Published papers

Background: Client reminders are known to increase cancer screening attendance rates. However, there are significant costs associated with them, and their effect by population size is unknown. Methods. In 2007 and 2008, the Japanese Government surveyed breast and cervical cancer screening in every municipality in Japan. From the results, we selected all 1,464 municipalities that carried out both screening types. We examined whether changes in screening attendance rates between 2007 and 2008 were associated with client reminders, number of public health nurses per 100,000 population, financial strength index, and 2007 attendance rates for different population sizes. We then calculated cost-effectiveness estimates of client reminders by population size and screening type. Results: Client reminders were associated with increased attendance rates in populations <100,000. For populations of 50,000-100,000, there was a 2.76% increase in breast cancer screening (95% CI: 0.41, 5.11), and a 2.25% increase in cervical cancer screening (95% CI: 0.89, 3.61). The incremental cost per additional attendance was higher in populations <50,000 than in populations of 50,000-100,000 (breast, $100 versus $54; cervical, $149 versus $67 respectively). Conclusions: Client reminders for breast and cervical cancer screening increased attendance rates in smaller municipalities in Japan. © 2014 Komoto et al.; licensee BioMed Central Ltd.

Background: Waist-to-height ratio (WHtR) has been shown to be a useful screening tool for metabolic syndrome and cardiovascular disease (CVD). We investigated the association of WHtR with CVD incidence by age group. Methods: We conducted a 13.0-year cohort study of Japanese adults (2600 men and 2888 women) with no history of CVD. WHtR was calculated as waist circumference (cm) (WC) divided by height (cm). We stratified participants by sex and age group (30-49, 50-69, ≥70 years). Using the Cox proportional hazards model, we calculated hazard ratios (HRs) and 95% CIs for CVD in relation to WHtR quartile for participants aged 50 to 69 years and 70 years or older. Results: Men aged 50 to 69 years in the highest quartile had significantly increased risks of CVD and coronary heart disease as compared with the lowest quartile; the HRs (95% CI) were 1.82 (1.13-2.92) and 2.42 (1.15-5.12), respectively. Women aged 50 to 69 years in the highest quartile had a significantly increased risk of stroke (HR, 2.43; 95% CI, 1.01-5.85). No significant results were observed in men or women aged 70 years or older. The likelihood ratio test showed that the predictive value of WHtR was greater than that of WC among men aged 50 to 69 years. Conclusions: The association between WHtR and CVD risk differed among age groups. WHtR was useful in identifying middle-aged Japanese at higher risk of CVD and was a better predictor than WC of CVD, especially in men. © 2013 Yukako Tatsumi et al.

Background: Physical activity (PA) is complex and a difficult behavior to assess as there is no ideal assessment tool(s) that can capture all contexts of PA. Therefore, it is important to understand how different assessment tools rank individuals. We examined the extent to which self-report and direct assessment PA tools yielded the same ranking of PA levels. Methods: PA levels were measured by the Modifiable Activity Questionnaire (MAQ) and pedometer at baseline among 855 white (W), African-American (AA), Japanese-American (JA), and Korean (K) men (mean age 45.3 years) in 3 geographic locations in the ERA JUMP study. Results: Korean men were more active than W, AA, and JA men, according to both the MAQ and pedometer (MAQ total PA [mean ± SD]: 41.6 ± 17.8, 20.9 ± 9.9, 20.0 ± 9.1, and 29.4 ± 10.3 metabolic equivalent [MET] hours/week, respectively; pedometer: 9584.4 ± 449.4, 8363.8 ± 368.6, 8930.3 ± 285.6, 8335.7 ± 368.6 steps/day, respectively). Higher levels of total PA in Korean men, as shown by MAQ, were due to higher occupational PA. Spearman correlations between PA levels reported on the MAQ and pedometer indicated positive associations ranging from rho = 0.29 to 0.42 for total activity, rho = 0.13 to 0.35 for leisure activity, and rho = 0.10 to 0.26 for occupational activity. Conclusions: The 2 assessment methods correlated and were complementary rather than interchangeable. The MAQ revealed why Korean men were more active. In some subpopulations it may be necessary to assess PA domains other than leisure and to use more than 1 assessment tool to obtain a more representative picture of PA levels. © 2013 Marie A. Berger et al.

