 3 4 Social environment 5 4 0 1 Lifestyle improvement  Nutrition 5 1 1 3 0  Exercise 3 1 0 2 0  Rest 2 1 1 0 0  Alcohol 3 1 1 1 0  Tobacco 4 1 3 0 0  Oral health 5 3 0 1 1 Total 53 21 12 18 1 “On Target” means that it is improving and likely to have been achieved by 2022. “Better” means that, although improving, the target is unlikely to be achieved by 2022 if the current trend continues. One target of “social life function” was judged to be difficult to evaluate. Abbreviation: NCD, noncommunicable disease. Open in new tab Table 1 Summary of the 2018 interim evaluation1 Target . Goals . On Target . Better . Unchanged . Worse . Healthy life expectancy 2 2 0 0 0 NCD prevention 12 3 3 6 0 Social life function 12 4 3 4 Social environment 5 4 0 1 Lifestyle improvement  Nutrition 5 1 1 3 0  Exercise 3 1 0 2 0  Rest 2 1 1 0 0  Alcohol 3 1 1 1 0  Tobacco 4 1 3 0 0  Oral health 5 3 0 1 1 Total 53 21 12 18 1 Target . Goals . On Target . Better . Unchanged . Worse . Healthy life expectancy 2 2 0 0 0 NCD prevention 12 3 3 6 0 Social life function 12 4 3 4 Social environment 5 4 0 1 Lifestyle improvement  Nutrition 5 1 1 3 0  Exercise 3 1 0 2 0  Rest 2 1 1 0 0  Alcohol 3 1 1 1 0  Tobacco 4 1 3 0 0  Oral health 5 3 0 1 1 Total 53 21 12 18 1 “On Target” means that it is improving and likely to have been achieved by 2022. “Better” means that, although improving, the target is unlikely to be achieved by 2022 if the current trend continues. One target of “social life function” was judged to be difficult to evaluate. Abbreviation: NCD, noncommunicable disease. Open in new tab Thus, only 21 targets were judged as likely to achieved by 2022. These 21 targets included 2 of 2 healthy life expectancy targets, 3 of 12 non-communicable disease prevention targets, 4 of 12 social life function targets, 4 of 5 social environment targets, and 8 of 22 life-style improvement targets. CONCLUSION To achieve the goals of Health Japan 21 (second term), further efforts are needed to strengthen health promotion programs all over Japan. Acknowledgments Author contributions. The author wrote, revised, and approved the manuscript. Funding. This work was supported by a grant-in-aid from the Ministry of Health, Labour and Welfare; and Health and Labour Sciences research grants, Japan (Comprehensive Research on Cardiovascular and Life-Style Related Diseases: 19FA2001). No funding agencies had any role in the design, analysis, or writing of this article. Declaration of interest. The author has no conflict of interest to declare. Reference 1 Ministry of Health, Labour and Welfare of Japan. The Report on the Interim Evaluation of Health Japan 21 (2nd term). Available at: https://www.mhlw.go.jp/content/000378318.pdf. Accessed April 09, 2020 . © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Sasaki,, Satoshi;for Working Group 1 of the Healthy Diet Research Committee of International Life Sciences Institute,, Japan

doi: 10.1093/nutrit/nuaa099pmid: 33259625

Abstract The Japanese people have enjoyed longevity for several decades, and Japanese dietary habits are considered to contribute to this longevity. The scientific definition of the Japanese diet, however, is not yet fully established. The Working Group 1 of the Healthy Diet Research Committee of the International Life Sciences Institute Japan reviewed the literature to collect definitions of the Japanese diet appearing in articles in the fields of diet, nutrition, foods, and human health. This report addresses the definitions and the questions raised by these definitions. Among 283 relevant articles identified, 116 were carefully screened and included in the analysis. In most of the articles, the authors self-defined the Japanese diet; some studies used a government-proposed definition. This review revealed no systematic approach to define the Japanese diet from the viewpoints of nutrition and health. Before conducting studies to determine whether the Japanese diet is healthy, it is important to address the question of what the Japanese diet is from the viewpoint of human nutrition rather than culinary culture. clinical trial, Japanese diet, Japanese food, literature review, nutrition INTRODUCTION The Japanese diet has been hypothesized to be healthy and to contribute to the longevity of the Japanese people.1–3 Human studies examining this hypothesis are scarce, however, compared with other diets, such as the Mediterranean diet.4 Inconsistent definitions or even a lack of a definition of the Japanese diet in these studies may be responsible for this situation, whereas many definitions for Mediterranean diet have been proposed from different professional groups and for different purposes and have been discussed.5,6 Therefore, it is important to sort out the present situation on the definition of Japanese diet. Accordingly, this review evaluated the definitions of Japanese diet in published articles that examined the relationship between Japanese diet and health outcomes. METHODS Publication search PubMed was searched for relevant articles using the search terms (“Japanese diet” OR “Japanese diets” OR “Japanese food” OR “Japanese foods”) AND (human OR clinical). The final access date was December 14, 2017. A total of 283 relevant articles were extracted. On the basis of the titles and abstracts independently read by 2 groups, selected articles were screened according to 3 inclusion criteria: (1) human study, (2) peer-reviewed article, and (3) article related to diet, food, or substance; and 2 exclusion criteria: (1) not an original article and (2) a case report or a case series. After this process, 137 articles were excluded from the analysis, leaving 146 articles. Next, by reading the content of all the articles, the remaining articles were further screened according to the same aforementioned inclusion and exclusion criteria. When the decisions of the 2 teams were contradictory, a conclusion was drawn by consensus among the responsible screeners. A total of 116 articles fulfilling the criteria were included in the analysis. Analysis The definition of the Japanese diet used in each article was classified into 1 of 5 categories: class 1: the definition covered a universal Japanese diet; class 2: definition was proposed by a public agency (within class 2: class 2a, concrete evidence for the definition was cited; class 2 b, concrete evidence was not cited); class 3: the definition was proposed by the author(s) in the cited article(s); class 4: the definition was defined in the article by the author(s) (within class 4: class 4a, a reference was provided for the definition; class 4 b, no reference was provided for the definition); and class 5: others (Figure 1). Figure 1 Open in new tabDownload slide Classification of articles defining the Japanese diet used in the study. The number of studies is indicated in the boxes. Figure 1 Open in new tabDownload slide Classification of articles defining the Japanese diet used in the study. The number of studies is indicated in the boxes. On the basis of the definition of the Japanese diet used in the studies, the articles were classified into 1 of 4 groups according to their (1) nutrient level, (2) food level, (3) recipe level, and (4) meal level. The articles were further classified according to the research design used in the studies into 1 of 5 groups: (1) descriptive epidemiological study, (2) analytical epidemiological study, (3) intervention study, (4) other type of epidemiological study, and (5) study impossible to classify. RESULTS Table 1 shows the result of the classification of the definitions used in the articles. Among the 116 articles, 47 were categorized as class 5, 38 as class 4 b, and 20 as class 4a (thus together, these 3 categories comprised 91% of the total number of articles). No article was categorized as class 1. One article was categorized as class 2a and 11 articles were categorized as class 2 b. Table 1 Association between dietary factors used in the definition of the Japanese diet and classification of articles defining the Japanese diet used in the study Classa . Factors used in the definition of the Japanese dietb, No. . . Nutrient . Food . Recipe . Meal . Total . 2a 0 0 0 8 8 2b 0 0 0 0 0 2a and 4a 1 1 1 1 4 2b and 4b 0 1 0 0 1 3 1 3 1 0 5 4a 3 8 3 5 19 4b 5 22 6 5 38 4a and 4b 1 0 0 1 2 Total 11 35 11 20 77 Classa . Factors used in the definition of the Japanese dietb, No. . . Nutrient . Food . Recipe . Meal . Total . 2a 0 0 0 8 8 2b 0 0 0 0 0 2a and 4a 1 1 1 1 4 2b and 4b 0 1 0 0 1 3 1 3 1 0 5 4a 3 8 3 5 19 4b 5 22 6 5 38 4a and 4b 1 0 0 1 2 Total 11 35 11 20 77 a Class 2a: definition proposed by a public agency with concrete evidence for the definition cited; class 2 b: definition proposed by a public agency with concrete evidence not cited; class 3: the definition was proposed by the authors in the cited articles; class 4a: the definition was defined in the article by the authors with a reference provided for the definition; class 4 b: the definition was defined in the article by the authors with no reference provided for the definition. b Some articles included > 1 category. Therefore, the total number (n = 77) is less than the total number of articles included in this analysis (n = 116). Open in new tab Table 1 Association between dietary factors used in the definition of the Japanese diet and classification of articles defining the Japanese diet used in the study Classa . Factors used in the definition of the Japanese dietb, No. . . Nutrient . Food . Recipe . Meal . Total . 2a 0 0 0 8 8 2b 0 0 0 0 0 2a and 4a 1 1 1 1 4 2b and 4b 0 1 0 0 1 3 1 3 1 0 5 4a 3 8 3 5 19 4b 5 22 6 5 38 4a and 4b 1 0 0 1 2 Total 11 35 11 20 77 Classa . Factors used in the definition of the Japanese dietb, No. . . Nutrient . Food . Recipe . Meal . Total . 2a 0 0 0 8 8 2b 0 0 0 0 0 2a and 4a 1 1 1 1 4 2b and 4b 0 1 0 0 1 3 1 3 1 0 5 4a 3 8 3 5 19 4b 5 22 6 5 38 4a and 4b 1 0 0 1 2 Total 11 35 11 20 77 a Class 2a: definition proposed by a public agency with concrete evidence for the definition cited; class 2 b: definition proposed by a public agency with concrete evidence not cited; class 3: the definition was proposed by the authors in the cited articles; class 4a: the definition was defined in the article by the authors with a reference provided for the definition; class 4 b: the definition was defined in the article by the authors with no reference provided for the definition. b Some articles included > 1 category. Therefore, the total number (n = 77) is less than the total number of articles included in this analysis (n = 116). Open in new tab Of the 12 articles categorized into class 2, 7 used “the Japanese spinning top” (Figure 2) as the definition of a Japanese diet. Because an insufficient number of scientific articles were referred to in the report on the establishment of the Japanese Food Guide spinning top,7 these 7 articles were categorized as class 2 b rather than class 2a. Figure 2 Open in new tabDownload slide Japanese Food Guide spinning top. Figure 2 Open in new tabDownload slide Japanese Food Guide spinning top. Table 2 shows a matrix of the 116 articles according to the definition class and dietary factors used for defining the Japanese diet (from nutrients to meals). The greatest number of articles (n = 35) were classified as “food level.” Most of the articles (n = 22) were categorized in class 4 b. Table 2 The list of the 116 studies included in the analysis Reference . Classa . Basis of the definition . Research designb . Nishimura T, et al. Adherence to the food-based Japanese dietary guidelines in relation to metabolic risk factors in young Japanese women. Br J Nutr. 2015;114:645–653 2b Meal 2 Takaizumi K, et al. 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Food/nutrient intake and risk of atrophic gastritis among the Helicobacter pylori-infected population of northeastern Japan. Cancer Sci. 2003;94:372–377 4a Food, recipe 2 Okuda N, et al. Food sources of dietary sodium in the Japanese adult population: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). Eur J Nutr. 2017;56:1269–1280 4b Recipe 2 Yamasaki K, et al. Soy and soy products intake, all-cause mortality, and cause-specific mortality in Japan: The Jichi Medical School Cohort Study. Asia Pac J Public Health. 2015;27:531–541 4b Food 1 Pierce BL, et al. Measuring dietary acculturation in Japanese Americans with the use of confirmatory factor analysis of food-frequency data. Am J Clin Nutr. 2007;86:496–503. 4a Food 1 Sakamoto N, et al. The effect of diet on blood vitamin K status and urinary mineral excretion assessed by a food questionnaire. Nutr Health. 1999;13:1–10 4b Food 2 Niu K, et al. The traditional Japanese dietary pattern and longitudinal changes in cardiovascular disease risk factors in apparently healthy Japanese adults. Eur J Nutr. 2016;55:267–279 5 N/A 2 Freire RD, et al. Nutritional status of Japanese-Brazilian subjects: comparison across gender and generation. Br J Nutr. 2003;89:705–713 4b Food, recipe 1 Hirose K, et al. Dietary factors protective against breast cancer in Japanese premenopausal and postmenopausal women. Int J Cancer. 2003;107:276-282 5 N/A 2 Iizumi H, et al. Effect of food consumption pattern on total serum cholesterol level: a methodological approach. J Nutr Sci Vitaminol (Tokyo). 1986;32:205–218 4a Food 1 Hankin JH, et al. Dietary patterns among men of Japanese ancestry in Hawaii. Cancer Res. 1975;35:3259–3264 4b Food, recipe 2 Mishima I, et al. Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese. Scand J Gastroenterol. 2005;40:1005–1009 5 N/A 2 Nagata C, et al. Associations of acrylamide intake with circulating levels of sex hormones and prolactin in premenopausal Japanese women. Cancer Epidemiol Biomarkers Prev. 2015;24:249–254 5 N/A 2 Okita M, et al. n-3 and n-6 Fatty acid intake and serum phospholipid fatty acid composition in middle-aged women living in rural and urban areas in Okayama Prefecture. J Nutr Sci Vitaminol (Tokyo). 1995;41:313–323 5 N/A 2 Yano K, et al. Childhood cultural experience and the incidence of coronary heart disease in Hawaii Japanese men. Am J Epidemiol. 1979;109:440–450 5 N/A 2 Takada H, et al. Eating habits, activity, lipids and body mass index in Japanese children: the Shiratori Children Study. Int J Obes Relat Metab Disord. 1998;22:470–476 5 N/A 2 Ishizuki Y, et al. [Urinary iodide excretion in Japanese people and thyroid dysfunction]. Nihon Naibunpi Gakkai Zasshi. 1992;68:550–556 5 N/A 2 Shimazu T, et al. Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study. Int J Epidemiol. 2007;36:600–609 4a Meal 2 Tamaki J, et al. Stages of change for salt intake and urinary salt excretion: baseline results from the High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study. Hypertens Res. 2004;27:157–166 5 N/A 2 Nakamura M, et al. Feasibility and effect on blood pressure of 6-week trial of low sodium soy sauce and miso (fermented soybean paste). Circ J. 2003;67:530–534 4b Food 3 Yano K, et al. The effects of childhood residence in Japan and testing language on cognitive performance in late life among Japanese American men in Hawaii. J Am Geriatr Soc. 2000;48:199–204 5 N/A 2 Tajima K, et al. Dietary habits and gastro-intestinal cancers: a comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan. Jpn J Cancer Res. 1985;76:705–716 4b Food, recipe 2 Mshui ME, et al. QT interval and QT dispersion before and after diet therapy in patients with simple obesity. Proc Soc Exp Biol Med. 1999;220:133–138 5 N/A 3 Michikawa T, et al. Serum antioxidants and age-related macular degeneration among older Japanese. Asia Pac J Clin Nutr. 2009;18: 1-7 5 N/A 2 Kamao M, et al. Vitamin K content of foods and dietary vitamin K intake in Japanese young women. J Nutr Sci Vitaminol (Tokyo). 2007;53:464–470 5 N/A 1 Uenishi T, et al. Role of foods in irregular aggravation of atopic dermatitis. J Dermatol. 2003;30:91–97 5 N/A 1 Sakai H, et al. Food-based diet quality score in relation to depressive symptoms in young and middle-aged Japanese women. Br J Nutr. 2017;117:1674–1681 5 N/A 2 Rodriguez BL, et al. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: the Honolulu Heart Program. Diabetes Care. 1999;22:1262–1265 5 N/A 2 Hozawa A, et al. Relationship between serum isoflavone levels and disability-free survival among community-dwelling elderly individuals: nested case-control study of the Tsurugaya project. J Gerontol A Biol Sci Med Sci. 2013;68:465–472 5 N/A 2 Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:103–109 5 N/A 2 Greenway F, et al. A clinical trial testing the safety and efficacy of a standardized Eucommia ulmoides Oliver bark extract to treat hypertension. Altern Med Rev. 2011;16:338–347 5 N/A 3 Oba S, et al. Dietary glycemic index, glycemic load and incidence of type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Nutr J. 2013;12:165 5 N/A 2 Katsuyama H, et al. Usual dietary intake of fermented soybeans (Natto) is associated with bone mineral density in premenopausal women. J Nutr Sci Vitaminol (Tokyo). 2002;48:207–215 4b Food 2 Finegold SM, et al. Fecal microbial flora in Seventh Day Adventist populations and control subjects. Am J Clin Nutr. 1977;30:1781–1792 5 N/A 2 Fukushima Y, et al. 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Public Health Nutr. 2017;20:649–659 5 N/A 1 Sanaka M, et al. Effects of agar and pectin on gastric emptying and post-prandial glycaemic profiles in healthy human volunteers. Clin Exp Pharmacol Physiol. 2007;34:1151–1155. 4b Food 3 Takamura N, et al. Abnormal folic acid-homocysteine metabolism as maternal risk factors for Down syndrome in Japan. Eur J Nutr. 2004;43:285–287 4b Nutrient 2 Takezaki T, et al. Risk factors of thyroid cancer among women in Tokai, Japan. J Epidemiol. 1996;6:140–147 4a, 4b Nutrient, meal 1 Miura T, et al. Rice cake ileus--a rare and ethnic but important disease status in east-southern Asia. Intern Med. 2011;50:2737–2739 4b Food 1 Sakamoto S, et al. Pre-germinated brown rice could enhance maternal mental health and immunity during lactation. Eur J Nutr. 2007;46:391–396 5 N/A 3 Sawada R, et al. Fat content modulates rapid detection of food: a visual search study using fast food and Japanese diet. Front Psychol. 2017;8:1033 5 N/A 4 Morimoto A, et al. 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J Epidemiol. 2005;15:29–37 5 N/A 1 Dunn JE Jr, et al. Cancer epidemiology in the San Francisco Bay Area. Natl Cancer Inst Monogr. 1977;47:93–98 5 N/A 1 Yano K, et al. Dietary intake and the risk of coronary heart disease in Japanese men living in Hawaii. Am J Clin Nutr. 1978;31:1270–1279 3 Food 2 Ishihara J, et al. Food frequency questionnaire is a valid tool in the nutritional assessment of Brazilian women of diverse ethnicity. Asia Pac J Clin Nutr. 2009;18:76–80 5 N/A 4 Maeda H, et al. Effects of agar (kanten) diet on obese patients with impaired glucose tolerance and type 2 diabetes. Diabetes Obes Metab. 2005;7:40–46 4b Food 3 Insull W Jr, et al. Studies of arteriosclerosis in Japanese and American men. I. Comparison of fatty acid composition of adipose tissue. J Clin Invest. 1969;48:1313–1327 3 Nutrient 2 Kobayashi C, et al. Experience-induced changes in taste identification of monosodium glutamate. Physiol Behav. 2002;75:57–63 4b Nutrient 3 Hirose K, et al. Dietary patterns and the risk of breast cancer in Japanese women. Cancer Sci. 2007;98:1431–1438 4b Meal 2 Ogunleiye AJ, et al. Effect of fish oil and safflower oil in common Japanese diet on human plasma fatty acid composition. J Nutr Sci Vitaminol (Tokyo). 1990;36:423–430 4b Meal 3 Kato I, et al. Per capita foods/nutrients intake and mortality from gastrointestinal cancers in Japan. Jpn J Cancer Res. 1987;78:453–459 4b Food 1 Fukushima T, et al. Food intake, serum lipids and amino acids of school children in agricultural communities in Japan. Eur J Clin Nutr. 1999;53:207–210 4b Food 2 Miyake Y, et al. Dietary intake of seaweed and minerals and prevalence of allergic rhinitis in Japanese pregnant females: baseline data from the Osaka Maternal and Child Health Study. Ann Epidemiol. 