Roundtable Discussion: Leading a Well-Being Society in the 100-Year Life Era

TheKeio University Center for Preventive Medicinewill relocate from Shinanomachi to Azabudai Hills and open in November 2023. I would like to take this opportunity to focus on preventive medicine and ask everyone from various fields to talk about its future vision.

The Center for Preventive Medicine opened 11 years ago in 2012, and at that time, it was featured in Mita-hyoron (official monthly journal published by Keio University Press) (December 2012 issue, special feature "The Forefront of Preventive Medicine"). Eleven years have passed since then, and while I believe the Center for Preventive Medicine has gained a certain reputation for its high-precision comprehensive medical checkups, a major challenge now is determining the direction to take in order to build the future-oriented preventive medicine required for the coming era.

Now, in considering the direction of preventive medicine in this new era, it is important to consider what problems Japan will face and what kind of society it will become as we enter the 100-year life era and a super-aged society. From that perspective, I would like to ask Dr. Oguma to start the discussion.

As you know, the aging of the population, referred to as the "2025 problem," means we are entering an era where the entire baby boomer generation will be 75 years of age or older, classified as the late-stage elderly. By 2025, one in 3.3 people will be 75 or older, and one in 2.6 will be 65 or older. Medical costs will also soar, with some predictions suggesting that medical expenses for the late-stage elderly will be about five times higher than for those under 65, which presents a major challenge.

I am also conducting research on the super-elderly (here referring to those aged 85 and over) with Dr. Yasumichi Arai and others at the Center for Supercentenarian Medical Research at the Juku School of Medicine. We are in an age where the super-elderly are no longer a rarity, and while the number of healthy elderly people is increasing, so is the number of those who are "frail" (a state where muscle strength and physical and mental vitality decline with age, making them more likely to need nursing care).

Frailty is reversible, meaning it is a condition from which one can recover, so it is necessary to notice the signs early and intervene properly.

During the COVID-19 pandemic, many people refrained from going out and were restricted from their usual exercise, and numerous studies have shown an increase in people with advanced frailty. I have been regularly measuring the exercise and physical activity of the elderly in Fujisawa City for several years, and when I measured them for the first time in a while after the pandemic, I realized that their physical strength had generally declined.

However, highly conscious elderly people are using their ingenuity to find ways to resolve issues like lack of exercise and communication even under behavioral restrictions, and those who are able to do so remain healthy. I feel that this is creating health disparities in the community. From the perspective of motor function, I am aware of the problem that we need to identify and support those whose frailty is progressing.

So, in a super-aged society, the gap between those who can properly maintain their own health and those who cannot becomes more pronounced?

Yes, research papers are showing such results.

Dr. Kishimoto, what do you think will be the biggest challenge in the 100-year life era?

Related to frailty, dementia will undoubtedly become a very large problem as well. By 2025, we will enter an era where one in five elderly people and one in 17 of the total population will have dementia. The advent of lecanemab (a new drug approved in September that directly targets the causative substance of Alzheimer's disease) will likely change dementia treatment significantly in the future, but drugs are not a panacea, and the number of people who can receive treatment is limited. There are also concerns that treatment costs will strain society.

In fact, there is data showing that if all dementia risks, such as lifestyle-related diseases, are eliminated, the onset of dementia can be suppressed by about 40%. A very important point is how to guide the lifestyles of the elderly in a healthy direction, thereby reducing the risk of dementia onset while curbing the rise in medical costs.

Furthermore, as Japan has a large number of elderly people with dementia, the world is watching to see if it can create a dementia-friendly society, as it leads the world in its aging rate. In this context, the health of the working-age population that supports society is also important. The previous social structure was a "mikoshi" (portable shrine) model, where many people supported one elderly person. In 2020, it became a "kibasen" (cavalry battle) model, with three people supporting one. By 2060, it will become a "kataguruma" (piggyback) model, with one person supporting one.

In a society where one young person supports one elderly person, we must also create a society where young people can be more active and healthy, both physically and mentally.

Are you saying that the generation supporting the elderly is at risk of suffering mental damage?

That's right. In the field of occupational health, mental health issues such as depression are now overwhelming. For example, the number of workers' compensation claims for mental disorders is about three times that for cerebrovascular and heart diseases.

That's surprising.

In that sense, I think concepts like the well-being of the working generation and the engagement of company employees are gaining attention.

Mr. Ando, from your position of supporting the food industry, how do you view this super-aged society?

Recently, our company has been developing optimized nutritional food, and we have also established a joint research course with Dr. Hiroshi Ito and Dr. Takanori Kanai of the Juku School of Medicine.

The mechanism behind frailty in seniors is that their appetite diminishes, leading to reduced food intake and nutritional intake. This results in a lack of necessary nutrients, which in turn causes a decrease in muscle mass and activity levels. As a food manufacturer, we are working on initiatives to solve this situation.