2006;16:614–621 4b Food 2 Sobko T, et al. Dietary nitrate in Japanese traditional foods lowers diastolic blood pressure in healthy volunteers. Nitric Oxide. 2010;22:136–140 4b Food 3 Yukawa GS, et al. Effects of coffee consumption on oxidative susceptibility of low-density lipoproteins and serum lipid levels in humans. Biochemistry (Mosc). 2004;69:70–74 5 N/A 3 Katagiri R, et al. Iodine excretion in 24-hour urine collection and its dietary determinants in healthy Japanese adults. J Epidemiol. 2016;26:613–621 4b Nutrient 2 Matsuda-Inoguchi N, et al. Estimation of nutrient intake by the new version of Japanese food composition tables in comparison with that by the previous version. Tohoku J Exp Med. 2001;194:229–239 5 N/A 1 Kutoh E, et al. Alogliptin as an initial therapy in patients with newly diagnosed, drug naïve type 2 diabetes: a randomized, control trial. Endocrine. 2012;41:435–441 4a Meal 3 Imaeda N, et al. Usual dietary intakes of selected trace elements (Zn, Cu, Mn, I, Se, Cr, and Mo) and biotin revealed by a survey of four-season 7-consecutive day weighed dietary records in middle-aged Japanese dietitians. J Nutr Sci Vitaminol (Tokyo). 2013;59:281–288 4b Food 1 Guo H, et al. Association of Japanese dietary pattern with serum adiponectin concentration in Japanese adult men. Nutr Metab Cardiovasc Dis. 2012;22:277–284 4a Food 2 Kawasaki T, et al. Reduction in blood pressure with a sodium-reduced, potassium- and magnesium-enriched mineral salt in subjects with mild essential hypertension. Hypertens Res. 1998;21:235–243 5 N/A 3 [No authors listed] Dietary and other risk factors of ulcerative colitis. A case-control study in Japan. Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Clin Gastroenterol. 1994;19:166–171 5 N/A 2 Kimura N, et al. Vitamin intake in Japanese women college students. J Nutr Sci Vitaminol (Tokyo). 2003;49:149–155 5 N/A 2 [No authors listed] A case-control study of ulcerative colitis in relation to dietary and other factors in Japan. The Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Gastroenterol. 1995;30(suppl 8):9–12 5 N/A 2 Muraki S, et al. Diet and lifestyle associated with increased bone mineral density: cross-sectional study of Japanese elderly women at an osteoporosis outpatient clinic. J Orthop Sci. 2007;12:317–320 5 N/A 2 Akehi Y, et al. VLCD-induced weight loss improves heart rate variability in moderately obese Japanese. Exp Biol Med (Maywood). 2001;226:440–445 5 N/A 3 Stemmermann G, et al. Epidemiologic pathology of gastric ulcer and gastric carcinoma among Japanese in Hawaii. J Natl Cancer Inst. 1977;58:13-20 5 N/A 2 Suga H, et al. Effect of seasonality on the estimated mean value of nutrients and ranking ability of a self-administered diet history questionnaire. Nutr J. 2014;13:51 5 N/A 2 Miki T, et al. Dietary patterns derived by reduced rank regression (RRR) and depressive symptoms in Japanese employees: The Furukawa Nutrition and Health Study. Psychiatry Res. 2015;229:214–219 5 N/A 2 Montani A, et al. Food/nutrient intake and risk of atrophic gastritis among the Helicobacter pylori-infected population of northeastern Japan. Cancer Sci. 2003;94:372–377 4a Food, recipe 2 Okuda N, et al. Food sources of dietary sodium in the Japanese adult population: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). Eur J Nutr. 2017;56:1269–1280 4b Recipe 2 Yamasaki K, et al. Soy and soy products intake, all-cause mortality, and cause-specific mortality in Japan: The Jichi Medical School Cohort Study. Asia Pac J Public Health. 2015;27:531–541 4b Food 1 Pierce BL, et al. Measuring dietary acculturation in Japanese Americans with the use of confirmatory factor analysis of food-frequency data. Am J Clin Nutr. 2007;86:496–503. 4a Food 1 Sakamoto N, et al. The effect of diet on blood vitamin K status and urinary mineral excretion assessed by a food questionnaire. Nutr Health. 1999;13:1–10 4b Food 2 Niu K, et al. The traditional Japanese dietary pattern and longitudinal changes in cardiovascular disease risk factors in apparently healthy Japanese adults. Eur J Nutr. 2016;55:267–279 5 N/A 2 Freire RD, et al. Nutritional status of Japanese-Brazilian subjects: comparison across gender and generation. Br J Nutr. 2003;89:705–713 4b Food, recipe 1 Hirose K, et al. Dietary factors protective against breast cancer in Japanese premenopausal and postmenopausal women. Int J Cancer. 2003;107:276-282 5 N/A 2 Iizumi H, et al. Effect of food consumption pattern on total serum cholesterol level: a methodological approach. J Nutr Sci Vitaminol (Tokyo). 1986;32:205–218 4a Food 1 Hankin JH, et al. Dietary patterns among men of Japanese ancestry in Hawaii. Cancer Res. 1975;35:3259–3264 4b Food, recipe 2 Mishima I, et al. Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese. Scand J Gastroenterol. 2005;40:1005–1009 5 N/A 2 Nagata C, et al. Associations of acrylamide intake with circulating levels of sex hormones and prolactin in premenopausal Japanese women. Cancer Epidemiol Biomarkers Prev. 2015;24:249–254 5 N/A 2 Okita M, et al. n-3 and n-6 Fatty acid intake and serum phospholipid fatty acid composition in middle-aged women living in rural and urban areas in Okayama Prefecture. J Nutr Sci Vitaminol (Tokyo). 1995;41:313–323 5 N/A 2 Yano K, et al. Childhood cultural experience and the incidence of coronary heart disease in Hawaii Japanese men. Am J Epidemiol. 1979;109:440–450 5 N/A 2 Takada H, et al. Eating habits, activity, lipids and body mass index in Japanese children: the Shiratori Children Study. Int J Obes Relat Metab Disord. 1998;22:470–476 5 N/A 2 Ishizuki Y, et al. [Urinary iodide excretion in Japanese people and thyroid dysfunction]. Nihon Naibunpi Gakkai Zasshi. 1992;68:550–556 5 N/A 2 Shimazu T, et al. Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study. Int J Epidemiol. 2007;36:600–609 4a Meal 2 Tamaki J, et al. Stages of change for salt intake and urinary salt excretion: baseline results from the High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study. Hypertens Res. 2004;27:157–166 5 N/A 2 Nakamura M, et al. Feasibility and effect on blood pressure of 6-week trial of low sodium soy sauce and miso (fermented soybean paste). Circ J. 2003;67:530–534 4b Food 3 Yano K, et al. The effects of childhood residence in Japan and testing language on cognitive performance in late life among Japanese American men in Hawaii. J Am Geriatr Soc. 2000;48:199–204 5 N/A 2 Tajima K, et al. Dietary habits and gastro-intestinal cancers: a comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan. Jpn J Cancer Res. 1985;76:705–716 4b Food, recipe 2 Mshui ME, et al. QT interval and QT dispersion before and after diet therapy in patients with simple obesity. Proc Soc Exp Biol Med. 1999;220:133–138 5 N/A 3 Michikawa T, et al. Serum antioxidants and age-related macular degeneration among older Japanese. Asia Pac J Clin Nutr. 2009;18: 1-7 5 N/A 2 Kamao M, et al. Vitamin K content of foods and dietary vitamin K intake in Japanese young women. J Nutr Sci Vitaminol (Tokyo). 2007;53:464–470 5 N/A 1 Uenishi T, et al. Role of foods in irregular aggravation of atopic dermatitis. J Dermatol. 2003;30:91–97 5 N/A 1 Sakai H, et al. Food-based diet quality score in relation to depressive symptoms in young and middle-aged Japanese women. Br J Nutr. 2017;117:1674–1681 5 N/A 2 Rodriguez BL, et al. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: the Honolulu Heart Program. Diabetes Care. 1999;22:1262–1265 5 N/A 2 Hozawa A, et al. Relationship between serum isoflavone levels and disability-free survival among community-dwelling elderly individuals: nested case-control study of the Tsurugaya project. J Gerontol A Biol Sci Med Sci. 2013;68:465–472 5 N/A 2 Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:103–109 5 N/A 2 Greenway F, et al. A clinical trial testing the safety and efficacy of a standardized Eucommia ulmoides Oliver bark extract to treat hypertension. Altern Med Rev. 2011;16:338–347 5 N/A 3 Oba S, et al. Dietary glycemic index, glycemic load and incidence of type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Nutr J. 2013;12:165 5 N/A 2 Katsuyama H, et al. Usual dietary intake of fermented soybeans (Natto) is associated with bone mineral density in premenopausal women. J Nutr Sci Vitaminol (Tokyo). 2002;48:207–215 4b Food 2 Finegold SM, et al. Fecal microbial flora in Seventh Day Adventist populations and control subjects. Am J Clin Nutr. 1977;30:1781–1792 5 N/A 2 Fukushima Y, et al. Coffee and green tea as a large source of antioxidant polyphenols in the Japanese population. J Agric Food Chem. 2009;57:1253–1259 5 N/A 1 Seino F, et al. Dietary lipids and incidence of cerebral infarction in a Japanese rural community. J Nutr Sci Vitaminol (Tokyo). 1997;43:83–99 4b Nutrient 2 Burchfiel CM, et al. Characteristics associated with rapid decline in forced expiratory volume. Ann Epidemiol. 1996;6:217–227 4a Meal 2 Tsuda M, et al. Marked increase in the urinary level of N-nitrosothioproline after ingestion of cod with vegetables. Cancer Res. 1988;48:4049–4052 4b Recipe 4 Koga M, et al. Mediators of the effects of rice intake on health in individuals consuming a traditional Japanese diet centered on rice. PLoS One. 2017;12:e0185816 4a Food 2 Nomaki R, et al. A Japanese diet with low glycaemic index and glycaemic load is associated with both favourable and unfavourable aspects of dietary intake patterns in three generations of women. Public Health Nutr. 2017;20:649–659 5 N/A 1 Sanaka M, et al. Effects of agar and pectin on gastric emptying and post-prandial glycaemic profiles in healthy human volunteers. Clin Exp Pharmacol Physiol. 2007;34:1151–1155. 4b Food 3 Takamura N, et al. Abnormal folic acid-homocysteine metabolism as maternal risk factors for Down syndrome in Japan. Eur J Nutr. 2004;43:285–287 4b Nutrient 2 Takezaki T, et al. Risk factors of thyroid cancer among women in Tokai, Japan. J Epidemiol. 1996;6:140–147 4a, 4b Nutrient, meal 1 Miura T, et al. Rice cake ileus--a rare and ethnic but important disease status in east-southern Asia. Intern Med. 2011;50:2737–2739 4b Food 1 Sakamoto S, et al. Pre-germinated brown rice could enhance maternal mental health and immunity during lactation. Eur J Nutr. 2007;46:391–396 5 N/A 3 Sawada R, et al. Fat content modulates rapid detection of food: a visual search study using fast food and Japanese diet. Front Psychol. 2017;8:1033 5 N/A 4 Morimoto A, et al. Low prevalence of metabolic syndrome and its components in rural Japan. Tohoku J Exp Med. 2008;216:69–75 4b Food 2 Terasaki H, et al. Association of lifestyle and body structure to ocular axial length in Japanese elementary school children. BMC Ophthalmol. 2017;17:123 4b Meal 2 Abbreviations: N/A, not applicable. a Class 2a: definition proposed by a public agency with concrete evidence cited; 2 b: definition proposed by a public agency with concrete evidence not cited; 3: the definition was proposed by the author(s) in the cited article(s); 4a: the definition was defined in the article by the author(s) and a reference was provided for the definition; 4 b: the definition was defined in the article by the author(s) with no reference provided for the definition; 5: others. b Research designs are numbered as follows: (1) descriptive epidemiological study, (2) analytical epidemiological study, (3) intervention study, and (4) other type of epidemiological study. Open in new tab Table 2 The list of the 116 studies included in the analysis Reference . Classa . Basis of the definition . Research designb . Nishimura T, et al. Adherence to the food-based Japanese dietary guidelines in relation to metabolic risk factors in young Japanese women. Br J Nutr. 2015;114:645–653 2b Meal 2 Takaizumi K, et al. Influence of awareness of the Japanese Food Guide spinning top on eating behavior and obesity. Asia Pac J Clin Nutr. 2011;20:95–101 2b Meal 2 Kurotani K, et al. Quality of diet and mortality among Japanese men and women: Japan Public Health Center–based prospective study. BMJ. 2016;352:1209 2b Meal 2 Takaizumi K, et al. Impact of awareness of the Japanese Food Guide spinning top on eating behaviour. Public Health Nutr. 2012;15:399–406 2b Meal 2 Oba S, et al. Diet based on the Japanese Food Guide spinning top and subsequent mortality among men and women in a general Japanese population. J Am Diet Assoc. 2009;109:1540–1547 2b Meal 2 Takaizumi K, et al. [Change of awareness level of the Japanese Food Guide spinning top and relation with sociodemographic and health-related characteristics]. In Japanese. Nihon Koshu Eisei Zasshi. 2011;58:948–958 2b Meal 1 Chiba M, et al. Development and application of a plant-based diet scoring system for Japanese patients with inflammatory bowel disease. Perm J. 2016;20:62–68 2b Meal 3 Kuriyama N, et al. Development of a food-based diet quality score for Japanese: associations of the score with nutrient intakes in young, middle-aged and older Japanese women. J Nutr Sci. 2016;5:e41 2b Meal 2 Okubo H, et al. Designing optimal food intake patterns to achieve nutritional goals for Japanese adults through the use of linear programming optimization models. Nutr J. 2015;14:57 2a, 4a Nutrient, food, recipe 1 Koyama T, et al. Relationship of consumption of meals including grain, fish and meat, and vegetable dishes to the prevention of nutrient deficiency: the INTERMAP Toyama Study. J Nutr Sci Vitaminol (Tokyo). 2016;62:101–107 2b, 4a Meal 2 Oita A, et al. Food nitrogen footprint reductions related to a balanced Japanese diet [epub ahead of print, 2017]. Ambio. 2b, 4a Meal 4 Yamori Y, et al. Soy and fish as features of the Japanese diet and cardiovascular disease risks. PLoS One. 2017;12:e0176039 2b, 4a Food 2 Tomata Y, et al. Dietary patterns and incident dementia in elderly Japanese: The Ohsaki Cohort 2006 Study. J Gerontol A Biol Sci Med Sci. 2016;71:1322–1328 4a Meal 2 Wen CP, et al. Changes in serum cholesterol and coronary heart disease mortality associated with changes in the postwar Japanese diet. Am J Clin Nutr. 1973;26:616–619 5 N/A 2 Nomura A, et al. Breast cancer and diet among the Japanese in Hawaii. Am J Clin Nutr. 1978;31:2020–2025 4b Recipe 2 Shibata K, et al. Relationship between urinary concentrations of nine water-soluble vitamins and their vitamin intakes in Japanese adult males. Nutr Metab Insights. 2014;7:61–75 5 N/A 3 Yoshikawa E, et al. Association between frequency of fried food consumption and resilience to depression in Japanese company workers: a cross-sectional study. Lipids Health Dis. 2016;15:156 4a Food 2 Zhang R, et al. The difference in nutrient intakes between Chinese and Mediterranean, Japanese and American diets. Nutrients. 2015;7:4661–4688 4a Nutrient 1 Nakamura M, et al. Japanese and Western diet and risk of idiopathic sudden deafness: a case-control study using pooled controls. Int J Epidemiol. 2001;30:608–615 4b Food 2 Sugiyama M, et al. Glycemic index of single and mixed meal foods among common Japanese foods with white rice as a reference food. Eur J Clin Nutr. 2003;57:743–752 5 N/A 3 Kikuchi S, et al. Cerebral activation focusing on strong tasting food: a functional magnetic resonance imaging study. Neuroreport. 2005;16:281–283 4a Food 3 Fan R, et al. Sustaining effect of intensive nutritional intervention combined with health education on dietary behavior and plasma glucose in type 2 diabetes mellitus patients. Nutrients. 2016;8:e560 3 Food, recipe 3 Hirayama F, et al. Dietary intake of isoflavones and polyunsaturated fatty acids associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease: possible protective effect of traditional Japanese diet. Mol Nutr Food Res. 2010;54:909–917 3 Food 2 Yamada M, et al. Estimation of caffeine intake in Japanese adults using 16 d weighed diet records based on a food composition database newly developed for Japanese populations. Public Health Nutr. 2010;13:663–672 5 N/A 1 Kuratsune M, et al. Dietary fiber in the Japanese diet as investigated in connection with colon cancer risk. Jpn J Cancer Res. 1986;77:736–738 4a Nutrient 1 Nakamura K, et al. Fish as a major source of vitamin D in the Japanese diet. Nutrition. 2002;18:415–416 4a Recipe 1 Hirai K, et al. Cholesterol, phytosterol and polyunsaturated fatty acid levels in 1982 and 1957 Japanese diets. J Nutr Sci Vitaminol (Tokyo). 1986;32:363–372 4a Nutrient 1 Sasaki S, et al. Development of substituted fatty acid food composition table for the use in nutritional epidemiologic studies for Japanese populations: its methodological backgrounds and the evaluation. J Epidemiol. 1999;9:190–207 5 N/A 1 Suzuki T, et al. Japanese dietary pattern consistently relates to low depressive symptoms and it is modified by job strain and worksite supports. J Affect Disord. 2013;150:490–498 4b Meal 2 Sonoda T, et al. A case-control study of diet and prostate cancer in Japan: possible protective effect of traditional Japanese diet. Cancer Sci. 2004;95:238–242 4b Food 2 Mower HF, et al. Analysis of fecal bile acids and diet among the Japanese in Hawaii. J Nutr. 1978;108:1289–1296 4b Food 2 Omura T, et al. Geographical distribution of cerebrovascular disease mortality and food intakes in Japan. Soc Sci Med. 1987;24:401–407 4b Food 2 Nakamura Y, et al. A Japanese diet and 19-year mortality: National integrated project for prospective observation of non-communicable diseases and its trends in the aged, 1980. Br J Nutr. 2009;101:1696–1705 4b Meal 2 Kimura S, et al. Gender differences in childhood food preference: Evaluation using a subjective picture choice method. Pediatr Int. 2014;56:389–394 4b Recipe 3 Nakamura Y, et al. Cancer risk to Japanese population from the consumption of inorganic arsenic in cooked hijiki. J Agric Food Chem. 2008;56:2536–2540 4b Food 1 Horie R, et al. Comparative studies on the relation between nutritional conditions and blood pressure levels of two rural populations with lower incidences of ischemic heart diseases in Japan and Spain. J Cardiovasc Pharmacol. 1990;16(suppl 8):S38–39 4b Nutrient 2 Fukuda S, et al. Pattern of dietary fiber intake among the Japanese general population. Eur J Clin Nutr. 2007;61:99–103 5 N/A 2 Hirayama F, et al. Dietary intake of six minerals in relation to the risk of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:572–577 5 N/A 2 Manabe M. Saltiness enhancement by the characteristic flavor of dried bonito stock. J Food Sci. 2008;73:S321–325 4b Food 3 Hatano S, et al. Stroke mortality and proportional expenditure on selected food items in Japanese communities. Ann Clin Res. 1984;16(suppl 43):163–169 5 N/A 2 Adlercreutz H, et al. Urinary excretion of lignans and isoflavonoid phytoestrogens in Japanese men and women consuming a traditional Japanese diet. Am J Clin Nutr. 1991;54:1093–1100 4b Food 2 Yoshino K, et al. Trends in dietary intake of folate, vitamins B6, and B12 among Japanese adults in two rural communities from 1974 through 2001. J Epidemiol. 2005;15:29–37 5 N/A 1 Dunn JE Jr, et al. Cancer epidemiology in the San Francisco Bay Area. Natl Cancer Inst Monogr. 1977;47:93–98 5 N/A 1 Yano K, et al. Dietary intake and the risk of coronary heart disease in Japanese men living in Hawaii. Am J Clin Nutr. 1978;31:1270–1279 3 Food 2 Ishihara J, et al. Food frequency questionnaire is a valid tool in the nutritional assessment of Brazilian women of diverse ethnicity. Asia Pac J Clin Nutr. 2009;18:76–80 5 N/A 4 Maeda H, et al. Effects of agar (kanten) diet on obese patients with impaired glucose tolerance and type 2 diabetes. Diabetes Obes Metab. 2005;7:40–46 4b Food 3 Insull W Jr, et al. Studies of arteriosclerosis in Japanese and American men. I. Comparison of fatty acid composition of adipose tissue. J Clin Invest. 1969;48:1313–1327 3 Nutrient 2 Kobayashi C, et al. Experience-induced changes in taste identification of monosodium glutamate. Physiol Behav. 2002;75:57–63 4b Nutrient 3 Hirose K, et al. Dietary patterns and the risk of breast cancer in Japanese women. Cancer Sci. 2007;98:1431–1438 4b Meal 2 Ogunleiye AJ, et al. Effect of fish oil and safflower oil in common Japanese diet on human plasma fatty acid composition. J Nutr Sci Vitaminol (Tokyo). 