There have been foods that claim to have a balanced nutritional profile, but when trying to pack all the necessary nutrients into a single meal, many of them ended up not tasting good due to the bitterness and astringency of vitamins and minerals. The concept of a complete nutritional food has been around for a long time, but this is why there are no major brands in the world.

However, in our 65 years of developing instant ramen, we have honed our technologies for calorie reduction, salt reduction, and sugar/fat reduction. By applying these technologies, we have become able to mask the bitterness and astringency, and as an optimized nutritional food, we have succeeded in appropriately balancing the main nutrients while achieving a taste that is no different from a regular meal.

Optimized nutritional food packs a balanced array of nutrients into a small portion. For example, we recently established a technology to pack ample calories and nutrients that tend to be lacking for seniors whose appetites are declining.

Seniors tend to have a biased diet, with some saying they are fine with just fried chicken and beer (laughs). To put it extremely, if we could pack the necessary calories and nutrients into that fried chicken and beer, perhaps this person would not become frail. We believe our food tech can create such meals for seniors.

On our side, as a food manufacturer, we want to create a situation where people can eat what they like without any behavioral changes in their eating habits or menu choices, with the concept of preventing frailty. Even if a menu seems biased, we can use food tech to balance the necessary nutrients. If we can extend healthy life expectancy, I believe it will lead to a reduction in nursing care and medical costs in the 100-year life era.

An approach for the younger generation will also be necessary, not just for the elderly.

That is exactly what we are researching with Dr. Ito. Even for young people, once they reach their 30s and 40s, their health risks of becoming pre-metabolic or developing lifestyle-related diseases suddenly increase.

For such people, we take the opposite approach to that for seniors. We offer a variety of menus that are substantial in volume but have calories suppressed as much as possible, for example, by 50%, and are packed with a good balance of major nutrients. I believe this will also lead to the prevention of lifestyle-related and adult diseases.

This is precisely food as preventive medicine and pre-symptomatic disease care. According to Dr. Ito's concept of the metabolic domino effect, various adult diseases all start from the first domino. It begins with increased visceral fat from diet and lack of exercise, leading to insulin resistance. From there, it progresses to high blood sugar, high cholesterol, and high blood pressure.

If we can stop the first domino from falling with optimized nutritional food, we might be able to reduce the risk of adult diseases. I am working with the hope that if we can collaborate with people in various categories to popularize optimized nutritional food, we can implement pre-symptomatic disease care for society as a whole.

Dr. Takaishi, what kind of initiatives are you undertaking for the 100-year life era within the new concept for the Center for Preventive Medicine?

The disease structure in Japan has shifted from infectious diseases and nutritional disorders to lifestyle-related diseases and malignant tumors. With advances in diagnosis and treatment, the average life expectancy, which was less than 50 for both men and women before the war, has now extended to 81 for men and 87 for women. The keyword for the 100-year life era is the diversification of preventive medicine. Preventive medicine will become more personalized, focusing on prevention in pre-symptomatic and healthy states, and it is predicted that individuals will become more proactively involved in their healthcare. For this reason, the Center for Preventive Medicine aims to move beyond the idea that medical care is provided only in hospitals and build a system that makes checkups a part of daily life using wearable devices and remote medical systems, allowing for immediate guidance and therapeutic intervention if abnormalities arise.

In addition to performing more precise diagnosis, treatment, and preventive medicine for lifestyle-related diseases and malignant tumors, it is crucial to take measures against physical and mental/cognitive frailty to extend healthy life expectancy. For frailty prevention, primary prevention is particularly important, that is, "promoting health during a healthy period through improvements in lifestyle habits such as nutrition, exercise, and rest, improvements in the living environment, and health education."

Everyone has spoken about the 100-year life era from their respective viewpoints. Recently, the concept of "well-being"—being not just free from illness but also physically, mentally, and socially healthy and happy—has been gaining attention. How should we pursue well-being?

The definition of well-being is to be physically, mentally, and socially healthy. In other words, it doesn't just mean being physically healthy and free from illness; it signifies a multifaceted state of happiness, a state of satisfaction in one's life within society, a state of fulfillment.

Dr. Oguma, what kind of society do you envision as a well-being society?

From the perspective of exercise and physical activity, it's not just about the physical effects. The effects on mental aspects, including depression, and the subsequent social well-being are also extremely important.

I am currently promoting an initiative called KEIO SPORTS SDGs, where physical activity through sports and other means contributes to the SDGs. We have established a startup called the Keio University Global Research Institute Keio Sports SDGs Center (https://sportssdgs.keio.ac.jp/) for this purpose. As the World Health Organization (WHO) stated in 2018 (Global Action Plan on Physical Activity 2018-2030), physical inactivity is rampant worldwide, and it will worsen if not addressed seriously. There is solid evidence that changing behavior regarding physical activity is effective, so we need to make that change.