1990;36:423–430 4b Meal 3 Kato I, et al. Per capita foods/nutrients intake and mortality from gastrointestinal cancers in Japan. Jpn J Cancer Res. 1987;78:453–459 4b Food 1 Fukushima T, et al. Food intake, serum lipids and amino acids of school children in agricultural communities in Japan. Eur J Clin Nutr. 1999;53:207–210 4b Food 2 Miyake Y, et al. Dietary intake of seaweed and minerals and prevalence of allergic rhinitis in Japanese pregnant females: baseline data from the Osaka Maternal and Child Health Study. Ann Epidemiol. 2006;16:614–621 4b Food 2 Sobko T, et al. Dietary nitrate in Japanese traditional foods lowers diastolic blood pressure in healthy volunteers. Nitric Oxide. 2010;22:136–140 4b Food 3 Yukawa GS, et al. Effects of coffee consumption on oxidative susceptibility of low-density lipoproteins and serum lipid levels in humans. Biochemistry (Mosc). 2004;69:70–74 5 N/A 3 Katagiri R, et al. Iodine excretion in 24-hour urine collection and its dietary determinants in healthy Japanese adults. J Epidemiol. 2016;26:613–621 4b Nutrient 2 Matsuda-Inoguchi N, et al. Estimation of nutrient intake by the new version of Japanese food composition tables in comparison with that by the previous version. Tohoku J Exp Med. 2001;194:229–239 5 N/A 1 Kutoh E, et al. Alogliptin as an initial therapy in patients with newly diagnosed, drug naïve type 2 diabetes: a randomized, control trial. Endocrine. 2012;41:435–441 4a Meal 3 Imaeda N, et al. Usual dietary intakes of selected trace elements (Zn, Cu, Mn, I, Se, Cr, and Mo) and biotin revealed by a survey of four-season 7-consecutive day weighed dietary records in middle-aged Japanese dietitians. J Nutr Sci Vitaminol (Tokyo). 2013;59:281–288 4b Food 1 Guo H, et al. Association of Japanese dietary pattern with serum adiponectin concentration in Japanese adult men. Nutr Metab Cardiovasc Dis. 2012;22:277–284 4a Food 2 Kawasaki T, et al. Reduction in blood pressure with a sodium-reduced, potassium- and magnesium-enriched mineral salt in subjects with mild essential hypertension. Hypertens Res. 1998;21:235–243 5 N/A 3 [No authors listed] Dietary and other risk factors of ulcerative colitis. A case-control study in Japan. Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Clin Gastroenterol. 1994;19:166–171 5 N/A 2 Kimura N, et al. Vitamin intake in Japanese women college students. J Nutr Sci Vitaminol (Tokyo). 2003;49:149–155 5 N/A 2 [No authors listed] A case-control study of ulcerative colitis in relation to dietary and other factors in Japan. The Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Gastroenterol. 1995;30(suppl 8):9–12 5 N/A 2 Muraki S, et al. Diet and lifestyle associated with increased bone mineral density: cross-sectional study of Japanese elderly women at an osteoporosis outpatient clinic. J Orthop Sci. 2007;12:317–320 5 N/A 2 Akehi Y, et al. VLCD-induced weight loss improves heart rate variability in moderately obese Japanese. Exp Biol Med (Maywood). 2001;226:440–445 5 N/A 3 Stemmermann G, et al. Epidemiologic pathology of gastric ulcer and gastric carcinoma among Japanese in Hawaii. J Natl Cancer Inst. 1977;58:13-20 5 N/A 2 Suga H, et al. Effect of seasonality on the estimated mean value of nutrients and ranking ability of a self-administered diet history questionnaire. Nutr J. 2014;13:51 5 N/A 2 Miki T, et al. Dietary patterns derived by reduced rank regression (RRR) and depressive symptoms in Japanese employees: The Furukawa Nutrition and Health Study. Psychiatry Res. 2015;229:214–219 5 N/A 2 Montani A, et al. Food/nutrient intake and risk of atrophic gastritis among the Helicobacter pylori-infected population of northeastern Japan. Cancer Sci. 2003;94:372–377 4a Food, recipe 2 Okuda N, et al. Food sources of dietary sodium in the Japanese adult population: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). Eur J Nutr. 2017;56:1269–1280 4b Recipe 2 Yamasaki K, et al. Soy and soy products intake, all-cause mortality, and cause-specific mortality in Japan: The Jichi Medical School Cohort Study. Asia Pac J Public Health. 2015;27:531–541 4b Food 1 Pierce BL, et al. Measuring dietary acculturation in Japanese Americans with the use of confirmatory factor analysis of food-frequency data. Am J Clin Nutr. 2007;86:496–503. 4a Food 1 Sakamoto N, et al. The effect of diet on blood vitamin K status and urinary mineral excretion assessed by a food questionnaire. Nutr Health. 1999;13:1–10 4b Food 2 Niu K, et al. The traditional Japanese dietary pattern and longitudinal changes in cardiovascular disease risk factors in apparently healthy Japanese adults. Eur J Nutr. 2016;55:267–279 5 N/A 2 Freire RD, et al. Nutritional status of Japanese-Brazilian subjects: comparison across gender and generation. Br J Nutr. 2003;89:705–713 4b Food, recipe 1 Hirose K, et al. Dietary factors protective against breast cancer in Japanese premenopausal and postmenopausal women. Int J Cancer. 2003;107:276-282 5 N/A 2 Iizumi H, et al. Effect of food consumption pattern on total serum cholesterol level: a methodological approach. J Nutr Sci Vitaminol (Tokyo). 1986;32:205–218 4a Food 1 Hankin JH, et al. Dietary patterns among men of Japanese ancestry in Hawaii. Cancer Res. 1975;35:3259–3264 4b Food, recipe 2 Mishima I, et al. Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese. Scand J Gastroenterol. 2005;40:1005–1009 5 N/A 2 Nagata C, et al. Associations of acrylamide intake with circulating levels of sex hormones and prolactin in premenopausal Japanese women. Cancer Epidemiol Biomarkers Prev. 2015;24:249–254 5 N/A 2 Okita M, et al. n-3 and n-6 Fatty acid intake and serum phospholipid fatty acid composition in middle-aged women living in rural and urban areas in Okayama Prefecture. J Nutr Sci Vitaminol (Tokyo). 1995;41:313–323 5 N/A 2 Yano K, et al. Childhood cultural experience and the incidence of coronary heart disease in Hawaii Japanese men. Am J Epidemiol. 1979;109:440–450 5 N/A 2 Takada H, et al. Eating habits, activity, lipids and body mass index in Japanese children: the Shiratori Children Study. Int J Obes Relat Metab Disord. 1998;22:470–476 5 N/A 2 Ishizuki Y, et al. [Urinary iodide excretion in Japanese people and thyroid dysfunction]. Nihon Naibunpi Gakkai Zasshi. 1992;68:550–556 5 N/A 2 Shimazu T, et al. Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study. Int J Epidemiol. 2007;36:600–609 4a Meal 2 Tamaki J, et al. Stages of change for salt intake and urinary salt excretion: baseline results from the High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study. Hypertens Res. 2004;27:157–166 5 N/A 2 Nakamura M, et al. Feasibility and effect on blood pressure of 6-week trial of low sodium soy sauce and miso (fermented soybean paste). Circ J. 2003;67:530–534 4b Food 3 Yano K, et al. The effects of childhood residence in Japan and testing language on cognitive performance in late life among Japanese American men in Hawaii. J Am Geriatr Soc. 2000;48:199–204 5 N/A 2 Tajima K, et al. Dietary habits and gastro-intestinal cancers: a comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan. Jpn J Cancer Res. 1985;76:705–716 4b Food, recipe 2 Mshui ME, et al. QT interval and QT dispersion before and after diet therapy in patients with simple obesity. Proc Soc Exp Biol Med. 1999;220:133–138 5 N/A 3 Michikawa T, et al. Serum antioxidants and age-related macular degeneration among older Japanese. Asia Pac J Clin Nutr. 2009;18: 1-7 5 N/A 2 Kamao M, et al. Vitamin K content of foods and dietary vitamin K intake in Japanese young women. J Nutr Sci Vitaminol (Tokyo). 2007;53:464–470 5 N/A 1 Uenishi T, et al. Role of foods in irregular aggravation of atopic dermatitis. J Dermatol. 2003;30:91–97 5 N/A 1 Sakai H, et al. Food-based diet quality score in relation to depressive symptoms in young and middle-aged Japanese women. Br J Nutr. 2017;117:1674–1681 5 N/A 2 Rodriguez BL, et al. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: the Honolulu Heart Program. Diabetes Care. 1999;22:1262–1265 5 N/A 2 Hozawa A, et al. Relationship between serum isoflavone levels and disability-free survival among community-dwelling elderly individuals: nested case-control study of the Tsurugaya project. J Gerontol A Biol Sci Med Sci. 2013;68:465–472 5 N/A 2 Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:103–109 5 N/A 2 Greenway F, et al. A clinical trial testing the safety and efficacy of a standardized Eucommia ulmoides Oliver bark extract to treat hypertension. Altern Med Rev. 2011;16:338–347 5 N/A 3 Oba S, et al. Dietary glycemic index, glycemic load and incidence of type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Nutr J. 2013;12:165 5 N/A 2 Katsuyama H, et al. Usual dietary intake of fermented soybeans (Natto) is associated with bone mineral density in premenopausal women. J Nutr Sci Vitaminol (Tokyo). 2002;48:207–215 4b Food 2 Finegold SM, et al. Fecal microbial flora in Seventh Day Adventist populations and control subjects. Am J Clin Nutr. 1977;30:1781–1792 5 N/A 2 Fukushima Y, et al. Coffee and green tea as a large source of antioxidant polyphenols in the Japanese population. J Agric Food Chem. 2009;57:1253–1259 5 N/A 1 Seino F, et al. Dietary lipids and incidence of cerebral infarction in a Japanese rural community. J Nutr Sci Vitaminol (Tokyo). 1997;43:83–99 4b Nutrient 2 Burchfiel CM, et al. Characteristics associated with rapid decline in forced expiratory volume. Ann Epidemiol. 1996;6:217–227 4a Meal 2 Tsuda M, et al. Marked increase in the urinary level of N-nitrosothioproline after ingestion of cod with vegetables. Cancer Res. 1988;48:4049–4052 4b Recipe 4 Koga M, et al. Mediators of the effects of rice intake on health in individuals consuming a traditional Japanese diet centered on rice. PLoS One. 2017;12:e0185816 4a Food 2 Nomaki R, et al. A Japanese diet with low glycaemic index and glycaemic load is associated with both favourable and unfavourable aspects of dietary intake patterns in three generations of women. Public Health Nutr. 2017;20:649–659 5 N/A 1 Sanaka M, et al. Effects of agar and pectin on gastric emptying and post-prandial glycaemic profiles in healthy human volunteers. Clin Exp Pharmacol Physiol. 2007;34:1151–1155. 4b Food 3 Takamura N, et al. Abnormal folic acid-homocysteine metabolism as maternal risk factors for Down syndrome in Japan. Eur J Nutr. 2004;43:285–287 4b Nutrient 2 Takezaki T, et al. Risk factors of thyroid cancer among women in Tokai, Japan. J Epidemiol. 1996;6:140–147 4a, 4b Nutrient, meal 1 Miura T, et al. Rice cake ileus--a rare and ethnic but important disease status in east-southern Asia. Intern Med. 2011;50:2737–2739 4b Food 1 Sakamoto S, et al. Pre-germinated brown rice could enhance maternal mental health and immunity during lactation. Eur J Nutr. 2007;46:391–396 5 N/A 3 Sawada R, et al. Fat content modulates rapid detection of food: a visual search study using fast food and Japanese diet. Front Psychol. 2017;8:1033 5 N/A 4 Morimoto A, et al. Low prevalence of metabolic syndrome and its components in rural Japan. Tohoku J Exp Med. 2008;216:69–75 4b Food 2 Terasaki H, et al. Association of lifestyle and body structure to ocular axial length in Japanese elementary school children. BMC Ophthalmol. 2017;17:123 4b Meal 2 Reference . Classa . Basis of the definition . Research designb . Nishimura T, et al. Adherence to the food-based Japanese dietary guidelines in relation to metabolic risk factors in young Japanese women. Br J Nutr. 2015;114:645–653 2b Meal 2 Takaizumi K, et al. Influence of awareness of the Japanese Food Guide spinning top on eating behavior and obesity. Asia Pac J Clin Nutr. 2011;20:95–101 2b Meal 2 Kurotani K, et al. Quality of diet and mortality among Japanese men and women: Japan Public Health Center–based prospective study. BMJ. 2016;352:1209 2b Meal 2 Takaizumi K, et al. Impact of awareness of the Japanese Food Guide spinning top on eating behaviour. Public Health Nutr. 2012;15:399–406 2b Meal 2 Oba S, et al. Diet based on the Japanese Food Guide spinning top and subsequent mortality among men and women in a general Japanese population. J Am Diet Assoc. 2009;109:1540–1547 2b Meal 2 Takaizumi K, et al. [Change of awareness level of the Japanese Food Guide spinning top and relation with sociodemographic and health-related characteristics]. In Japanese. Nihon Koshu Eisei Zasshi. 2011;58:948–958 2b Meal 1 Chiba M, et al. Development and application of a plant-based diet scoring system for Japanese patients with inflammatory bowel disease. Perm J. 2016;20:62–68 2b Meal 3 Kuriyama N, et al. Development of a food-based diet quality score for Japanese: associations of the score with nutrient intakes in young, middle-aged and older Japanese women. J Nutr Sci. 2016;5:e41 2b Meal 2 Okubo H, et al. Designing optimal food intake patterns to achieve nutritional goals for Japanese adults through the use of linear programming optimization models. Nutr J. 2015;14:57 2a, 4a Nutrient, food, recipe 1 Koyama T, et al. Relationship of consumption of meals including grain, fish and meat, and vegetable dishes to the prevention of nutrient deficiency: the INTERMAP Toyama Study. J Nutr Sci Vitaminol (Tokyo). 2016;62:101–107 2b, 4a Meal 2 Oita A, et al. Food nitrogen footprint reductions related to a balanced Japanese diet [epub ahead of print, 2017]. Ambio. 2b, 4a Meal 4 Yamori Y, et al. Soy and fish as features of the Japanese diet and cardiovascular disease risks. PLoS One. 2017;12:e0176039 2b, 4a Food 2 Tomata Y, et al. Dietary patterns and incident dementia in elderly Japanese: The Ohsaki Cohort 2006 Study. J Gerontol A Biol Sci Med Sci. 2016;71:1322–1328 4a Meal 2 Wen CP, et al. Changes in serum cholesterol and coronary heart disease mortality associated with changes in the postwar Japanese diet. Am J Clin Nutr. 1973;26:616–619 5 N/A 2 Nomura A, et al. Breast cancer and diet among the Japanese in Hawaii. Am J Clin Nutr. 1978;31:2020–2025 4b Recipe 2 Shibata K, et al. Relationship between urinary concentrations of nine water-soluble vitamins and their vitamin intakes in Japanese adult males. Nutr Metab Insights. 2014;7:61–75 5 N/A 3 Yoshikawa E, et al. Association between frequency of fried food consumption and resilience to depression in Japanese company workers: a cross-sectional study. Lipids Health Dis. 2016;15:156 4a Food 2 Zhang R, et al. The difference in nutrient intakes between Chinese and Mediterranean, Japanese and American diets. Nutrients. 2015;7:4661–4688 4a Nutrient 1 Nakamura M, et al. Japanese and Western diet and risk of idiopathic sudden deafness: a case-control study using pooled controls. Int J Epidemiol. 2001;30:608–615 4b Food 2 Sugiyama M, et al. Glycemic index of single and mixed meal foods among common Japanese foods with white rice as a reference food. Eur J Clin Nutr. 2003;57:743–752 5 N/A 3 Kikuchi S, et al. Cerebral activation focusing on strong tasting food: a functional magnetic resonance imaging study. Neuroreport. 2005;16:281–283 4a Food 3 Fan R, et al. Sustaining effect of intensive nutritional intervention combined with health education on dietary behavior and plasma glucose in type 2 diabetes mellitus patients. Nutrients. 2016;8:e560 3 Food, recipe 3 Hirayama F, et al. Dietary intake of isoflavones and polyunsaturated fatty acids associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease: possible protective effect of traditional Japanese diet. Mol Nutr Food Res. 2010;54:909–917 3 Food 2 Yamada M, et al. Estimation of caffeine intake in Japanese adults using 16 d weighed diet records based on a food composition database newly developed for Japanese populations. Public Health Nutr. 2010;13:663–672 5 N/A 1 Kuratsune M, et al. Dietary fiber in the Japanese diet as investigated in connection with colon cancer risk. Jpn J Cancer Res. 1986;77:736–738 4a Nutrient 1 Nakamura K, et al. Fish as a major source of vitamin D in the Japanese diet. Nutrition. 2002;18:415–416 4a Recipe 1 Hirai K, et al. Cholesterol, phytosterol and polyunsaturated fatty acid levels in 1982 and 1957 Japanese diets. J Nutr Sci Vitaminol (Tokyo). 1986;32:363–372 4a Nutrient 1 Sasaki S, et al. Development of substituted fatty acid food composition table for the use in nutritional epidemiologic studies for Japanese populations: its methodological backgrounds and the evaluation. J Epidemiol. 1999;9:190–207 5 N/A 1 Suzuki T, et al. Japanese dietary pattern consistently relates to low depressive symptoms and it is modified by job strain and worksite supports. J Affect Disord. 2013;150:490–498 4b Meal 2 Sonoda T, et al. A case-control study of diet and prostate cancer in Japan: possible protective effect of traditional Japanese diet. Cancer Sci. 2004;95:238–242 4b Food 2 Mower HF, et al. Analysis of fecal bile acids and diet among the Japanese in Hawaii. J Nutr. 1978;108:1289–1296 4b Food 2 Omura T, et al. Geographical distribution of cerebrovascular disease mortality and food intakes in Japan. Soc Sci Med. 1987;24:401–407 4b Food 2 Nakamura Y, et al. A Japanese diet and 19-year mortality: National integrated project for prospective observation of non-communicable diseases and its trends in the aged, 1980. Br J Nutr. 2009;101:1696–1705 4b Meal 2 Kimura S, et al. Gender differences in childhood food preference: Evaluation using a subjective picture choice method. Pediatr Int. 2014;56:389–394 4b Recipe 3 Nakamura Y, et al. Cancer risk to Japanese population from the consumption of inorganic arsenic in cooked hijiki. J Agric Food Chem. 2008;56:2536–2540 4b Food 1 Horie R, et al. Comparative studies on the relation between nutritional conditions and blood pressure levels of two rural populations with lower incidences of ischemic heart diseases in Japan and Spain. J Cardiovasc Pharmacol. 1990;16(suppl 8):S38–39 4b Nutrient 2 Fukuda S, et al. Pattern of dietary fiber intake among the Japanese general population. Eur J Clin Nutr. 2007;61:99–103 5 N/A 2 Hirayama F, et al. Dietary intake of six minerals in relation to the risk of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:572–577 5 N/A 2 Manabe M. Saltiness enhancement by the characteristic flavor of dried bonito stock. J Food Sci. 2008;73:S321–325 4b Food 3 Hatano S, et al. Stroke mortality and proportional expenditure on selected food items in Japanese communities. Ann Clin Res. 1984;16(suppl 43):163–169 5 N/A 2 Adlercreutz H, et al. Urinary excretion of lignans and isoflavonoid phytoestrogens in Japanese men and women consuming a traditional Japanese diet. Am J Clin Nutr. 1991;54:1093–1100 4b Food 2 Yoshino K, et al. Trends in dietary intake of folate, vitamins B6, and B12 among Japanese adults in two rural communities from 1974 through 2001. J Epidemiol. 2005;15:29–37 5 N/A 1 Dunn JE Jr, et al. Cancer epidemiology in the San Francisco Bay Area. Natl Cancer Inst Monogr. 1977;47:93–98 5 N/A 1 Yano K, et al. Dietary intake and the risk of coronary heart disease in Japanese men living in Hawaii. Am J Clin Nutr. 1978;31:1270–1279 3 Food 2 Ishihara J, et al. Food frequency questionnaire is a valid tool in the nutritional assessment of Brazilian women of diverse ethnicity. Asia Pac J Clin Nutr. 2009;18:76–80 5 N/A 4 Maeda H, et al. Effects of agar (kanten) diet on obese patients with impaired glucose tolerance and type 2 diabetes. Diabetes Obes Metab. 2005;7:40–46 4b Food 3 Insull W Jr, et al. Studies of arteriosclerosis in Japanese and American men. I. Comparison of fatty acid composition of adipose tissue. J Clin Invest. 1969;48:1313–1327 3 Nutrient 2 Kobayashi C, et al. Experience-induced changes in taste identification of monosodium glutamate. Physiol Behav. 2002;75:57–63 4b Nutrient 3 Hirose K, et al. Dietary patterns and the risk of breast cancer in Japanese women. Cancer Sci. 2007;98:1431–1438 4b Meal 2 Ogunleiye AJ, et al. Effect of fish oil and safflower oil in common Japanese diet on human plasma fatty acid composition. J Nutr Sci Vitaminol (Tokyo). 