By involving not only experts in the health and sports fields but also people from various other fields, we can change societal well-being and improve the well-being of each individual. I believe the perspective of achieving well-being while also considering the environment and society, in line with the SDGs, is also important.

As a company, after 2030, whether or not we are truly improving the well-being of society will determine the company's evaluation. Well-being points will be directly linked to corporate ratings.

Every company will be questioned on whether they are implementing measures to improve the social, physical, and mental well-being of their employees, so each company is just now starting various initiatives. However, no company has found a definitive answer yet, and I think we are currently in a trial-and-error phase, searching for factors that lead to well-being.

Naturally, the connection between food and well-being is deep, but in fact, the relationship between food and well-being has not yet been clarified globally. Realizing this, last year we conducted the world's first survey on the relationship between food and well-being in 142 countries and regions.

The first question was, "Do you enjoy your food?" The second was, "Do you perceive the food you eat as healthy?" And finally, "Do you feel you have a wide range of choices in your diet?" These three questions yielded interesting results.

Naturally, people who are satisfied with all three have high well-being. But how high? It's at the same level as receiving an income they find satisfactory. This was the first time we understood that food is a very important factor in improving well-being.

Earlier, Dr. Kishimoto talked about the definition of well-being. Could you tell us how each element is evaluated to determine a state of well-being?

Yes, there are several ideas about what elements constitute well-being, but we often use a three-axis evaluation: how one evaluates their own life (life satisfaction), what emotions they experience within it (positive and negative affect), and what meaning and purpose they have in their life. Self-assessment questionnaires have been developed for each of these.

For maintaining physical function, exercise and diet are of course important, but another crucial element is sleep. The quality and quantity of sleep are related to various diseases, aren't they?

Yes, a connection has been shown with various diseases, including mortality rates. Furthermore, there is evidence that people with high well-being get good sleep.

What Japanese people should recognize is that, globally, they are a nation with extremely short sleep durations. However, because those around them also sleep for short periods, few people recognize that their own sleep time is short. If you stay at the office until 8 or 9 o'clock, your sleep time will naturally be shorter, and there is actual data to support this. It must be said that Japan has a weak awareness of the problem of sleep deprivation. I think it is necessary for society as a whole to understand the importance of sleep and to promote awareness.

Our company is also starting sleep education in preparation for 2030 and beyond, such as by holding seminars. By implementing measures like gamification, where we visualize how much people have slept and have departments compete, I believe we can change employees' awareness of sleep.

Separate from lack of exercise, the time within a 24-hour day that is spent neither sleeping nor being active, but just sitting still, is called "sedentary" or "sitting time." Evidence is accumulating that this "sitting time" is not good for you.

Globally, it seems Japanese people have the longest sitting times.

Yes. Within a 24-hour day, it's important to secure sleep time, secure time for physical activity, and reduce sitting time as much as possible. For example, it's recommended to move your body for two minutes every 30 minutes. Such perspectives are also said to be important.

So the concept of the new Center for Preventive Medicine is to actively intervene in these factors.

Yes, in the 2021 survey by the Organisation for Economic Co-operation and Development (OECD), Japan had the shortest sleep time at 7.33 hours. Sleep disorders reduce work efficiency and increase the risk of lifestyle-related diseases.

The Center for Preventive Medicine will address the prevention and resolution of sleep disorders using a wearable device developed by Dr. Masashi Yanagisawa, Director of the International Institute for Integrative Sleep Medicine at the University of Tsukuba, a leading authority in sleep research. Not only does it measure brain waves during sleep and analyze sleep quality with AI, but it also measures blood oxygen levels to detect sleep apnea syndrome (SAS). In collaboration with Professor Yanagisawa, we will advance sleep research together with Professor Emeritus Masaru Mimura and Dr. Kishimoto from the Juku School of Medicine's Department of Neuropsychiatry.

It is said that Japan is the only country where people sleep during meetings.

It seems to appear abnormal to people in the West. In the West, there is a strong belief that dozing off during a meeting is rude and embarrassing. However, they also seem to perceive that sleeping so much might be a sign of some illness.

As a company, we feel there is an issue with the way meetings are conducted. When there are many high-ranking attendees, opportunities to speak become limited, and people are just present without participating in the discussion.

We need to change the way meetings are held, or perhaps more fundamentally, the way the organization is structured.

The risk of dementia in relation to sleep has also recently gained attention. There are still many mysteries about sleep, but there is a concept that waste products in the brain are cleared out during sleep. It's called the glymphatic system, and evidence is accumulating that this system becomes more active during sleep.

Lack of sleep accumulates as sleep debt. So, waste products build up in the brain.

Yes, that's why Dr. Yanagisawa suggests that we should visualize our own sleep.

In the past, I think there was a mentality among people with dementia that they didn't want to know, because even if they found out, there was little that could be done. But that's not the case anymore, is it?

Yes, as I mentioned at the beginning, lecanemab will significantly change the way dementia is treated, and with it, the mentality of those affected will also change. However, since the number of people who can use lecanemab is limited, it is also important to reduce modifiable risks. Things like exercising, preventing diabetes, getting good sleep, and increasing social interactions. But while people can make an effort temporarily, it is surprisingly difficult to bring about such behavioral changes in the long term. How to maintain them is one of our research themes.

How will the Center for Preventive Medicine tackle dementia?

We are considering various methods. The target for treatment with lecanemab are patients with mild cognitive impairment (MCI) due to Alzheimer's disease, or mild dementia. The term "mild" is used because treatment needs to be started before the disease progresses and the brain's nerve cells lose their function.

Together with Professor Daisuke Ito from the Department of Physiology at the Juku School of Medicine and Project Associate Professor Jong-Mock Pae from the Department of Neuropsychiatry, we have developed a method to screen for suspected Alzheimer's disease at an early stage by measuring amyloidβand tau proteins in the blood. For those with suspected cases, Project Professor Mimura will conduct dementia tests at the Memory Clinic and make a definitive diagnosis using PET scans and cerebrospinal fluid tests. We are also developing a unique, high-precision brain age prediction model using MRI images with Dr. Kishimoto and Lecturer Jin Hirano from the Department of Neuropsychiatry. By introducing such tests, we hope to make early and accurate diagnoses.

So, we have entered an era where precise diagnostic methods are available for a field that previously received little attention due to a lack of effective interventions, and various behavioral changes and, in some situations, effective drugs can be used.

Is research on externally controlling sleep quality advancing?

Tomohiko Kimura, the president of Paramount Bed, is a classmate of mine from Yochisha Elementary School. In our discussions, the idea has come up of whether we can improve the daily sleep quality of employees by controlling their sleeping posture with bed technology to enhance their well-being points. I imagine that in the medical field, progress is being made in forcibly correcting people with sleep apnea syndrome or poor breathing posture by having sensors detect their breathing posture and angle, and automatically changing the angle.

Severe SAS might be difficult, but since the sinking of the tongue base improves when the body is turned on its side, it would likely have some effect.

Sleep tech is gaining a lot of attention right now. Various devices are emerging that estimate sleep status, such as smartphones, sensors attached to clothing, and wristband-like wearable devices.

However, I think there are certain limits to how well sleep stages can be estimated from data such as sound, acceleration, load, and pulse. I believe it would be difficult to be precise without measuring brain waves.

However, even with data without brain waves, it should be possible to understand general sleep duration, its rhythm, or the extent to which sleep is interrupted, and I think that alone is very useful.

I see. But according to current data, sleep and nutrition don't seem to be very related.

It is known that a large meal late at night puts a strain on the digestive tract, causes fluctuations in blood sugar levels during sleep, and that caffeine and alcohol have a negative impact on sleep.

Recently, lactic acid bacteria drinks that claim to "improve sleep quality" have been selling explosively. There may be a connection between gut bacteria and sleep. However, I don't think there is solid evidence yet.

At our group company, Nissin York, a lactic acid bacteria drink that improves sleep quality and reduces daily fatigue is selling like hotcakes right now.

There is a great demand for such health-conscious products and the desire to get good sleep. But the work of medically verifying whether they are truly effective for health is necessary.

Accumulating data and building evidence to meet health-conscious demands is our mission, isn't it?

Let's consider the broad theme of the future of preventive medicine. Dr. Takaishi, it has been 11 years since the Center for Preventive Medicine was established at Keio University Hospital. Could you briefly introduce its progress during this time?

The Center for Preventive Medicine was established in 2012. Fortunately, we have received very high evaluations from our clients. Currently, about 6,000 people undergo checkups at the Center for Preventive Medicine annually, and a large amount of high-quality data, including lifestyle history, family history, preferences, blood data, and imaging data, has been accumulated.

However, 10 years after its opening, challenges have emerged. The number of clients has increased so much that appointment slots are filled, making it difficult to get an annual checkup. Also, since Keio University considers preventive medicine to be the origin of Keio's medical sciences and has accumulated clinical and research experience, the staff of the Center for Preventive Medicine, as academics, have a strong desire to actively utilize data, create evidence, and contribute to preventive medicine from a research perspective.

While we were exploring the future direction of the Center for Preventive Medicine, Mori Building Co., Ltd. proposed that we work together with Keio University to create a city where residents and workers of Azabudai Hills can live healthy and vibrant lives through living and working there. As a result, the Center for Preventive Medicine will be relocating to Azabudai Hills. The "Hills Joint Research Laboratory for Future Preventive Medicine and Wellness," a joint research course for conducting research, was started in advance in 2021.

The Center for Preventive Medicine has been providing high-quality checkups until now. How do you envision the future direction of preventive medicine?