1990;36:423–430 4b Meal 3 Kato I, et al. Per capita foods/nutrients intake and mortality from gastrointestinal cancers in Japan. Jpn J Cancer Res. 1987;78:453–459 4b Food 1 Fukushima T, et al. Food intake, serum lipids and amino acids of school children in agricultural communities in Japan. Eur J Clin Nutr. 1999;53:207–210 4b Food 2 Miyake Y, et al. Dietary intake of seaweed and minerals and prevalence of allergic rhinitis in Japanese pregnant females: baseline data from the Osaka Maternal and Child Health Study. Ann Epidemiol. 2006;16:614–621 4b Food 2 Sobko T, et al. Dietary nitrate in Japanese traditional foods lowers diastolic blood pressure in healthy volunteers. Nitric Oxide. 2010;22:136–140 4b Food 3 Yukawa GS, et al. Effects of coffee consumption on oxidative susceptibility of low-density lipoproteins and serum lipid levels in humans. Biochemistry (Mosc). 2004;69:70–74 5 N/A 3 Katagiri R, et al. Iodine excretion in 24-hour urine collection and its dietary determinants in healthy Japanese adults. J Epidemiol. 2016;26:613–621 4b Nutrient 2 Matsuda-Inoguchi N, et al. Estimation of nutrient intake by the new version of Japanese food composition tables in comparison with that by the previous version. Tohoku J Exp Med. 2001;194:229–239 5 N/A 1 Kutoh E, et al. Alogliptin as an initial therapy in patients with newly diagnosed, drug naïve type 2 diabetes: a randomized, control trial. Endocrine. 2012;41:435–441 4a Meal 3 Imaeda N, et al. Usual dietary intakes of selected trace elements (Zn, Cu, Mn, I, Se, Cr, and Mo) and biotin revealed by a survey of four-season 7-consecutive day weighed dietary records in middle-aged Japanese dietitians. J Nutr Sci Vitaminol (Tokyo). 2013;59:281–288 4b Food 1 Guo H, et al. Association of Japanese dietary pattern with serum adiponectin concentration in Japanese adult men. Nutr Metab Cardiovasc Dis. 2012;22:277–284 4a Food 2 Kawasaki T, et al. Reduction in blood pressure with a sodium-reduced, potassium- and magnesium-enriched mineral salt in subjects with mild essential hypertension. Hypertens Res. 1998;21:235–243 5 N/A 3 [No authors listed] Dietary and other risk factors of ulcerative colitis. A case-control study in Japan. Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Clin Gastroenterol. 1994;19:166–171 5 N/A 2 Kimura N, et al. Vitamin intake in Japanese women college students. J Nutr Sci Vitaminol (Tokyo). 2003;49:149–155 5 N/A 2 [No authors listed] A case-control study of ulcerative colitis in relation to dietary and other factors in Japan. The Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Gastroenterol. 1995;30(suppl 8):9–12 5 N/A 2 Muraki S, et al. Diet and lifestyle associated with increased bone mineral density: cross-sectional study of Japanese elderly women at an osteoporosis outpatient clinic. J Orthop Sci. 2007;12:317–320 5 N/A 2 Akehi Y, et al. VLCD-induced weight loss improves heart rate variability in moderately obese Japanese. Exp Biol Med (Maywood). 2001;226:440–445 5 N/A 3 Stemmermann G, et al. Epidemiologic pathology of gastric ulcer and gastric carcinoma among Japanese in Hawaii. J Natl Cancer Inst. 1977;58:13-20 5 N/A 2 Suga H, et al. Effect of seasonality on the estimated mean value of nutrients and ranking ability of a self-administered diet history questionnaire. Nutr J. 2014;13:51 5 N/A 2 Miki T, et al. Dietary patterns derived by reduced rank regression (RRR) and depressive symptoms in Japanese employees: The Furukawa Nutrition and Health Study. Psychiatry Res. 2015;229:214–219 5 N/A 2 Montani A, et al. Food/nutrient intake and risk of atrophic gastritis among the Helicobacter pylori-infected population of northeastern Japan. Cancer Sci. 2003;94:372–377 4a Food, recipe 2 Okuda N, et al. Food sources of dietary sodium in the Japanese adult population: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP). Eur J Nutr. 2017;56:1269–1280 4b Recipe 2 Yamasaki K, et al. Soy and soy products intake, all-cause mortality, and cause-specific mortality in Japan: The Jichi Medical School Cohort Study. Asia Pac J Public Health. 2015;27:531–541 4b Food 1 Pierce BL, et al. Measuring dietary acculturation in Japanese Americans with the use of confirmatory factor analysis of food-frequency data. Am J Clin Nutr. 2007;86:496–503. 4a Food 1 Sakamoto N, et al. The effect of diet on blood vitamin K status and urinary mineral excretion assessed by a food questionnaire. Nutr Health. 1999;13:1–10 4b Food 2 Niu K, et al. The traditional Japanese dietary pattern and longitudinal changes in cardiovascular disease risk factors in apparently healthy Japanese adults. Eur J Nutr. 2016;55:267–279 5 N/A 2 Freire RD, et al. Nutritional status of Japanese-Brazilian subjects: comparison across gender and generation. Br J Nutr. 2003;89:705–713 4b Food, recipe 1 Hirose K, et al. Dietary factors protective against breast cancer in Japanese premenopausal and postmenopausal women. Int J Cancer. 2003;107:276-282 5 N/A 2 Iizumi H, et al. Effect of food consumption pattern on total serum cholesterol level: a methodological approach. J Nutr Sci Vitaminol (Tokyo). 1986;32:205–218 4a Food 1 Hankin JH, et al. Dietary patterns among men of Japanese ancestry in Hawaii. Cancer Res. 1975;35:3259–3264 4b Food, recipe 2 Mishima I, et al. Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese. Scand J Gastroenterol. 2005;40:1005–1009 5 N/A 2 Nagata C, et al. Associations of acrylamide intake with circulating levels of sex hormones and prolactin in premenopausal Japanese women. Cancer Epidemiol Biomarkers Prev. 2015;24:249–254 5 N/A 2 Okita M, et al. n-3 and n-6 Fatty acid intake and serum phospholipid fatty acid composition in middle-aged women living in rural and urban areas in Okayama Prefecture. J Nutr Sci Vitaminol (Tokyo). 1995;41:313–323 5 N/A 2 Yano K, et al. Childhood cultural experience and the incidence of coronary heart disease in Hawaii Japanese men. Am J Epidemiol. 1979;109:440–450 5 N/A 2 Takada H, et al. Eating habits, activity, lipids and body mass index in Japanese children: the Shiratori Children Study. Int J Obes Relat Metab Disord. 1998;22:470–476 5 N/A 2 Ishizuki Y, et al. [Urinary iodide excretion in Japanese people and thyroid dysfunction]. Nihon Naibunpi Gakkai Zasshi. 1992;68:550–556 5 N/A 2 Shimazu T, et al. Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study. Int J Epidemiol. 2007;36:600–609 4a Meal 2 Tamaki J, et al. Stages of change for salt intake and urinary salt excretion: baseline results from the High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study. Hypertens Res. 2004;27:157–166 5 N/A 2 Nakamura M, et al. Feasibility and effect on blood pressure of 6-week trial of low sodium soy sauce and miso (fermented soybean paste). Circ J. 2003;67:530–534 4b Food 3 Yano K, et al. The effects of childhood residence in Japan and testing language on cognitive performance in late life among Japanese American men in Hawaii. J Am Geriatr Soc. 2000;48:199–204 5 N/A 2 Tajima K, et al. Dietary habits and gastro-intestinal cancers: a comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan. Jpn J Cancer Res. 1985;76:705–716 4b Food, recipe 2 Mshui ME, et al. QT interval and QT dispersion before and after diet therapy in patients with simple obesity. Proc Soc Exp Biol Med. 1999;220:133–138 5 N/A 3 Michikawa T, et al. Serum antioxidants and age-related macular degeneration among older Japanese. Asia Pac J Clin Nutr. 2009;18: 1-7 5 N/A 2 Kamao M, et al. Vitamin K content of foods and dietary vitamin K intake in Japanese young women. J Nutr Sci Vitaminol (Tokyo). 2007;53:464–470 5 N/A 1 Uenishi T, et al. Role of foods in irregular aggravation of atopic dermatitis. J Dermatol. 2003;30:91–97 5 N/A 1 Sakai H, et al. Food-based diet quality score in relation to depressive symptoms in young and middle-aged Japanese women. Br J Nutr. 2017;117:1674–1681 5 N/A 2 Rodriguez BL, et al. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: the Honolulu Heart Program. Diabetes Care. 1999;22:1262–1265 5 N/A 2 Hozawa A, et al. Relationship between serum isoflavone levels and disability-free survival among community-dwelling elderly individuals: nested case-control study of the Tsurugaya project. J Gerontol A Biol Sci Med Sci. 2013;68:465–472 5 N/A 2 Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19:103–109 5 N/A 2 Greenway F, et al. A clinical trial testing the safety and efficacy of a standardized Eucommia ulmoides Oliver bark extract to treat hypertension. Altern Med Rev. 2011;16:338–347 5 N/A 3 Oba S, et al. Dietary glycemic index, glycemic load and incidence of type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Nutr J. 2013;12:165 5 N/A 2 Katsuyama H, et al. Usual dietary intake of fermented soybeans (Natto) is associated with bone mineral density in premenopausal women. J Nutr Sci Vitaminol (Tokyo). 2002;48:207–215 4b Food 2 Finegold SM, et al. Fecal microbial flora in Seventh Day Adventist populations and control subjects. Am J Clin Nutr. 1977;30:1781–1792 5 N/A 2 Fukushima Y, et al. Coffee and green tea as a large source of antioxidant polyphenols in the Japanese population. J Agric Food Chem. 2009;57:1253–1259 5 N/A 1 Seino F, et al. Dietary lipids and incidence of cerebral infarction in a Japanese rural community. J Nutr Sci Vitaminol (Tokyo). 1997;43:83–99 4b Nutrient 2 Burchfiel CM, et al. Characteristics associated with rapid decline in forced expiratory volume. Ann Epidemiol. 1996;6:217–227 4a Meal 2 Tsuda M, et al. Marked increase in the urinary level of N-nitrosothioproline after ingestion of cod with vegetables. Cancer Res. 1988;48:4049–4052 4b Recipe 4 Koga M, et al. Mediators of the effects of rice intake on health in individuals consuming a traditional Japanese diet centered on rice. PLoS One. 2017;12:e0185816 4a Food 2 Nomaki R, et al. A Japanese diet with low glycaemic index and glycaemic load is associated with both favourable and unfavourable aspects of dietary intake patterns in three generations of women. Public Health Nutr. 2017;20:649–659 5 N/A 1 Sanaka M, et al. Effects of agar and pectin on gastric emptying and post-prandial glycaemic profiles in healthy human volunteers. Clin Exp Pharmacol Physiol. 2007;34:1151–1155. 4b Food 3 Takamura N, et al. Abnormal folic acid-homocysteine metabolism as maternal risk factors for Down syndrome in Japan. Eur J Nutr. 2004;43:285–287 4b Nutrient 2 Takezaki T, et al. Risk factors of thyroid cancer among women in Tokai, Japan. J Epidemiol. 1996;6:140–147 4a, 4b Nutrient, meal 1 Miura T, et al. Rice cake ileus--a rare and ethnic but important disease status in east-southern Asia. Intern Med. 2011;50:2737–2739 4b Food 1 Sakamoto S, et al. Pre-germinated brown rice could enhance maternal mental health and immunity during lactation. Eur J Nutr. 2007;46:391–396 5 N/A 3 Sawada R, et al. Fat content modulates rapid detection of food: a visual search study using fast food and Japanese diet. Front Psychol. 2017;8:1033 5 N/A 4 Morimoto A, et al. Low prevalence of metabolic syndrome and its components in rural Japan. Tohoku J Exp Med. 2008;216:69–75 4b Food 2 Terasaki H, et al. Association of lifestyle and body structure to ocular axial length in Japanese elementary school children. BMC Ophthalmol. 2017;17:123 4b Meal 2 Abbreviations: N/A, not applicable. a Class 2a: definition proposed by a public agency with concrete evidence cited; 2 b: definition proposed by a public agency with concrete evidence not cited; 3: the definition was proposed by the author(s) in the cited article(s); 4a: the definition was defined in the article by the author(s) and a reference was provided for the definition; 4 b: the definition was defined in the article by the author(s) with no reference provided for the definition; 5: others. b Research designs are numbered as follows: (1) descriptive epidemiological study, (2) analytical epidemiological study, (3) intervention study, and (4) other type of epidemiological study. Open in new tab Figure 3 shows the research designs used in the articles. The 116 articles were categorized into 1 of 4 designs. An analytical epidemiological design was used in 68 articles (59%). A descriptive epidemiological design was used in 24 articles and an interventional design in 20 articles. Table 2 lists the 116 studies included in the analysis. Figure 3 Open in new tabDownload slide Epidemiological methods used in the studies. The number of studies is indicated in the boxes. Figure 3 Open in new tabDownload slide Epidemiological methods used in the studies. The number of studies is indicated in the boxes. DISCUSSION The Japanese diet has been hypothesized to be healthy and to contribute to the longevity of the Japanese people.1–3 This literature review, however, revealed the need for a scientifically sound definition before initiating studies investigating the Japanese diet and health outcomes. The most notable finding was that many of the authors proposed their own definition of the Japanese diet, investigated the health effects within this context, and preferentially used a food-based definition. Although a deeper analysis of the Japanese diet defined in each study could not be performed, the defined diets seemed to reflect only a part, rather than whole or wide aspects, of the actual Japanese diet, because food is only a part of the dietary culture. The other typical definition of the Japanese diet was based on the Japanese Food Guide spinning top issued by the Ministry of Agriculture, Forestry, and Fisheries of Japan.7 However, enough evidence to provide a scientific basis through the process of the development of the Japanese Food Guide spinning top could not be found. It may be possible to define the Japanese diet sociologically or culturally and anthropologically, such as Washoku, the traditional diet cultures of the Japanese listed by the United Nations Education, Social, and Cultural Organization in 2013 as an intangible cultural heritage.8 However, because such diets are only a part of recent ordinary diets for the Japanese, it is easily expected that the diets may not contribute to the longevity of the Japanese people. It seems much more difficult to quantitatively, rather than qualitatively, define the Japanese diet from the viewpoints of nutrition and health. This literature review showed that many authors defined the Japanese diet according to their own thoughts in their studies. For example, authors who were interested in green tea defined the Japanese diet as a diet with green tea.9 This was also the case for other food items such as tofu, natto (fermented soy bean), fish, and rice.10–13 Some studies used nutrient-based definitions of the Japanese diet, such as the ratio of n-3 to n-6 fatty acids or the ratio of animal to vegetable proteins.14,15 One systematic review conducted in Japan showed that some major dietary patterns were reproducible in different populations and different studies in Japan, but others were not.16 Some major dietary patterns greatly changed over the course of 13 years (from 2003 to 2015) in Japan.17 These studies indicated that a much more careful and comprehensive approach with a sufficient volume of data is needed to define the Japanese diet. CONCLUSION In the majority of the articles examined in this literature review, the Japanese diet was self-defined by the authors. Some studies used a definition proposed by the government. In this method, no systematic approach for defining the Japanese diet from the viewpoints of nutrition and health was found. Before examining the association of the Japanese diet with health outcomes, it is essential to address the question of what the Japanese diet is, researched from the viewpoint of human nutrition rather than the culinary culture. Acknowledgments Author Contributions. Under the supervision of S.S., the members of the Working Group 1 of the Healthy Diet Research Committee of the International Life Sciences Institute Japan equally contributed to conducting literature search, analyzing the data, preparing the manuscript, and approving the final manuscript. Funding. This research was conducted as a part of the activities of the International Life Sciences Institute Japan Research Committee, which is on a noncompensated basis, except for travel expenses for academia members, as required. Declaration of interest. Companies to which authors belong are members of the International Life Sciences Institute (ILSI) Japan to support the activities conducted by ILSI Japan. References 1 Willett WC. Diet and health: what should we eat? Science 1994 ; 264 : 532 – 537 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kanauchi M , Kanauchi K. Proposal for an empirical Japanese diet score and the Japanese diet pyramid . Nutrients 2019 ; 11 : 2741 . Google Scholar Crossref Search ADS WorldCat 3 Gabriel AS , Ninomiya K , Uneyama H. The role of the Japanese traditional diet in healthy and sustainable dietary patterns around the world . Nutrients 2018 ; 10 : 173 . Google Scholar Crossref Search ADS WorldCat 4 Sofi F , Macchi C , Abbate R , et al. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score . Public Health Nutr. 2014 ; 17 : 2769 – 2782 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Davis C , Bryan J , Hodgson J , et al. 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Accessed June 11, 2020. 9 Fukushima Y , Ohie T , Yonekawa Y , et al. Coffee and green tea as a large source of antioxidant polyphenols in the Japanese population . J Agric Food Chem. 2009 ; 57 : 1253 – 1259 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Yamori Y , Sagara M , Arai Y , et al. Soy and fish as features of the Japanese diet and cardiovascular disease risks . PLoS One. 2017 ; 12 : E0176039 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Yamasaki K , Kayaba K , Ishikawa S. Soy and soy products intake, all-cause mortality, and cause-specific mortality in Japan: the Jichi Medical School Cohort Study . Asia Pac J Public Health. 2015 ; 27 : 531 – 541 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Sugiyama M , Tang AC , Wakaki Y , et al. Glycemic index of single and mixed meal foods among common Japanese foods with white rice as a reference food . Eur J Clin Nutr. 2003 ; 57 : 743 – 752 . 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Google Scholar Crossref Search ADS WorldCat Author notes Working Group 1 Members: Satoshi Sasaki (Leader, The University of Tokyo); Noriko Ohsaki, Shinichiro Saito, and Masanobu Hibi (Kao Corp.); Yoshiko Yokomukai (International Life Sciences Institute Japan); Hisamine Kobayashi (Ajinomoto Co., Inc.); Hiroyuki Suganuma, Takuro Inoue, and Ryohei Umeda (Kagome Co., Ltd.); Akio Obata (Kikkoman Corp.); Miho Komatsu (Kyowa Hakko Bio Co., Ltd); Takayoshi Kirisako and Masahiro Kita (Kirin Holdings Company, Ltd.); Nori Karasawa (NH Foods, Ltd.); Kayo Kurotani (National Institute of Health and Nutrition); and Satomi Kobayashi (The University of Tokyo). © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Sakata,, Takashi;for Working Group 2 of the Healthy Diet Research Committee of International Life Sciences Institute,, Japan

doi: 10.1093/nutrit/nuaa089pmid: 33259620