More than ever, we want to meet the clients' desire for early detection of diseases. In addition, the future Center for Preventive Medicine will emphasize dialogue with clients for health promotion. There are various demands from clients regarding preventive medicine.

For example, in terms of diversifying values, some people are worried about pancreatic cancer and want to have a pancreatic checkup more than twice a year. Others, with a family history of dementia and as business owners, do not want to manage their business without realizing they have dementia, and ask if they can receive tests that can diagnose dementia at a very early stage. Many people hope for health promotion programs to achieve their own goals, rather than just evidence-based medicine. We want to respond to their desire for peace of mind, so we will have thorough discussions with those who have such requests and respond to them when possible.

Our concept is "Medicine that walks alongside each person's life." We will provide highly personalized checkups tailored to individual needs.

So your idea is that preventive medicine should be based on core evidence, but also be tailored to the life each person desires and the values they hold dear.

Yes, I believe it is important that it leads to individual well-being.

Among physical frailties, particularly sarcopenia, which is a decline in muscle strength due to aging, the number of deaths from accidental falls and tumbles among people aged 65 and over exceeds 9,000 per year. This is more than four times the current number of traffic accident fatalities, which is around 2,000.

The psoas major muscle is responsible for lifting the legs to avoid tripping. To avoid falling even after tripping, the quadriceps femoris, the thigh muscle, is important. At the new Center for Preventive Medicine, we will use the world's first upright CT scanner, developed by Professor Masahiro Jinzaki of the Department of Radiology in collaboration with Canon Medical Systems, to evaluate the condition of muscles and joints related to fall prevention (※This will be implemented in the "Keio University Hospital Preventive Medicine Membership," a new membership system offered with the relocation). The upright CT can visualize the structure of the human body under gravity. It will enable the evaluation of many functions and pathologies, such as respiratory function and circulatory dynamics in standing and sitting positions, as well as walking function, so we believe it can contribute to healthy longevity.

We also focused on eye and oral examinations, which were not emphasized in conventional checkup facilities. Eye diseases not only directly affect QOL but are also deeply related to dementia, falls, and fractures, and can be a cause of needing nursing care. Early detection and early response to eye diseases are very important for extending healthy life expectancy and leading a rich and healthy life.

At the Center for Preventive Medicine, although some are optional, we will perform precise diagnoses using the latest ophthalmic medical equipment to diagnose eye diseases early (※Same as above). If surgery is required, the affiliated Keio University Hospital Department of Ophthalmology will provide the best medical care based on that data.

For dentistry and oral surgery, we will also conduct oral frailty (oral hypofunction) tests using precision equipment such as cone-beam CT, and based on the results, provide guidance on chewing, swallowing, and aspiration prevention, regular checkups for teeth and periodontal disease through preventive dentistry, and oral cancer screenings.

Oral frailty is associated with various comorbidities and affects the function of the entire body. Indeed, preventing oral frailty is also very important for nutrition. Mr. Ando, can optimized nutritional food also intervene in aspects like the hardness of food?

We can control swallowing. However, when it comes to dysphagia diets, it affects the texture and taste. I think a breakthrough is needed there.

So, not only nutrients but also the texture itself can be personalized. It's possible to create something that suits a person's oral function or preference.

If possible, we would like to develop the stage before that even more.

Certainly, eating a mushy jelly every day, no matter how nutritious, is a bit unappealing.

About 6,000 people aged 65 and over die from choking due to difficulty swallowing each year. Could we develop something like a training food for swallowing function?

To be honest, we have not yet worked on developing food for people who need nursing care. Right now, our research and development is focused on how to delay the need for nursing care.

However, I think we could develop it if we tried. Controlling quality, texture, and material properties is our greatest strength.

As the concept of preventive medicine is changing significantly, Dr. Oguma, what are your thoughts on the "place" where preventive medicine should be provided?

We are now in an era where we can obtain more personalized and diverse data. Information about the body can be continuously obtained not only at the time of a medical examination but also from devices like smartphones and watches. I believe what is required is precision, in the sense of accurately responding to individual wishes and being able to consult on the next steps as early as possible, including this data.

By connecting daily life aspects, such as daily exercise, with examination data from checkups and medical care at hospitals, I believe we can provide better services. I think there is a need to connect these two.

Remote medical care has progressed rapidly during the COVID-19 pandemic, and we can now collect various data from daily life through so-called wearable devices. I believe we are entering an era where this will be applied to preventive medicine. Dr. Kishimoto, this is your area of expertise.

Yes, as symbolized by the term IoT (Internet of Things), we are in an era where various things are connected to the internet. Through IoT, we can non-invasively observe our daily lives, and research and development to use this for early disease detection and health promotion are actively underway.

The ability to obtain continuous data from all aspects of daily life, whereas before we could only do spot checks at the hospital, is a major development. In the future, I think it will be important to skillfully link advanced medical information that can only be obtained at a hospital with information obtained from daily wearable devices and the like. In that sense, I believe the Center for Preventive Medicine has a great opportunity.

Furthermore, while hospitals typically only examine areas related to a specific illness, the Center for Preventive Medicine collects data longitudinally across multiple organs. This data has a different value from hospital data. If we can successfully connect this with continuous data from daily life and find some kind of relationship, I believe its value will be extremely large.

At Azabudai Hills, a joint research course has already been established with Mori Building, which is responsible for the new city development, and you are already conducting research there, Dr. Kishimoto.

Yes, we are conducting multiple studies utilizing wearable devices. For example, we conducted a study where participants wore a wristband-type activity meter and a 24-hour glucose meter simultaneously to examine the relationship between glucose fluctuations and sleep, daytime activity, drowsiness, and vitality.

We also receive health checkup data from employees of companies in Hills and accumulate it to see what kind of work styles and rest patterns lead to physical health and well-being. We hope to give back the knowledge gained from this to the Center for Preventive Medicine and the many people who use the city.

So, various multifaceted research projects are underway to create the future of preventive medicine.

Mr. Ando, from a non-medical standpoint and in the field of supporting nutrition, what are your expectations for preventive medicine?

Dietary guidance is often paired with comprehensive medical checkups. However, there is also data showing that the effects of dietary guidance are very limited. After all, a diet consisting only of seaweed and mushrooms, however healthy, is not sustainable for long.

To increase the effectiveness of dietary guidance, I believe it is necessary to enhance remote guidance. I think it's a significant burden for general clinics to hire registered dietitians, so the question is how to share them within remote medical care, reduce costs, and make dietary guidance effective.

And a sustainable menu is also important. Generally, a healthy diet tends to be bland and vegetable-centric, so I don't think it fits everyone.

I think it's common for people who used to eat whatever they wanted to develop lifestyle-related diseases and get flagged during a comprehensive medical checkup. How do we solve their nutritional problems while satisfying their appetite? We want to clear this with the technology of optimized nutritional food.

We doctors also provide nutritional and dietary guidance, but as you say, after repeated guidance, people tend not to listen much. It's no good to always say the same thing, as it becomes monotonous. Even with various工夫, they won't listen unless there is some data. I wish there were clear data showing what would happen in 10 years if they continued their current lifestyle.

For example, showing them what their liver will look like in 10 years if they continue to drink this much, or what their lungs will look like if they continue to smoke?

Yes, that's right.

Right now, long-term follow-up data from comprehensive medical checkups, health screenings, and cohort studies are being accumulated and made available for use. This will allow us to predict what will happen in the future if a certain type of person continues a certain lifestyle. I think such simulations will be useful in future preventive medicine. In fact, such services already seem to exist, especially for diabetes risk.

Then it becomes a drive to change the future, doesn't it?

Yes, I believe it can be applied not only to glucose metabolism but also to the prediction of various health conditions.

So, we are entering an era where we can predict things like, "If you continue with this lack of exercise and long sitting hours, you won't be able to play tennis like you do now when you're 65."

Yes, and it's not just about predicting future diseases. It's also possible to use AI to estimate what would be the best thing to do to overturn that prediction. What should I do to achieve the future I desire? I think it will be possible to provide hints for each individual in the future.

Will it be possible to give more personalized, tailor-made suggestions, like "If you do this kind of exercise, your health will improve much more"?

I think it will become possible with higher accuracy. For that, we need to accumulate high-quality data.

Currently, at the Center for Preventive Medicine, if something is flagged in a comprehensive medical checkup, how many months later is the re-examination?

It's often after three months. Depending on the disease, it could be six months.

If there is solid evidence in the data for things like glucose metabolism and lipid metabolism, then I think we should provide personalized food during that three-month period. According to the results of our clinical trials, a significant improvement can be expected in just three months. If patients eat as suggested by the Keio Center for Preventive Medicine for three months and actually improve, I think their trust in us will increase tremendously.

As I mentioned earlier, bringing about sustained behavioral change is extremely difficult. People can make an effort temporarily, but they often revert to their old ways in three or six months. I think behavioral science is where we can make a difference in making these changes sustainable.

Behavioral science is an important keyword. The question is how to apply behavioral science to preventive medicine.

That's right. Even if you uniformly say, "This is good for your health," it resonates with some people but not with others. And the reasons why it doesn't resonate are varied. Some people become even more suspicious when given a scientific, logical explanation.

It is also known that it is effective to stratify the target audience to some extent. For example, when it comes to a certain medical screening, some people may not understand the necessity of the test, while others may want to take it but are hesitant because it seems like a hassle. The way we communicate and the type of support we provide need to be tailored to each group. I believe there is still much room for improvement in the guidance for promoting health.