Abstract Working Group 2 of the Healthy Diet Research Committee of International Life Sciences Institute Japan (WG2) assessed the concept and practice of healthy eating in the ready-to-eat food/meal industry in Japan. WG2 interviewed 14 arbitrarily selected member companies that included “health” or “nutrition” in their management policy, and sent a questionnaire to 338 member companies of the Japan Ready-Made Meal Association. Ready-to-eat food/meal suppliers mainly referred to Dietary Reference Intakes for Japanese, the Japanese Food Guide, and/or Healthy Japan 21 for their menu construction. They increased dietary fiber, variety, vegetables, whole-grain cereals, millet rice, and soy bean products; and reduced energy, carbohydrates, and salt in “healthy” food. They tended to avoid making direct appeals to health. Many companies reduced the salt content without drawing attention to the practice. They continually strive to improve flavor as the single most important factor for selling healthy food. The cycling of menus is used to increase diversity in food consumption. These industries require both academia and the government to define priorities for increasing and decreasing particular nutrients as the main targets and to establish the maximum time for balancing each nutrient. governmental guidelines, ingredient, nutrient, ready-made meal, sales tactic INTRODUCTION Ready-to-eat food or meals in Japan is defined as “food or a meal that can be eaten without cooking or heating at home, workplace, school, etc., such as lunch boxes and daily dishes with a short shelf life.”1 The sales of ready-to-eat food/meals is growing and, in 2017, they exceeded JPY 10 trillion.1 The expected increase in the number of elderly people and the results of women’s empowerment in Japan should favor this sector of the food industry. The main products of these ready-to-eat food/meal suppliers are cooked rice (50%) and daily dishes (34%), namely lunch boxes, rice balls, sandwiches, croquettes, and vegetable salads in the Tokyo metropolitan area.1 These products are sold mainly via convenience stores (32%), specialty stores (29%), and food supermarkets (26%).1 Objectives We conducted a survey to evaluate the concept of “healthy eating” among ready-to-eat food companies that are expected to grow in Japan, and we summarized the findings for academic research and governmental policy and regulation needed to achieve healthy eating. METHODS Working Group 2 of the Healthy Diet Research Committee of International Life Sciences Institute (ILSI) Japan (WG2) conducted a round-table discussion with the Japan Ready-Made Meal Association (JRMA) to clarify the general business structure, and then performed semistructured interviews to arbitrarily select 14 (of 24 approached) JRMA member companies stating “health” or “nutrition” in their management policy. We administered a nationwide online questionnaire via Google forms to only the 14 selected JRMA member companies via the JRMA. JRMA is a national association comprising 338 regular member companies, 216 supporting member companies, and 40 cooperating companies. RESULTS Findings from interviews Of 24 member companies of JRMA that publish statements on healthy or nutritious food in their policies and were selected for visits by WG2, 14 companies accepted the visit. Annual sales of these 14 companies exceeded JPY 40 billion; the average annual sales of JRMA regular member companies in 2019 totaled JPY 12.6 billion (Table 1). Table 1 Characteristics of interviewed companies Sales route . Sales area . Annual sales (billion JPY) . Respondent . Supermarket Metropolitan and Kansai 700 Dept. of Public Relations Supermarket Metropolitan 400 Dept. of Operations Supermarket Metropolitan 200 Dept. of Merchandise Specialty store Nationwide 200 Executives, Corporate Planning and Domestic Operations Specialty store Nationwide 100 Depts. of General Affairs and of Merchandise Specialty store Nationwide 60 Dept. of Marketing Specialty store Nationwide 30 Executive, Production Control Delivery Local 5 Dept. of Nutritional Quality Control Own delicatessen store Nationwide 50 Executive, Dept. of Quality Control Own store and supermarket Nationwide 90 Executive, Products, Dept. of General Affairs Own delicatessen/lunchbox store Metropolitan and Kansai 50 Depts. of Management Strategy and of Product Development Restaurant Nationwide 200 Executive, Product Development, Dept. of Planning Lunchbox Nationwide 50 Corporate Planning Office, Dept. of Products Delivery Nationwide 60 Dept. of Operation Sales route . Sales area . Annual sales (billion JPY) . Respondent . Supermarket Metropolitan and Kansai 700 Dept. of Public Relations Supermarket Metropolitan 400 Dept. of Operations Supermarket Metropolitan 200 Dept. of Merchandise Specialty store Nationwide 200 Executives, Corporate Planning and Domestic Operations Specialty store Nationwide 100 Depts. of General Affairs and of Merchandise Specialty store Nationwide 60 Dept. of Marketing Specialty store Nationwide 30 Executive, Production Control Delivery Local 5 Dept. of Nutritional Quality Control Own delicatessen store Nationwide 50 Executive, Dept. of Quality Control Own store and supermarket Nationwide 90 Executive, Products, Dept. of General Affairs Own delicatessen/lunchbox store Metropolitan and Kansai 50 Depts. of Management Strategy and of Product Development Restaurant Nationwide 200 Executive, Product Development, Dept. of Planning Lunchbox Nationwide 50 Corporate Planning Office, Dept. of Products Delivery Nationwide 60 Dept. of Operation Abbreviations: Dept., department; JPY, Japanese yen. Open in new tab Table 1 Characteristics of interviewed companies Sales route . Sales area . Annual sales (billion JPY) . Respondent . Supermarket Metropolitan and Kansai 700 Dept. of Public Relations Supermarket Metropolitan 400 Dept. of Operations Supermarket Metropolitan 200 Dept. of Merchandise Specialty store Nationwide 200 Executives, Corporate Planning and Domestic Operations Specialty store Nationwide 100 Depts. of General Affairs and of Merchandise Specialty store Nationwide 60 Dept. of Marketing Specialty store Nationwide 30 Executive, Production Control Delivery Local 5 Dept. of Nutritional Quality Control Own delicatessen store Nationwide 50 Executive, Dept. of Quality Control Own store and supermarket Nationwide 90 Executive, Products, Dept. of General Affairs Own delicatessen/lunchbox store Metropolitan and Kansai 50 Depts. of Management Strategy and of Product Development Restaurant Nationwide 200 Executive, Product Development, Dept. of Planning Lunchbox Nationwide 50 Corporate Planning Office, Dept. of Products Delivery Nationwide 60 Dept. of Operation Sales route . Sales area . Annual sales (billion JPY) . Respondent . Supermarket Metropolitan and Kansai 700 Dept. of Public Relations Supermarket Metropolitan 400 Dept. of Operations Supermarket Metropolitan 200 Dept. of Merchandise Specialty store Nationwide 200 Executives, Corporate Planning and Domestic Operations Specialty store Nationwide 100 Depts. of General Affairs and of Merchandise Specialty store Nationwide 60 Dept. of Marketing Specialty store Nationwide 30 Executive, Production Control Delivery Local 5 Dept. of Nutritional Quality Control Own delicatessen store Nationwide 50 Executive, Dept. of Quality Control Own store and supermarket Nationwide 90 Executive, Products, Dept. of General Affairs Own delicatessen/lunchbox store Metropolitan and Kansai 50 Depts. of Management Strategy and of Product Development Restaurant Nationwide 200 Executive, Product Development, Dept. of Planning Lunchbox Nationwide 50 Corporate Planning Office, Dept. of Products Delivery Nationwide 60 Dept. of Operation Abbreviations: Dept., department; JPY, Japanese yen. Open in new tab Interviewed companies generally based their meals and menus on Dietary Reference Intakes for Japanese,2 the Japanese Food Guide,3 or Healthy Japan 21.4 These companies intended to increase or improve ingredient variety (n = 5 companies), vegetables (n = 4), dietary fiber (n = 3), lactic acid bacteria (n = 2), green and yellow vegetables, millet rice, organic ingredients, quinoa, ω3-fatty acids, iron, lycopene, calcium, protein, and nutrient balance. They intended to reduce or omit salt (n = 8 companies), energy (n = 5), additives (n = 4), chemical seasoning (n = 3), carbohydrates (n = 2), and lipids. It was a general tendency of all interviewed companies to avoid direct health appeals such as “reduced salt,” although many of them actually reduced the salt content in their products gradually but continuously. These companies considered direct health appeals to be unpopular and to reduce sales. They emphasized a healthy atmosphere as a whole. It was also noted that some positive wording such as “rice bowl with lots of vegetables” increased sales. All companies considered good flavor to be the single most important sales factor. Therefore, they regularly worked to improve the flavor of their products and tested the customers’ opinions of the improvements often via face-to-face tastings as points of sale, which resulted in an increase or recovery of the sales. One company selling warm lunchboxes developed 2 series of cycling menus for 1 week, one with large portions and another relatively fit with respect to energy and salt content. The main customers of the company are busy people who do not pay much attention to nutrition or health. The company intended to increase the variety of ingredients and tried to balance the nutrient intake if the customer purchases the same cycling menu, even without considering the contents of the lunch box. Interestingly, most of these customers purchased the large-portion meals and the fit meals alternately, that is, there was approximately a 50% improvement. This can be an important tactic for improving the nutritional status of laymen without pressing them to behave healthily. Findings from nationwide questionnaire JRMA distributed the questionnaire to 338 member companies online in July 2019. In total, 88 companies responded the questionnaire (response rate, 26.0%). Just 50 of the 88 responding companies had annual sales of more than JPY 1 billion. Considering the average annual sales of JRMA regular member companies of JPY 12.6 billion, response rate should have been higher in smaller companies than in large companies. The proportion of responding companies selling via supermarket was approximately twice that of the JRMA regular member companies. Therefore, the results may have sampling bias and, accordingly, may not represent the overall tendency of JRMA members. Distributions of their main product and route of sales indicated that the composition of these companies approximately, but not entirely, reflected the composition of the JRMA (Figure 1). Therefore, the results may not represent the status quo of all JRMA member companies. Figure 1 Open in new tabDownload slide Main products and routes of sales of responding Japan Ready-Made Meal Association member companies (multiple answers, n = 88). Abbreviation: EC, electronic commerce. Figure 1 Open in new tabDownload slide Main products and routes of sales of responding Japan Ready-Made Meal Association member companies (multiple answers, n = 88). Abbreviation: EC, electronic commerce. Approximately 60% of the responding companies had health- or nutrition-oriented wording in their management policies or on their homepage. Approximately 75% of the responding companies produced health- or nutrition-oriented products (Figure 2). The responding companies most often cited Dietary Reference Intakes for Japanese2 and Japanese Food Guide Spinning Top as the resources on which they based their the menu design (Figure 3). Figure 2 Open in new tabDownload slide Health or nutrient orientation of responding companies (n = 88). Figure 2 Open in new tabDownload slide Health or nutrient orientation of responding companies (n = 88). Figure 3 Open in new tabDownload slide Governmental guidelines or policies on which responding companies based their menu construction (multiple answers, n = 88). *Ministry of Health, Labour and Welfare; **Ministry of Health, Labour and Welfare, and Ministry of Agriculture, Forestry and Fisheries; ***Ministry of Health, Labour and Welfare, Ministry of Agriculture, Forestry and Fisheries, and Ministry of Education, Culture, Sports, Science and Technology. Figure 3 Open in new tabDownload slide Governmental guidelines or policies on which responding companies based their menu construction (multiple answers, n = 88). *Ministry of Health, Labour and Welfare; **Ministry of Health, Labour and Welfare, and Ministry of Agriculture, Forestry and Fisheries; ***Ministry of Health, Labour and Welfare, Ministry of Agriculture, Forestry and Fisheries, and Ministry of Education, Culture, Sports, Science and Technology. Nutrients focused on in successful health- or nutrition-oriented products were energy, carbohydrate, dietary fiber, sodium, protein, and lipid. Ingredients in successful health- or nutrition-oriented products were vegetables, whole-grain cereals, soy products, miscellaneous grains, seasoning, animal meat, seafood, fermented products, and oil (Figure 4). There was no marked tendency with regard to focused nutrient or ingredient in failed health- or nutrition-oriented products. Figure 4 Open in new tabDownload slide Nutrients and ingredients focused in successful health or nutrition-oriented products (multiple answers, n = 88). Abbreviation: Na, sodium. Figure 4 Open in new tabDownload slide Nutrients and ingredients focused in successful health or nutrition-oriented products (multiple answers, n = 88). Abbreviation: Na, sodium. The challenges for responding companies in the development and sales of health- or nutrition-oriented products were to produce good-tasting products at a low cost that appeal to the consumer via an efficient production process with stabilization of the food content. SUGGESTIONS On the basis of the surveys findings, WG2 wants to highlight the importance of developing and disseminating simple and easily understandable guidelines and labeling policies for the production of healthy and nutritious ready-to-eat food/meals. In this regard, WG2 proposes to define priorities for which nutrients to increase or decrease, to prioritize target population (eg, those who are establishing food habits or those who eat without consideration of what they eat), and to indicate the maximum time to balance each nutrient. Acknowledgments The WG2 members sincerely express their gratitude for the generous cooperation of Japan Ready-Made Meal Association and its member companies, which was essential for conducting this study. The study plan of the survey was reviewed by the Ethics Committee for Human Studies of Ishinomaki Senshu University (application no. 2018–001) and determined to be a study not requiring the permission of the committee. Although, many authors belong to private companies, all authors wrote a pledge stating that all information gathered during this survey belongs to ILSI Japan and will not be used otherwise without the consent of ILSI Japan. Author contributions. T.S. supervised the study. All authors equally contributed to develop the research design, conduct the survey, analyze the data, and prepare the manuscript, and all approved the final manuscript. Funding. This research was conducted as a part of the activities of the International Life Sciences Institute Japan Research Committee, which are not compensated except for travel expenses for academia members, as required. Declaration of interest. T.S. is a vice president and a member of the Board of Trustees for International Life Sciences Institute (ILSI) Japan. He is also a member of the organizing committee and the program committee for the 8th International Conference on Nutrition and Aging held October 1-2, 2019. R.A. is a member of the program committee for the 8th International Conference on Nutrition and Aging. Companies to which authors belong are members of ILSI Japan and support the organization’s activities. References 1 White Paper of Japan Ready-Made Meal Association (2018) (Digest on-line edition). Japan Ready-Made Meal Association. http://www.nsouzai-kyoukai.or.jp/wp-content/uploads/hpb-media/hakusho2018_digest1.pdf. 2 Ministry of Health, Labour and Welfare. Overview of Dietary Reference Intakes for Japanese (2015). Available at: https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/Overview.pdf. Accessed April 18, 2020. 3 Ministry of Health, Labour and Welfare; Ministry of Agriculture, Forestry, and Fisheries. Japanese Food Guide Spinning Top. Do you have a well-balanced diet? https://www.maff.go.jp/j/balance_guide/b_use/pdf/eng_reiari.pdf. Accessed April 18, 2020. 4 Ministry of Health, Labour and Welfare. A basic direction for comprehensive implementation of national health promotion. Ministerial Notification No. 430 of the Ministry of Health, Labour and Welfare. Available at: https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000047330.pdf. Accessed April 28, 2020. Author notes Working Group 2 Members: Takashi Sakata (Leader, Ishinomaki Senshu University), Takeaki Akabane (ADEKA Corp.), Chikako Akagaki (SEVEN-ELEVEN JAPAN Co., Ltd.), Rie Akamatsu (Ochanomizu University and The Japanese Society of Nutrition and Dietetics), Toshihiko Hagiwara (NICHIREI Corp.), Naoki Hayashi (Ajinomoto Co., Inc.), Li Han (Nippon Suisan Kaisha, Ltd.), Hajime Kato (Yano Research Institute Ltd.), Kayo Kurotani and Kazuko Ishikawa-Takata (the National Institutes of Biomedical Innovation, Health and Nutrition), Shunsuke Omoto (Kirin Holdings Company, Ltd.), Takashi Tanaka (YAMAZAKI BAKING Co. Ltd.), and Yoshiko Yokomukai (International Life Science Institute JAPAN) © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Kuwata,, Tamotsu;for Working Group 3 of the Healthy Diet Research Committee of International Life Sciences Institute,, Japan

doi: 10.1093/nutrit/nuaa080pmid: 33259617