We would like the joint research course at Azabudai Hills for the Center for Preventive Medicine to become a platform for establishing behavioral science as a solid academic field.

I agree. I think it's necessary to bring together the knowledge of professors from various fields such as medical sciences, psychology, sociology, and economics.

So, will the relocation of the Center for Preventive Medicine develop in the direction of creating a new academic discipline by bringing together people from various social sciences and humanities?

Yes, I think it's a field where Keio, as a comprehensive university, should leverage its strengths.

For five years, Keio University Hospital was certified by the Cabinet Office as an AI Hospital model hospital and engaged in various activities, but there are limits to medical care that is developed only within the hospital building. I have a very strong impression that from now on, we will be moving towards a form of medical care that watches over life itself and the community itself, using various remote medical technologies. In fact, technologies that support such things are emerging one after another.

In this context, how will we change our lives in the parts related to health from now on? I would like you to speak from this perspective.

Strictly speaking from our perspective in the food category, to achieve innovative health promotion through food on a global scale, it's actually better not to force behavioral change. The results are more likely to change that way.

If humanity could exercise self-restraint for the sake of health, the world wouldn't be so obese. The appetite, one of the three major desires, is that difficult to control. People with extremely strong self-control or high incomes might be able to do it, but if we aim to improve health through food for the entire world, food manufacturers and the medical side should provide things that allow people to eat what they want, as much as they want, whenever they want, without needing to change their behavior.

Using the technology of optimized nutritional food that I mentioned earlier, we can change the components of the food people always eat into something that helps with pre-symptomatic disease care. By doing so, I believe the relationship between food and health will change dramatically.

That would also maintain mental well-being. As you mentioned earlier, food has a strong correlation with well-being. So, you're improving diet without restricting it.

With Dr. Ito, we launched the Japan Association for Optimized Nutritional Food this July. Products that meet the nutritional design standards registered with this association will be given a certification mark. It's a mark that guarantees that the main nutrients are well-balanced and appropriately adjusted. One solution is to create an environment where people can eat what they normally want to eat and still be okay, without them even knowing it.

We want to realize this by popularizing such a system at all touchpoints where food is available, not just with us manufacturers, but also in the restaurant industry, supermarkets, convenience stores, and so on.

This idea is amazing. That it's better not to change behavior.

Yes, I hadn't thought that far. I had thought that since endurance doesn't last, a behavioral change that doesn't require endurance would be good. Project Professor Tomohiro Tanikawa of the Graduate School of Information Science and Technology at the University of Tokyo, with whom I am conducting joint research, showed me experimental results where making the cookie a person is eating appear larger makes them feel full more easily. In the sense of not forcing behavioral change, I think this is similar.

As for exercise, recently there are methods of electrically stimulating muscles, rather than exercising hard and sweating. Are we entering an era where physical functions can be maintained without effort or pain?

I think there are such methods, and health is not the only purpose, but rather a means. Sports are also enjoyable, so I think there are ways to do it without forcing oneself for the sake of health.

Exercise, in particular, has large individual differences and is diverse in terms of individual abilities and ways of thinking. How should we respond to this?

Rather than having to do a certain amount, it's also important to increase it even a little from the current level. So, I think it's about personalizing it and understanding that not everyone has to aim for the same goal. The revised version of the Physical Activity Guidelines for Health Promotion 2013 (to be released by the Ministry of Health, Labour and Welfare this fiscal year), which we are currently working on, is expected to include this message.

Can the optimal goal for a person be medically indicated?

Yes, that's right. I believe it's necessary to include not only medical but also behavioral science evaluations. There is also the perspective of proceeding with small steps while setting medium- to long-term goals. For high-risk individuals, such as those with multiple diseases, the safety margin for exercise is narrow, so more precise settings are required.

Maintaining motivation is also important. It's called gamification, where game elements are incorporated, having users compete with each other or giving rewards. More directly, promoting health through the enjoyment of the game itself is also possible. In fact, a program that improves the attention function of children with ADHD (Attention-Deficit/Hyperactivity Disorder) by having them play a video game has been approved as a programmed medical device in the United States. During the game, they are made to perform two tasks, training them to pay attention to both.

So, I believe that various approaches are being developed and becoming available for the goal of preventing disease and promoting health.

Dr. Kishimoto, as an occupational physician, how do you plan to change the workplace environment from now on?

I believe the mental health issue I mentioned earlier is a difficult challenge, but I also feel that simple awareness campaigns can be effective in some areas.

In one company where I am involved as an occupational physician, human relations were not necessarily good. Leaves of absence due to depression and other issues were endless and had become a major problem. So, by sending a top-down message to promote well-being and by the HR department planning a dialogue with me, awareness gradually began to change. An employee who returned to work recently told me that the company seems to have changed a little, which made me happy.

However, since self-reports like stress checks are not completely reliable, we are also advancing a project to digitize and quantify the stress of employees.