Abstract Many issues regarding the social implementation of healthy diets remain to be solved. The structure of these issues and the route to achieve social implementation are not well organized. Working Group 3 of the Healthy Diet Research Committee of International Life Sciences Institute, Japan, surveyed some precedent cases aiming to establish a healthy diet and, by categorizing the success factors, developed recommendations for the social implementation of a healthy diet. Interviews were conducted with 8 “good health management” companies in various industries that target the “work area.” In the hearing, the Reach, Effectiveness, Adoption, Implementation, Maintenance model was used as a reference for evaluating the intervention effects. Many problems in implementation were revealed, especially with respect to continuity in and approaches to addressing indifference to health. “Management intention,” “Linking with their own business,” and “Visualization” were cited as factors for successful implementation of the health measures. behavior change, food choice, healthy diet, social implementation INTRODUCTION Many issues regarding the social implementation of healthy diets remain to be solved. The structures of these issues and methods of implementing the ideal diet for public health, however, are not well understood. Therefore, Working Group 3 of the Healthy Diet Research Committee of the International Life Sciences Institute, Japan(WG3), aimed to study some precedents to clarify the factors associated with success and challenges of social implementation of healthy diets. Dependence on dining out and home-meal replacement will continue to increase. Therefore, food providers must supply healthy meals at an accessible price to improve and broaden the eating habits of people. It is necessary to improve the eating environment. On the other hand, a wide range of educational programs and dissemination of information about healthy meals are needed to improve the health literacy of people in parallel with actions to promote healthy food selection by consumers. People in Japan spend their daily lives in at least 1 of the following 3 areas: local communities, workplace, and schools. Therefore, it was decided to survey the precedents in each of these areas. The formation of food preferences and eating habits for each life stage is strongly influenced by dietary education at school, school lunches, and eating experiences at home from early childhood to school age. Therefore, dietary education is very important. Control of eating habits in adulthood, however, directly contributes to decreasing the risk of lifestyle-related diseases, especially in middle-aged and older people. For conducting health-promotion programs for the prevention of lifestyle-related diseases, the workplace is the best of these 3 areas. Many companies perform regular health examinations and provide lunches. In this context, the possibility of social implementation of healthy diets at the workplace was examined. Trends in health management at worksites and selection of destinations In Japan, the Ministry of Economy, Trade, and Industry has been promoting and spreading “health and productivity management” in companies,1 and many companies are attempting to reform working practices, such as by increasing the rate of medical examinations received, increasing employees’ physical activity, securing sleeping hours, supporting oral health and mental health, and providing breakfast and healthy meal menus in the employee cafeteria. In addition, programs that promote dietary education and information about other dietary habits are offered.2 For this study, 8 companies with a proven track record in health management were interviewed. Three local governments and 1 university that have succeeded in promoting health measures were also investigated (Table 1). Specific interviews were conducted by group members visiting with 4 to 6 people and interviewing practitioners in the department in charge. Group members contacted the practitioners and presented the contents of the questions in advance of the interview. Table 1 List of organizations interviewed Organization type . Quantity dataa . Locationb . Date of interview . Company No. Industry sector 1 Chemical Listed Tokyo April 2018 2 Pharmaceutical Listed Osaka August 2018 3 Food Listed Tokyo November 2018 4 Printing Listed Tokyo August 2018 5 Insurance Listed Tokyo October 2018 6 Nonferrous metal Listed Tokyo March 2019 7 Financial Listed Aomori November 2018 8 Manufacturing Unlisted Saitama November 2018 Local government No. Administrative unit 1 Prefecture 2000 Central Japan July 2018 2 Prefecture 1000 Kyushu July 2018 3 City 80 Tohoku July 2019 University No. Type of university 1 Private 20 Tokyo/Kanagawa July 2019 Organization type . Quantity dataa . Locationb . Date of interview . Company No. Industry sector 1 Chemical Listed Tokyo April 2018 2 Pharmaceutical Listed Osaka August 2018 3 Food Listed Tokyo November 2018 4 Printing Listed Tokyo August 2018 5 Insurance Listed Tokyo October 2018 6 Nonferrous metal Listed Tokyo March 2019 7 Financial Listed Aomori November 2018 8 Manufacturing Unlisted Saitama November 2018 Local government No. Administrative unit 1 Prefecture 2000 Central Japan July 2018 2 Prefecture 1000 Kyushu July 2018 3 City 80 Tohoku July 2019 University No. Type of university 1 Private 20 Tokyo/Kanagawa July 2019 a Company: listed or unlisted; local government: population (in thousands); university: number of students (in thousands). b Company: city; local government: district; university: city. Open in new tab Table 1 List of organizations interviewed Organization type . Quantity dataa . Locationb . Date of interview . Company No. Industry sector 1 Chemical Listed Tokyo April 2018 2 Pharmaceutical Listed Osaka August 2018 3 Food Listed Tokyo November 2018 4 Printing Listed Tokyo August 2018 5 Insurance Listed Tokyo October 2018 6 Nonferrous metal Listed Tokyo March 2019 7 Financial Listed Aomori November 2018 8 Manufacturing Unlisted Saitama November 2018 Local government No. Administrative unit 1 Prefecture 2000 Central Japan July 2018 2 Prefecture 1000 Kyushu July 2018 3 City 80 Tohoku July 2019 University No. Type of university 1 Private 20 Tokyo/Kanagawa July 2019 Organization type . Quantity dataa . Locationb . Date of interview . Company No. Industry sector 1 Chemical Listed Tokyo April 2018 2 Pharmaceutical Listed Osaka August 2018 3 Food Listed Tokyo November 2018 4 Printing Listed Tokyo August 2018 5 Insurance Listed Tokyo October 2018 6 Nonferrous metal Listed Tokyo March 2019 7 Financial Listed Aomori November 2018 8 Manufacturing Unlisted Saitama November 2018 Local government No. Administrative unit 1 Prefecture 2000 Central Japan July 2018 2 Prefecture 1000 Kyushu July 2018 3 City 80 Tohoku July 2019 University No. Type of university 1 Private 20 Tokyo/Kanagawa July 2019 a Company: listed or unlisted; local government: population (in thousands); university: number of students (in thousands). b Company: city; local government: district; university: city. Open in new tab Evaluation of health promotion programs The Reach, Effectiveness, Adoption, Implementation, Maintenance model, which has been studied previously, was used as an evaluation model for a local government’s business3 and a population approach for promoting physical activity.4 This model is an evaluation method presented by Glasgow et al.5 It makes it possible to oversee activities from the 5 aspects in the model’s name. The Reach phase refers to the number of people in the target population participating in the intervention and the level to which the participants represent the population. In the Effect phase, WG3 looked at whether the outcome improved in individuals who were reached by the intervention and if so, WG3 tried to quantify the improvement. In the implementation phase, WG3 assessed if there was any difference in the implementation of interventions by staff. In the Maintenance phase, WG3 asked if the effect lasted a long time at the individual level, at the organizational level, and at the environmental level. What were the entries made? Was the program continued? Comprehensive evaluation of interview responses The interviewers comprehensively evaluated the precedents for trying to implement a healthy diet from the 5 aspects of the Reach, Effectiveness, Adoption, Implementation, Maintenance model. Although some issues were not quantified and were commented on in the interviewers’ personal impressions, the interviewers’ ratings were generally similar. Furthermore, successful cases had many points in common (Table 2). Table 2 Common points of successful cases 1. The top management views health management as a management issue itself and allocates necessary management resources. 2. Good communication within the organization and smooth communication 3. The program is suitable for corporate culture and work environment. 4. The programs are provided for all employees and multiple programs are applied for specific groups. 5. Interventions that do not put much stress on the participants and are easy to sustain without forcing 6. Providing healthy menus and pricing strategies to encourage their selection 7. Wide range of nutrition-related information that is easy for employees to understand 8. Various data are linked and shared by the company. 9. Lunch system incorporating “nudge theory” 10. There is a mechanism to visualize the results and enhance the self-efficacy of the participants. 11. There is a mechanism to increase the motivation for self-management based on the intentions of the participants in setting their own goals. 1. The top management views health management as a management issue itself and allocates necessary management resources. 2. Good communication within the organization and smooth communication 3. The program is suitable for corporate culture and work environment. 4. The programs are provided for all employees and multiple programs are applied for specific groups. 5. Interventions that do not put much stress on the participants and are easy to sustain without forcing 6. Providing healthy menus and pricing strategies to encourage their selection 7. Wide range of nutrition-related information that is easy for employees to understand 8. Various data are linked and shared by the company. 9. Lunch system incorporating “nudge theory” 10. There is a mechanism to visualize the results and enhance the self-efficacy of the participants. 11. There is a mechanism to increase the motivation for self-management based on the intentions of the participants in setting their own goals. Open in new tab Table 2 Common points of successful cases 1. The top management views health management as a management issue itself and allocates necessary management resources. 2. Good communication within the organization and smooth communication 3. The program is suitable for corporate culture and work environment. 4. The programs are provided for all employees and multiple programs are applied for specific groups. 5. Interventions that do not put much stress on the participants and are easy to sustain without forcing 6. Providing healthy menus and pricing strategies to encourage their selection 7. Wide range of nutrition-related information that is easy for employees to understand 8. Various data are linked and shared by the company. 9. Lunch system incorporating “nudge theory” 10. There is a mechanism to visualize the results and enhance the self-efficacy of the participants. 11. There is a mechanism to increase the motivation for self-management based on the intentions of the participants in setting their own goals. 1. The top management views health management as a management issue itself and allocates necessary management resources. 2. Good communication within the organization and smooth communication 3. The program is suitable for corporate culture and work environment. 4. The programs are provided for all employees and multiple programs are applied for specific groups. 5. Interventions that do not put much stress on the participants and are easy to sustain without forcing 6. Providing healthy menus and pricing strategies to encourage their selection 7. Wide range of nutrition-related information that is easy for employees to understand 8. Various data are linked and shared by the company. 9. Lunch system incorporating “nudge theory” 10. There is a mechanism to visualize the results and enhance the self-efficacy of the participants. 11. There is a mechanism to increase the motivation for self-management based on the intentions of the participants in setting their own goals. Open in new tab Intervention studies on health promotion programs conducted by local government agencies have shown results, in many cases, according to evaluations of the intervention period and short-term evaluation after the intervention, but the support period of the research was interrupted every 3 years. Therefore, it was not possible to determine whether the behavioral changes continued in those who took the intervention test. Food and nutrition science incorporating behavioral changes After the interview survey, WG3 considered that behavioral science research was necessary to promote dietary choices, and invited experts who have produced many research results in this field to learn the basic theory of behavioral change. WG3 members learned a great deal from one of the experts, Professor Rie Akamatsu, advisor of the Healthful Diet Research Committee at Ochanomizu University, who provided detailed explanations on behavioral science that promote human behavior change and examples in the dietary field.6 After reviewing the articles presented, the articles were later interpreted, but in many cases, the behavioral science methodology was adopted as a background factor for the success stories obtained in the interviews. Developing another important social environment for healthy food choices To reduce the level of indifference related to eating habits, it is important to have uninterrupted food education for growing schoolchildren in families, nursery schools, and elementary schools. Current dietary habits are affected by school lunches, according to the results of a memory-based awareness survey on dietary education received at elementary school and junior high school, and dietary education at home for university students.7 Many students were conscious that this was linked to health promotion and said they enjoyed their school life. University students who live alone have poor practical skills related to eating and cooking and have a limited understanding of the importance of proper eating. Even after becoming a member of society, many people continue the eating habits of their student days, and most of them never consider that such eating habits directly relate to their own health. Therefore, to reduce the health risks, dietary education in college and by employers will be necessary to manage the eating habits of employees. Grouping of subjects and necessity of a target-specific approach for each group In summary, even if the same programs are applied to 2 groups, 1 that is indifferent to their diet and 1 that is more health conscious, the group that is more health-conscious becomes healthier than the group that is more indifferent to health. For health-conscious groups, a program that incorporates visualization (eg, physical measurement, serum biochemistry values, visceral fat values, judgment of vegetable intake, step-count recording), awareness of belonging to the company, competition between offices, internal awards, and social pressure are effective. On the other hand, nudge theory–based activity that does not make them aware of health may be effective for the people who lack interest in their own health. Summary of the factors that make the social implementation of healthy diets successful Although direct interviews were limited, Table 3 lists some of the factors related to success in implementing healthy diets in society in comparison with previous studies. Table 3 Success factors for implementing healthy diets in society 1. Top management attaches great importance to promoting the health of employees as a key management measure. 2. Communication within the organization is smooth. 3. The meal menu offered at the employee cafeteria is delicious and cheap, and there are many ideas to encourage proper meal selection. 4. Employees have goals that incorporate their will for health. 5. It is easy and fun to participate in health promotion programs, and each employee has a sense of self-fulfillment. 6. Tools for monitoring health are being used. 1. Top management attaches great importance to promoting the health of employees as a key management measure. 2. Communication within the organization is smooth. 3. The meal menu offered at the employee cafeteria is delicious and cheap, and there are many ideas to encourage proper meal selection. 4. Employees have goals that incorporate their will for health. 5. It is easy and fun to participate in health promotion programs, and each employee has a sense of self-fulfillment. 6. Tools for monitoring health are being used. Open in new tab Table 3 Success factors for implementing healthy diets in society 1. Top management attaches great importance to promoting the health of employees as a key management measure. 2. Communication within the organization is smooth. 3. The meal menu offered at the employee cafeteria is delicious and cheap, and there are many ideas to encourage proper meal selection. 4. Employees have goals that incorporate their will for health. 5. It is easy and fun to participate in health promotion programs, and each employee has a sense of self-fulfillment. 6. Tools for monitoring health are being used. 1. Top management attaches great importance to promoting the health of employees as a key management measure. 2. Communication within the organization is smooth. 3. The meal menu offered at the employee cafeteria is delicious and cheap, and there are many ideas to encourage proper meal selection. 4. Employees have goals that incorporate their will for health. 5. It is easy and fun to participate in health promotion programs, and each employee has a sense of self-fulfillment. 6. Tools for monitoring health are being used. Open in new tab CONCLUSION It is not easy to achieve goals for health and longevity for the whole population and minimize medical expenses for the elderly without raising awareness of health indifference and improving health behavior. Long-term interventions will be necessary. Acknowledgments The authors thank the 8 private companies that cooperated with the interview survey on the status of efforts toward health management, the 3 local government agencies that cooperated with the investigation into health policy initiatives, and the university that gave us an overview of dietary support for students. The authors also express deep gratitude to Professor Rie Akamatsu (Ochanomizu University) for her guidance in behavioral science analysis of food selection. Author Contributions. Under the supervision of T.K., all authors equally contributed to developing the research design, conducting the survey, analyzing the data, and preparing the manuscript, and all approved the final manuscript. Funding. This research was conducted as a part of the activities of the International Life Sciences Institute Japan(ILSI Japan) Research Committee, which are not compensated except for travel expenses for academia members as required. Declaration of interest. T.K. is a vise-president and a member of the board of trusteefor ILSI Japan.TK is also a member of the organizing committee and the program committee for the 8th International conference on Nutrition and Aging held on October 1st and 2nd 2019. Companies to which authors belong are members of ILSI Japan to support the activities conducted by ILSI Japan. References 1 Ministry of Economy, Trade and Industry of Japan. Handbook for Health and Productivity Management 2017 . Tokyo : The Tokyo Chamber of Commerce and Industry ; 2017. 2 Next Generation Healthcare Industry Council 17th Health Investment Working Group; Prof. Takemi Yukari. Improving eating habits and eating quality in the workplace (in Japanese). Available at: https://www.meti.go.jp/committee/kenkyukai/shoujo/jisedai_healthcare/kenkou_toushi_wg/pdf/017_06_00.pdf. Accessed May 7, 2020. 3 King DK , Glasgow RE , Leeman-Castillo B. Reaiming RE-AIM: using the model to plan, implement, and evaluate the effects of environmental change approaches to enhancing population health . Am J Public Health. 2010 ; 100 : 2076 – 2084 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Kamada M , Kitayuguchi J , Abe T , et al. Community-wide intervention and population-level physical activity: a 5-year cluster randomized trial . Int J Epidemiol . 2018 ; 47 : 642 – 653 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Glasgow RE , Vogt TM , Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework . Am J Public Health. 1999 ; 89 : 1322 – 1327 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Ainuki T , Akamatsu R , Hayashi F , et al. Association of enjoyable childhood mealtimes with adult eating behaviors and subjective diet-related quality of life . J Nutr Educ Behav . 2013 ; 45 : 274 – 278 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Inoue S , Katayama K , Xianquas C. Influence of childhood dietary experience on dietary habits of university students . Arch Yamaguchi Prefect Univ . 2019 ; 12 : 105 – 114 . Google Scholar OpenURL Placeholder Text WorldCat Author notes Working Group 3 Members: T. Kuwata (Leader, University of Human Arts and Sciences), M. Arita (Kirin Holdings Company, Limited), Y. Katsuragi (Kao Corporation), M. Kato (Kyowa Hakko Bio Co., Ltd.), H. Suganuma (Kagome Co., Ltd.), L. Cao (Ajinomoto Co., Inc.), H. Sonoki (Morinaga Milk Industry Co., Ltd.), H. Takase (Kao Corporation), Y. Takeda (Morinaga Milk Industry Co., Ltd.), Y. Nakanishi (International Life Science Institute, Japan, Center for Health Promotion), Y. Nozawa (Ajinomoto Co., Inc.), N. Hayashi (Ajinomoto Co., Inc.), Y. Yokomukai (International Life Science Institute Japan), and N. Waki (Kagome Co., Ltd.) © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Abe,, Keiko;Okada,, Shinji;Ishijima,, Tomoko

doi: 10.1093/nutrit/nuaa090pmid: 33259622

INTRODUCTION This endowed chair was founded at the Graduate School of Agricultural and Life Sciences, The University of Tokyo, on December 1, 2003. The activities continued for the subsequent 15 years, encompassing 3 terms, until March 31, 2019. The main purpose of this endowed chair was to assist in a global understanding of the importance of genomics-based functional food science and technology – in collaboration with ILSI Japan-member companies – for the purpose of introducing a new wave of technology into the national and international food industry. This goal was posited on the fact that the genomes of major animals, including humans, plants, and microbes had already been verified.1,2 CHAIR ACTIVITIES AND RESULTS Term I activities (December 2003 to November 2008) In the first 5 years of the endowed chair, statistical nutrigenomics was launched, revealing a significant expression of a number of transcriptomes in target tissues and organs following food consumption (Figure 1).3 In collaboration with some food companies,4–14 many papers were published in high-level journals. Figure 1 Open in new tabDownload slide Term I activities. Figure 1 Open in new tabDownload slide Term I activities. Term II activities (December 2008 to November 2013) In the second 5-year term, DNA microarray studies were carried out in association with bioinformatics research, generating highly reliable and reproducible data showing that nutrigenomics is an in-depth analysis method applicable to foods whose functions are gradually revealed. The scientific evidence for food functionalities was investigated by proteomics and metabolomics (Figure 2). The results revealed the feasibility of designing some functional foods.15–42 Figure 2 Open in new tabDownload slide Term II activities. Figure 2 Open in new tabDownload slide Term II activities. Term III activities (December 2013 to March 2019) The activities in the third 5-year term included nutrigenomics based on the first- and second-term investigations and outcomes. Some changes in approaches were also attempted. While conventional functional food studies generally targeted the control of metabolic syndrome, such as by antioxidation, in the third term there was a focus on brain science, such as cognition research and behavioral science, aimed at improving locomotion by proper alimentation (Figure 3). In particular, studies centered around the development of food components that contribute to a high quality of life in advanced-aged individuals. Figure 3 Open in new tabDownload slide Term III activities. Figure 3 Open in new tabDownload slide Term III activities. This objective was realized by the formation of a national project called the Cross-ministerial Strategic Innovation Promotion Program (“SIP”) by the Ministry of Agriculture, Forestry and Fishery/Cabinet (Figure 4). The editors of the journal Nature (2017)43 were interested in this program and reported on it in a special issue called “Spotlight on Food Science in Japan” – a highly unusual move that reflected the strong national and international interest. Figure 4 Open in new tabDownload slide National project “SIP” as the next-generation agriculture subprogram. Figure 4 Open in new tabDownload slide National project “SIP” as the next-generation agriculture subprogram. FUTURE OUTLOOK The scientific papers originating from the endowed chair are widely cited in top-tier journals and were written in collaboration with ILSI Japan-member food companies.44–75 Since 2015, when a national system for approval of functional food claims was established, related studies have gradually adopted a new approach in terms of research objects and methodologies. In particular, research into functional foods for the next generation needs to explore cognitive activation and locomotion improvement and to provide evidence that these functionalities are effective for enhancing quality of life. To achieve this, it will be necessary to develop novel methods, including verification of each functionality by human intervention. Several obstacles must be overcome to increase the international acceptance of Japanese functional food products, such as the need for basic science, surmounting the difficulties of human intervention trials using healthy subjects, and the need for highly effective preclinical markers that can contribute to observing even a miniscule breakdown of a healthy state (Figure 5). Through the 15-year activities of this ILSI Japan-endowed chair, several new subjects have emerged. In 2016, the JSPS Frontier Innovative Research Committee proposed “Studies that aim to identify some preclinical markers as indexes for maintenance of our bodily homeostasis,” and the proposal was approved. Figure 5 Open in new tabDownload slide Human intervention trials. Figure 5 Open in new tabDownload slide Human intervention trials. SUMMARY AND APPRECIATION On April 1, 2019, “Food Functionality Science” was founded at the University of Tokyo for studies incorporating an industry-ministry-academia consortium. The research targets include a wide area of food functionalities – from basic to applied. We will continue to promote this philosophy to benefit everyone. This innovation is undoubtedly the result of social evaluation of our activities. The ILSI Japan collaboration is greatly appreciated. The figures provided show some of the findings from the ILSI Japan-endowed chair on functional food genomics, emphasizing the importance of the academia-industry consortium for the development of future functional food studies. Acknowledgments Author contributions. All authors contributed equally to the preparation, revision, and approval of this manuscript. Funding. The ILSI Japan endowed chair has been supported by the funds from participated members of ILSI Japan. Declaration of interest. The authors have no relevant interests to declare. References 1 Lander ES , Linton LM , et al. Initial sequencing and analysis of the human genome . Nature . 2001 ; 409 : 860 – 921 . 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For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Miyachi,, Motohiko

doi: 10.1093/nutrit/nuaa083pmid: 33259611

Abstract The Life Science Symposium held by the Nutrition Research Committee of the International Life Sciences Institute (ILSI) Japan in 2018, “Fusion of Nutrition and Exercise Sciences Leading to Extension of Healthy Life Expectancy,” covered current topics in the science of nutrition and exercise to address extending healthy life expectancy. Presentation topics included (1) lifestyle and gut microbiota; (2) how to use lipids in sports nutrition; (3) the effect and molecular mechanism of improvement of arteriosclerosis by exercise and nutrition; (4) physical activity and nutrition that support brain function; (5) skeletal muscles and food ingredients that support healthy longevity; (6) measures against sarcopenia by exercise and nutrient intake; (7) physical activity/exercise for disease prevention; (8) nutritional epidemiology research for the Japanese population; (9) new developments in health science in viewed from nutrition and intestinal flora; (10) why do Asians develop nonobese metabolic disease?; and (11) social implementation of the health promotion program by ILSI Japan. The speakers emphasized the promotion of research on exercise and nutrition interactions and encouraged social implementation of the research results in public and private sectors. food, fusion, health, nutrition, sport INTRODUCTION The Nutrition Research Committee of the nonprofit International Life Sciences Institute (ILSI) Japan has been holding its Life Science Symposium since 2006 to meet its mission of disseminating scientific information relating to health, nutrition, food safety, and the environment while ensuring international harmonization. Both physical activity and diet are important for disease prevention and extending healthy life expectancy.1,2 New areas of research, such as sports nutrition and integrative biology of exercise and diet, are also evolving. Moreover, Japanese researchers and practitioners in the nutritional and sport fields wanted an opportunity to discuss these topics while sharing the same platform in advance of the Tokyo 2020 Olympic and Paralympic Games. Thus, the 8th symposium was held on July 26, 2018, at Ichijo Memorial Hall, Tokyo Japan, with the theme “Fusion of nutrition and exercise sciences leading to extension of healthy life expectancy.” The symposium included 2 sessions: “Basic science of nutrition and exercise” in the morning and “Applied research for health care practice” in the afternoon. A total of 11 speakers presented research reports (described in the following paragraphs), and panel discussions at each session led to lively debates on the floor. Here, an overview of the symposium is reported. MORNING SESSION: BASIC SCIENCE OF NUTRITION AND EXERCISE “Knowledge of Gut Microbiota for a Healthy Lifestyle” This presentation was by Hiromi Yano, PhD, Department of Health and Sports Science, Kawasaki University of Medical Welfare. Interactions between the host and gut microbiota strongly influence human health and various diseases.3 The aim of this lecture by Dr. Yano was to summarize the relationship between several diseases, including lifestyle diseases, and the gut microbiota, and to discuss the point of contact between lifestyle (exercise and nutrition) and the gut microbiota. The ratio of Firmicutes to Bacteroidetes might be associated with obesity. Both type 2 diabetes and hypertension may be regulated by inflammation in the intestinal tract and gut microbiota–induced short-chain fatty acids. Also, it seems that trimethylamine-producing microbiota are involved in arteriosclerotic cardiovascular disease. The gut microbiota may also influence colorectal and liver cancers and depression. Moreover, by altering the gut flora by stool transplantation, the physical characteristics of the donor are transmitted to the recipient. Yano et al reported that transplanting the stool of exercise-trained rats into sedentary rats increased physical activity in the sedentary rats through changes in the intestinal flora.4 Author’s comment: It would be very interesting if behaviors such as physical activity in humans propagate through the microbiome. “How to Use Lipids in Sports Nutrition” This was a presentation by Shin Terada, PhD, Graduate School of Arts and Sciences, The University of Tokyo. Lipids are often treated as bad nutritional factors that harm health or deteriorate performance. Lipids are nutrients that must be consumed daily and may contribute to improve performance and health when taken correctly. Dietary intake of medium-chain triacylglycerols may delay the progression of hyperglycemia in ob/ob mice, possibly by stimulating glucose uptake in the intra-abdominal fat tissue through enhanced insulin secretion.5 Dietary intake of medium-chain triacylglycerols at least partly alleviates immobilization-induced muscle atrophy by inhibiting the ubiquitin-proteasome pathway.6 Moreover, coconut oil intake may improve brain health by directly activating ketogenesis in astrocytes, thereby providing fuel to neighboring neurons.5 Thus, devising ways to ingest lipids and use unique fatty acids called functional lipids may promote the effects of lipids to improve performance and maintain and promote health. Author’s comment: A positive effect of medium-chain triacylglycerol intake on skeletal muscle function has been observed in human research, and evidence regarding optimal routes of lipid intake is gradually accumulating. “Improvement of Arterial Stiffness by Exercise and Nutrition” This presentation was by Motoyuki Iemitsu, PhD, Faculty of Sport and Health Science, Ritsumeikan University. Cardiovascular diseases (ie, heart and cerebrovascular diseases) are among the leading causes of death around the world. Prevention and improvement of cardiovascular diseases are important medical topics because arterial stiffness increases with advanced age. Regular aerobic exercise (eg, jogging, bicycling) reduces arterial stiffness by enhancing and improving arterial function.7 In recent years, the possibility of reducing arterial stiffness by stretching exercises has been demonstrated. Vasodilators secreted by endothelial cells are involved in mechanisms resulting in reduced arterial stiffness after exercise. Additionally, combined effects of exercise and tailored nutrition, including lactotripeptides, curcumin, and chlorella, to induce greater reductions in arterial stiffness have been reported.8,9 Thus, it is reasonable to expect future scientific evidence and studies to clarify the beneficial effects of exercise and nutrition on preventing or reducing arterial stiffness. Author’s comment: The foods and nutrients that act in combination with exercise to prevent atherosclerosis are diverse, but comprehensive exploration is still required. “Physical Activity and Diet for Brain Function, Including Dementia and Depression” This presentation was by Takeshi Nishijima, PhD, Graduate School of Human Health Sciences, Laboratory of Sport Neuroscience, Tokyo Metropolitan University. To understand the underlying mechanisms of exercise-induced improvement in brain function, most studies so far have focused on neuronal plasticity. This presentation highlighted the fact that exercise can also improve cerebrovascular plasticity. Thus, it is important to further elucidate the mechanisms underlying how diet improves brain function, the interactions between diet and exercise, and to examine whether exercise and diet confer synergistic effects. Differences between exercise and physical activity were discussed, and physical inactivity as a risk factor for brain function was underscored.10,11 Because diet has been shown to affect physical activity of rodents, the diet may affect brain function through changes in the amount of physical activity, a new hypothesis that requires in-depth studies. Author’s comment: Although research in humans remains insufficient, establishing preventive measures for brain and neurological disorders such as dementia and depression is an important research theme for building a sustainable society. “Importance of Skeletal Muscle for Supporting Healthy Longevity and the Effects of Food Ingredients” This was a presentation by Shinji Miura, PhD, School of Food and Nutritional Sciences, University of Shizuoka. As a health problem specific to super-aging societies, sarcopenia, which attenuates skeletal muscle function, has been attracting attention. Because both muscle endurance improvement and muscle mass increase are necessary for maintaining muscle function, exercise training and proper nutrient intake have long been considered important.12 Currently recommended treatment methods to counter muscle function decline often have insufficient effects, and their execution is often impossible. In addition, there is no drug-based therapy available, and thus prevention of muscle function decline has not yet been achieved. Food ingredients that improve skeletal muscle function are expected to become widely available and accepted for health maintenance,13 but there are currently few products on the market for sarcopenia. Focusing on PGC1α and FOXO1, Miura et al14 are conducting a survey of compounds and food ingredients useful for maintaining and promoting skeletal muscle function, based on research on the effects of exercise training vs inactivity on skeletal muscle and the underlying molecular mechanisms. Novel ingredients that are considered promising against sarcopenia were also explained (eg, the function of tomatidine and medium-chain triacylglycerols). There is growing expectation for an effective food ingredient for sarcopenia as a product for healthy longevity. Author’s comment: The foods and nutrients that will contribute to prevent sarcopenia in combination with exercise are diverse and still require comprehensive exploration and human studies. AFTERNOON SESSION: APPLIED RESEARCH FOR THE PRACTICE OF HEALTH PROMOTION “Measures Against Sarcopenia by Exercise and Nutrient Intake” This presentation was by Satoshi Fujita, PhD, Faculty of Sport and Health Science, Ritsumeikan University. Age-associated loss of skeletal muscle mass and strength (sarcopenia) increases the risk of injury due to falls and the incidence of diabetes, which subsequently becomes a significant factor for disability among the elderly population.15 Nutrient intake, especially the amino acid leucine, and meal-induced insulin both independently stimulate muscle-protein synthesis. Age-specific changes in muscle anabolic responses to leucine become apparent, however, when the amount of habitual leucine intake is not sufficient in the elderly. Furthermore, insulin resistance of muscle-protein metabolism with aging has been demonstrated in healthy nondiabetic older people. Resistance exercise is another anabolic stimulus that increases myofibrillar muscle-protein synthesis in young and older individuals. Increased muscle anabolism is apparent within 2–3 hours after a single bout of heavy resistance exercise and remains elevated for up to 2 days after the exercise. Activation of the mammalian target of rapamycin signaling pathway in skeletal muscle is associated with an increased rate of muscle-protein synthesis during the early recovery phase after a bout of resistance exercise.16 Finally, recent evidence on the cumulative effects of resistance exercise in combination with nutritional supplement intake on muscle-protein metabolism was discussed to propose a possible preventive measure against sarcopenia.17 Author’s comment: Combining protein or amino acid intake with muscle training is the most effective way to prevent sarcopenia, but evidence is required for appropriate combinations from randomized controlled trials in humans. “Evidence of Physical Activity Guideline (Active Guide) for Health Promotion” This presentation was by Susumu S. Sawada, PhD, Faculty of Sport Sciences, Waseda University. The Ministry of Health, Labor, and Welfare started the “National Health Promotion Movement in the 21st Century, 2nd edition,” called “Health Japan 21 (second term),” in April 2013. In the “Physical activity and exercise” section in Health Japan 21 (second term), there are 3 targets: increasing daily steps, increasing the number of people with an exercise habit, and increasing municipalities that engage in community development and environmental improvement to make it easy to participate in physical activity. Moreover, the Ministry of Health, Labor, and Welfare presented the “Physical Activity Reference 2013 for Health Promotion” and the “Physical Activity Guideline (Active Guide)” to assist Health 21 (second term) in March 2013. The Active Guide, based on “Physical Activity Reference 2013 for Health Promotion,” introduced “+10 (Plus Ten)” as a catchword for encouraging daily physical activity. Plus Ten involves 10 minutes of increasing daily physical activity, especially walking. Several epidemiological studies scientifically supported the phrase +10 (Plus Ten) for the prevention of noncommunicable diseases.18 Moreover, different recommendations are made for different age groups. The Active Guide recommended more than 60 minutes of moderate physical activity, such as walking every day, and vigorous exercise 60 minutes per week for people aged 18 to 64 years. Furthermore, it recommended 40 minutes of light physical activity, such as standing, walking, or housework, every day for people older than 65 years.19 These evidence-based physical activity guidelines hopefully will contribute to increasing healthy life expectancy. Author’s comment: Although the usefulness of the +10 (Plus Ten) message is internationally recognized, research is needed to establish strategies for achieving it in the future. “Diet for Extending Healthy Life Expectancy” This presentation was by Kayo Kurotani, PhD, Department of Nutritional Epidemiology and Shokuiku, National Institutes of Biomedical Innovation, Health, and Nutrition. Numerous studies have demonstrated that diet plays an important role in extending healthy life expectancy. The Global Burden of Disease Study 2013 showed that dietary factors such as low intake of vegetables, fruits, and whole grains, and extreme intake of red meat, sodium, and sugar-sweetened beverages result in a 21% higher risk of mortality worldwide.20 