How far has the quantification of stress progressed? My impression is that the psychiatric field is not an area with many available biomarkers.

As you pointed out, quantifying mental states is difficult. The difficulty in quantification is a hindrance to all aspects of disease prevention and treatment, so we are currently developing a medical device that can quantify the symptoms of depression. It basically uses AI technology, and the input information includes daily activities, sleep, and pulse from a wristband-type device.

Regarding your question about the degree of stress, heart rate variability, salivary cortisol, and skin potential are used as objective indicators. In fact, a certain relationship is found between the degree of stress assessed by questionnaires and such biomarkers. In particular, heart rate variability can now be obtained much more easily than before with recent digital technology, so its future application is expected.

Are you saying that an era is coming when we can evaluate the workplace environment in more detail from various angles?

It will come. The introduction of the stress check system has achieved a certain degree of "visualization" of stress, but conducting it only once a year makes it difficult to address problems at the right time, and concealment inevitably occurs. I think it will be possible in the future to quantify stress situations in real time with digital tools.

Dr. Oguma, to what extent has personal evaluation been established in your field?

In terms of establishment, I think there are still many parts that are not actually connected. Exercise often operates separately from medical care, so it is important to educate the general public about engaging in safe and secure exercise based on medical assessment, and the Japan Medical Association is focusing on this.

The Japan Sports Agency and the Japan Medical Association have been working together for the past couple of years to create such a system in local communities (Development of a Map of Exercise and Sports-Related Resources). I think it's still a work in progress. For private fitness facilities, being able to provide personal evaluations and collaborating with medical institutions will become an increasingly important selling point.

In some countries, system development is progressing. In Japan, partly because the benefits for doctors, such as medical fees, are not clearly defined, there are still few examples where family doctors and other local physicians are firmly involved and collaborating with fitness facilities.

So, you're saying it's not being evaluated in routine medical practice.

That's right. Exercise guidance and prescription that are completed within a medical consultation take a lot of time. From now on, I think it's important to link it with health checkups, use it as a place for regular evaluation, and collaborate with co-medical staff and fitness facilities to propose daily exercise, creating a continuous flow.

At the relocated Center for Preventive Medicine, you are starting a membership-based medical service called the "Preventive Medicine Membership" to realize future-oriented preventive medicine. In the "Preventive Medicine Membership," a personal support team centered on a primary doctor will work on health promotion. A primary doctor needs a very wide range of knowledge, and I think it's important how this is optimized and personalized for each patient.

It's a difficult challenge, but in the future, I believe the key is the use of digital technology and AI. At the knowledge level, AI will surpass human doctors, and if daily behavior and sleep are visualized and their connection to diseases is found, it will be easier to make tailor-made recommendations. Human doctors will skillfully use these technologies while supporting each user from their perspective.

Will the primary doctors at the Center for Preventive Medicine form a team and be able to respond to anyone at the same level?

Accurate knowledge will be required even in fields outside of one's specialty. For this reason, before the interview with the client, medical staff, including doctors centered on the primary doctor and coordinators composed of nurses, will gather to form a team and hold a thorough conference.

We would like to make a comprehensive judgment by collecting not only data from the Center for Preventive Medicine but also, if necessary, data from the client's visits to Keio University Hospital and other facilities as much as possible. By showing that we are providing comprehensive team-based medical care, we hope to build a relationship of trust with our clients.

That's important. It's about properly understanding an individual's data.

Diagnostic methods and treatments will continue to advance. I believe it's also important to create an environment where, if I think another primary doctor is better suited to handle matters outside my specialty, I can say, "I think this doctor would be better for this part, so please consult with them once." The fact that we have many specialists is also a strength of the Center for Preventive Medicine.

Also, the Center for Preventive Medicine wants to focus not only on disease prevention but also on accident prevention. In addition to fall prevention, nearly 6,000 elderly people die from drowning in the bath each year, and we need to think about countermeasures for such situations. Sixty to seventy percent of myocardial infarctions and strokes occur at home. The Center for Preventive Medicine cannot handle this alone, so we are aiming to build a system in collaboration with the Juku School of Medicine's Department of Emergency Medicine, where we team up with companies that have excellent sensing technology to provide an immediate alert and emergency response if something happens during nighttime sleep or bathing.

From the patient's or client's perspective, this is a source of reassurance. Daily life monitoring devices will likely be utilized for this.

Yes. Technologies that can monitor without being worn are also being developed one after another. We are also conducting research using sensors that are installed in the home, but in addition to improving accuracy, there are also difficult aspects such as privacy issues. As we move toward social implementation, discussions on ethical, legal, and social issues are also necessary.

As Keio University, we want to explore the future of preventive medicine. Through this, we hope to lead the way to a well-being society. Today, I have heard very interesting stories from each of your professional standpoints. I would like to continue to work together with all of you to lead the way to a happy future society. Thank you very much for today.