To maintain or enhance health, each country has dietary guidelines. In Japan, the “Japanese Food Guide Spinning Top” (JFGST) was formulated on the basis of “Dietary Guidelines for Japanese.” The JFGST is a chart designed for the general public that indicates the recommended daily servings for some food groups, with illustrations featuring examples of foods and dishes to meet these recommendations. Recently, several studies presented results to support the usefulness of the JFGST. For example, closer adherence to the JFGST was associated with lower mortality risk as well as lower probability of metabolic risk factors and depressive symptoms.21 In addition, meta-analyses revealed that the Healthy Eating Index, the Alternative Healthy Eating Index, and Dietary Approaches to Stop Hypertension, as well as the Mediterranean diet, were associated with a lower mortality risk,22 suggesting the potential of many diets, not just 1, to extend healthy life expectancy. It is necessary to clarify what “health” means for each target population and to examine the association between health and diet so that the diet that might lead to longer healthy life expectancy can be clarified. Thus, in pursuit of a healthy diet suited to Japanese people, more research on the definition of Japanese food and its relation to health is needed. Author’s comment: Although there are many cohort studies supporting the effectiveness of diverse diets, establishing evidence through randomized controlled trials is a future challenge. “New Development of Health Science Viewed from Nutrition and Intestinal Flora” This was a presentation by Jun Kunisawa, PhD, Laboratory of Vaccine Materials, Center for Vaccine, National Institutes of Biomedical Innovation, Health, and Nutrition. The intestine has a specialized immune system in which active immune responses to eliminate pathogenic microorganisms and immunological tolerance to food components and commensal microorganisms coexist.23 Collapse of the balance of active and regulatory immune responses increases the risk for infectious diseases and immunological diseases, such as allergy and enteritis. Therefore, maintenance of immunological homeostasis in the intestine is important for maintaining health. Intestinal immunity is functionally affected by food components and intestinal bacteria. Kunisawa et al focus on lipids that are ingested from the diet and examine the effects of the fatty acids in dietary oils on intestinal immunity and diseases. They found that linseed oil, which is high in the omega-3 fatty acid α-linolenic acid, could inhibit the onset of diarrhea caused by food allergy.24 Metabolome analysis revealed that, among metabolites derived from α-linolenic acid, 17,18-epoxy-5Z,8Z,11Z,14Z-eicosatetraenoic acid (17,18-EpETE) is an execution molecule that could inhibit intestinal allergy. Administration of synthetic 17,18-EpETE also inhibits contact hypersensitivity. These findings suggest that 17,18-EpETE can be applied to drug discovery. As another example, palmitic acid, which is contained in palm oil, and its metabolites, sphingolipids, enhance the production of immunoglobulin A antibodies in the intestine.25 Thus, fatty acids and their metabolites play an important role in regulating immune surveillance in the intestine. It was recently shown that dietary fatty acids are converted to biologically active metabolites by not only endogenous enzymes but also gut microbiota. Studies of the mechanisms regulating intestinal immunity by food components together with the effects of gut microbiota will advance the understanding of the relations among foods, gut microbiota, and the host, and clarify specific applications to prevent disease and promote health. Author’s comment: There is a lack of descriptive research on the microbiome in the Japanese population, and even cross-sectional research on humans is inadequate. Therefore, accelerating human microbiome research is essential. To accelerate this research, translational research is needed to exchange diverse knowledge regarding cells, animals, people, and populations. “Ectopic Fat and Insulin Resistance” This presentation was by Yoshifumi Tamura, MD, Department of Metabolism and Endocrinology, Sportology Center, Juntendo University. Insulin resistance plays an important role in the pathogenesis of metabolic syndrome and type 2 diabetes. Recent data suggest ectopic fat accumulation in muscle and liver induces insulin resistance in these organs, independent of obesity.26 For example, 3 days of a high-fat diet increased intramyocellular lipid (IMCL) levels and impaired insulin sensitivity.27 In contrast, 2 weeks of exercise therapy decreased IMCL levels and improved insulin sensitivity in type 2 diabetes.28 Interestingly, the IMCL level in endurance runners is elevated despite their high insulin sensitivity. This phenomenon is called the “athlete paradox.” Tamura et al found that a difference in fatty acid transporters in skeletal muscle is associated with this phenomenon through differences in the gene expression. Finally, Dr. Tamura addressed the association between fatty liver and insulin resistance in muscle. Author’s comment: Standardization of quantitative methods for measuring IMCL levels in humans is an important task for clarifying the function and pathology of IMCL. “Social Implementation of the Health Promotion Program by ILSI Japan” This presentation was by Mika Kimura, MS, Center for Health Promotion, ILSI Japan. The objective of ILSI Japan Center for Health Promotion is to contribute to society through scientific knowledge and technology from the fields of nutrition, public health, medicine, and sanitation, which have been developed by industry, government, or academia in Japan, aimed at solving public health issues the world is facing. The Center for Health Promotion promotes healthier lifestyles among people in their prime or advanced years and seeks to increase physical activity and improve nutrition in innovative ways. ILSI Japan promotes people’s health with the main message of take 10 minutes of exercise 2 or 3 times every day and eat from “TAKE10!®” food groups every day.29 Author’s comment: Hopefully, ILSI Japan will further promote social activities based on research findings on food and nutrition. DISCUSSION The venue for this symposium, Ichijo Hall, was filled with students, researchers, developers, and government officials. Eleven panelists presented research findings on a wide range of subjects, including animals, humans, and populations, using various research techniques from the fields of biology, physiology, and epidemiology. The diversity of topics in this symposium was impressive. All panelists presented the latest findings in physical activity and nutrition sciences. Several researchers focused on muscle issues, especially muscle metabolism and atrophy as causes of noncommunicable diseases and sarcopenia, respectively. The relationship between intestinal flora, which has recently attracted worldwide attention, and exercise and diet was also a discussion topic. Epidemiological research using populations and cohorts in Japan are increasing in both the physical activity and nutrition areas, and is being used in the Ministry of Health, Labor, and Welfare policy making and social activities. Exercise and nutrition have been studied in independent fields in sports and physical activity science and nutrition and food science. In panel discussions at each session, including insightful questions from the audience, most of the panelists emphasized the importance of research to clarify the mechanisms of interaction between exercise and nutrition. In addition, for extending a healthy life expectancy, they also mentioned the importance of further promoting collaborative research on nutrition and exercise sciences and the social implementation of those research results by uniting the public and private sectors. Unfortunately, even the panelists of this symposium have not been able to conduct the research and actions required to address these points. Physical activity and diet are important and indispensable components of human life and have a relationship similar to that between the front and back of a coin; the barrier between the 2 research areas must be quickly removed. CONCLUSION This symposium was a valuable opportunity to discuss solutions on the basis of the science of nutrition and exercise to address extending healthy life expectancy for a super-aging society. Acknowledgments The author deeply appreciates all the panelists of the symposium: Hiromi Yano, Shin Terada, Motoyuki Iemitsu, Takeshi Nishijima, Shinji Miura, Satoshi Fujita, Susumu Sawada, Kayo Kurotani, Jun Kunisawa, Yoshifumi Tamura, and Mika Kimura. The author also thanks ILSI Japan for the opportunity to plan the symposium, and thanks the symposium attendees. Author contributions. The author contributed to planning of the symposium, coordinating with panelists, writing and reviewing the article, and accepting the final version. The author is responsible for the integrity of the work as a whole. Funding. No specific funding was involved in the production of this manuscript. Declaration of interest. Motohiko Miyachi is a member of the program committee for the 8th International conference on Nutrition and Aging held on October 1st and 2nd 2019. References 1 Imai T , Miyamoto K , Sezaki A , et al. Traditional Japanese diet score—association with obesity, incidence of ischemic heart disease, and healthy life expectancy in a global comparative study . J Nutr Health Aging. 2019 ; 23 : 717 – 724 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Monma T , Takeda F , Noguchi H , et al. Exercise or sports in midlife and healthy life expectancy: an ecological study in all prefectures in Japan . BMC Public Health . 2019 ; 19 : 1238 . 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Google Scholar PubMed OpenURL Placeholder Text WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Nomura,, Shuhei;Miyata,, Hiroaki

doi: 10.1093/nutrit/nuaa073pmid: 33259613

Abstract Japan’s aging population and increasing medical costs threaten the sustainability of its healthcare system. Society 5.0, Japan’s growth strategy, calls for a paradigm shift in healthcare based on digital technology. Health is a topic of great public concern, and diet and nutrition are at the heart of health. Many different values are used to define health, and Society 5.0 focuses on creating personalized values for different styles of eating and health. Health is already at the core of global business, and Japan, which is ahead of the rest of the world in its super-aging society, has a unique opportunity to be the first to create new business solutions for diet and nutrition. business, digitalization, health value, Japan, Society 5.0 INTRODUCTION In Japan, half a century after the achievement of universal health insurance coverage, the sustainability of the healthcare system is threatened by the aging population and the growth of health expenditures.1 In 2015, a healthcare advisory panel to the Japanese Minister of Health, Labor, and Welfare created a vision of Health Care 2035 with the aim of rebuilding a sustainable healthcare system. This is a medium- to long-term vision for a healthcare policy that looks 20 years into the future and makes the power of data an important pillar.2 Japan’s new national growth strategy, Future Investment Strategy 2018, also calls for a shift to a data-driven Society 5.0 (which is interlocked with the sustainable development goals) where big data and new technologies (ie, information and communications technology) are anchored in a people-centered approach. The strategy cites the construction of a fully data-driven, new healthcare system as one of the flagship projects leading this shift.3 PARADIGM SHIFT IN JAPAN’S HEALTHCARE There are 3 major paradigm shifts in healthcare as advocated by Health Care 2035 and Society 5.0.2,4 The first is a shift from cure, which focuses on the treatment of diseases, to the care and prevention of diseases, such as lifestyle-related diseases. The second is personalized healthcare that respects an individual’s health values (eg, why is health desirable, how do people want to stay healthy)—from standardized care for average patients and symptoms to personalized care tailored to the different health values of each individual—so individuals can receive the prevention, care, and treatment that they need at the right time. The third is the independent health management of individuals. In the past, health maintenance was managed by medical professionals, but now individuals are able to manage their own health through wearable technology and by using the accumulated personal data. For example, by analyzing personal health and social life data, it is possible to predict the risk of illness before it occurs and to encourage individuals to take actions to avoid illness.5 APPROACHES TO DIET AND NUTRITION ISSUES IN THE SOCIETY 5.0 ERA The beginning of the Society 5.0 paradigm shift is digital innovation with artificial intelligence (AI), Internet of things (IoT), and other digital technologies and data. In the Society 5.0 era, in which individuals take the initiative in health management, it is important to learn how to support individual lifestyles through digital technology.4 For example, it is important to encourage people who, through public or private health examinations, are found to be at risk for a disease or condition to visit a medical institution at an early stage, to confirm whether they actually visited a medical institution, and to follow up on them,6 but this cannot be done without considerable administrative and programmatic effort.7–9 Digital technology, however, should make such an endeavor easier.10 For example, text messaging is used to follow up with patients after they have been treated for cancer. Although the signs of cancer recurrence are difficult to detect,11,12 the survival rate of cancer might be improved simply by asking certain questions regularly in a chat post and encouraging patients to return to the hospital, depending on the answer. In this way, existing communication tools can be used to scale things that used to be difficult and expensive to do.13,14 Although medical and clinical care are important pillars of the health system, better outcomes come from a prevention-oriented approach (ie, measures to prevent people from getting sick) not only in the clinic but also in social life.15,16 A previous report argued that there is a substantial return on investment in prevention, specifically, there is a 6-fold return on investment per dollar of prevention.17 In the Society 5.0 era, the goal is to encourage individuals to take the initiative in their health by providing them with information that will make them aware of themselves or that they will be happy to engage in. These measures will be a major target in the future healthcare system. By leveraging the information gathered from IoT and data from smartphones, it is possible to support lifestyles, including prevention, which has never before been possible.18 For example, with regard to exercise, the lack of which is one of the major risk factors for lifestyle-related diseases,19 it is already becoming possible to take a preventive approach by using smartphones. Pokémon Go—a smartphone game that fuses the real world with the digital world, allowing players to explore their neighborhoods to find creatures and treasures for in-game use—is a gaming application with 1 billion users worldwide, but it has also become a fun health companion thanks to a combination of features that make walking more fun.20 In Japan, an unhealthy diet and nutrition are the second most important risk factors, after smoking, contributing to health impairment, accounting for approximately 10% of disability-adjusted life-years (a mixed index of death and disability).19,21 Various nutrition applications already exist in Japan. For instance, Calorie Mama AI, a Japanese AI dieting and health application, is a smart-camera application that uses food image recognition to simplify calorie and nutrition tracking, automatically tracks physical activity, and provides diet and exercise planning for weight loss. Registering food items one by one on a smartphone can be a heavy burden for users, making it difficult to guarantee continuity. Although there is still room for improvement in accuracy, efforts to predict diet calories and nutrition through image analysis are growing. Asken Diet is another Japanese dieting application that can motivate other application users by sharing the user’s eating habits. In addition, an algorithm supervised by nutritionists provides application users with dietary guidance (eg, information about what diets are associated with what disease risks). By visualizing eating habits in this way, we will be able to make users aware of and improve their eating habits. This is an effort to provide a wide range of users within a digital framework the services that nutritionists have been providing individuals. COMMERCIALIZATION OF DIETARY AND NUTRITIONAL APPROACHES Globally, technology giants are also moving into healthcare.22 By taking advantage of their strengths in combination with medical data stored in hospitals, efforts to use daily information (ie, a life log) collected from smartphones and IoT have been initiated. Digitizing an approach to a problem depends on whether it can be commercialized.23 Service providers need to make it a viable business to maintain the continuity and sustainability of their services. The ability of service providers to monetize a service allows many people to continue to enjoy using the service. In other words, only when a service can be commercialized can it be expected to contribute to health. Although the sustainability and long-term health impacts of these digitized health-related applications remain debatable,20 in the case of Pokémon GO, collecting creatures and treasures results in increased walking and health. In addition, visiting historic sites, enjoying flowers of the 4 seasons, eating delicious food, and other activities are connected to the enjoyment of each user, and the use of the applications is expected to be more sustainable for the user.24 Eating is fun and a source of entertainment, but it will also be important to consider whether the enjoyment is sustainable. CONCLUSIONS Digital technologies contributing to sustainable development goals are an important policy issue for Society 5.0. Among the competing areas, such as education, environment, and security, health is the most tangible aspect for the public, with food and nutrition at the core. There are many different views regarding how to live and be healthy, and how to enjoy food and be healthy. Thus, it is important for Society 5.0 to propose various styles and values for each individual. Health is already at the heart of global business, and technology giants already have health as a primary target for their business strategies. In the case of Japan, the country is in the forefront of advancing the super-aging society and will be faced with a variety of issues associated with the aging society (eg, lifestyle-related diseases, complications, soaring medical costs). The positioning of health is also important in business in Japan, and it is an opportunity to create new solutions to diet and nutrition issues ahead of the rest of the world. Acknowledgments Author contributions.All authors contributed to the conceptualization of the paper, led the drafting of the paper, and contributed to and agreed up on the submitted version of the manuscript. Funding. None Declaration of interest. All authors declare no competing interests. References 1 The Lancet. Japan: universal health care at 50 years . Lancet . 2011 ; 378 : 1049 . 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Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)