Aim: Heterozygous patients with familial hypercholesterolemia (FH) are known to be associated with a high risk of coronary artery disease (CAD), which is a major determinant of their clinical outcome. The prognosis of heterozygous FH patients substantially varies, being dependent on the level of their CAD risk, and their therapeutic regimen should be individualized. We assessed critical levels of LDLcholesterol (LDL-C) and Achilles tendon thickness (ATT) to identify heterozygous FH patients at "very high" risk for CAD. Methods: One hundred and nine heterozygous FH patients who had no history of CAD and had had their plasma lipid profile and ATT assessed before treatment were followed up until their first CAD event or 31 December 2010. Multivariable logistic regression models were used to analyze the correlation of LDL-C and/or ATT levels with the risk of developing CAD. Results: During the follow-up period, 21 of the 109 patients had a CAD event, diagnosed by coronary angiogram. Individuals in the highest tertile of LDL-C had a CAD risk 8.29-fold higher than those in the lowest tertile. Individuals in the highest tertile of the ATT group had a 7.82-fold higher CAD risk than those in the lowest tertile. Those who had either LDL-C ≥260 mg/dL or ATT ≥14.5 had a 23.94-fold higher CAD risk than those with LDL-C ≥260 mg/dL and ATT ≥14.5 mm. Conclusions: In heterozygous FH patients, LDL-C 260 mg/dL or higher and/or ATT 14.5 mm or thicker are useful markers for extracting patients at "very high" risk for CAD.

Aim: High-sensitivity C-reactive protein (hs-CRP) identifies individuals at risk for cardiovascular disease (CVD) without an increased level of low-density lipoprotein cholesterol (LDL-C). The present study was performed to compare hs-CRP and LDL-C in association with the cardio-ankle vascular index (CAVI) in Japanese community dwellers considered to be at low risk for atherosclerosis from their level of traditional CVD risk factors. Methods: A community-based study involving 386 healthy Japanese (261 men and 125 women) without a history of CVD and medications for hypertension, diabetes, and dyslipidemia was performed. Multiple adjustments were performed with linear regression models to estimate the association between CAVI and hs-CRP or LDL-C levels. The participants were divided into four groups on the basis of whether they were above or below the median hs-CRP and LDL-C values, and CAVI was compared among the four groups by analysis of covariance after adjusting for confounders. Results: In multiple linear regression models, hs-CRP showed a significant positive association with CAVI; however, no clear association was observed between CAVI and LDL-C. These results were similar in the analyses among the participants with LDL-C <140 mg/dL or hs-CRP <1.0 mg/L. CAVI was higher in the groups with high hs-CRP than in those with low hs-CRP, irrespective of LDL-C; however, CAVI was highest in the group with high LDL-C and high hs-CRP. Conclusions: The present study suggests that hs-CRP could be a better risk factor assessor for atherosclerosis than LDL-C in individuals considered to be at low risk for atherosclerosis assessed by their traditional CVD risk factors.

Both American and European guidelines recommend coronary artery calcification (CAC) as a tool for screening asymptomatic individuals at intermediate risk for coronary heart disease (CHD). These recommendations are based on epidemiologic studies mostly in the United States. We review (1) the use of CAC in primary prevention of CHD in the United States, (2) epidemiologic studies of CAC in asymptomatic adults outside of the United States, and (3) international epidemiologic studies of CAC. This review will not consider clinical studies of CAC among patients or symptomatic individuals. US studies have shown that CAC is a strong independent predictor of CHD in both sexes among middle-aged and old age groups, various ethnic groups, and individuals with and without diabetes and that CAC plays an important role in reclassifying individuals from intermediate to high risk. Studies in Europe support these conclusions. The Electron-Beam Tomography, Risk Factor Assessment Among Japanese and US Men in the Post-World-War-II birth cohort (ERA JUMP) Study is the first international study to compare subclinical atherosclerosis, including CAC among Japanese, Japanese Americans, Koreans, and whites. It showed that as compared with whites, Japanese had lower levels of atherosclerosis, whereas Japanese Americans had similar or higher levels. CAC is being increasingly used as a screening tool for asymptomatic individuals in Europe and the United States. CAC is a powerful research tool, because it enables us to describe differences in atherosclerotic burden across populations. Such research could identify factors responsible for differences among populations, which may improve CHD prevention. © 2012 by the Japan Epidemiological Association.

Life expectancy (LE) among the Japanese population with or without diabetes mellitus was estimated. LE in 40-year old men and women was 41.1 and 47.5. years in those without diabetes and 32.3 and 40.9. years in those with diabetes. The LE of 40-year old men and women with diabetes was 8.8 and 6.6. years shorter than in those without diabetes. Diabetes mellitus leads to a decrease in LE. The presence of impaired glucose tolerance also affected LE inversely. © 2012 Elsevier Ireland Ltd.

Background and Purpose-Recent studies reported the differential effect of docosahexaenoic (DHA) and eicosapentaenoic acids (EPA). We examined the differential association of DHA and EPA with carotid intima-media thickness (IMT) in Japanese individuals in Japan and in U.S. white individuals and explored whether DHA or EPA contributes to the difference in IMT between the two groups. Methods-A population-based cross-sectional study in 608 Japanese and U.S. white men aged 40 to 49 was conducted to assess IMT, serum DHA, EPA, and other cardiovascular risk factors. Results-Japanese compared to U.S. whites had significantly lower IMT (mean±SD, 618±81 and 672±94 μm for Japanese and whites, respectively; P<0.001) and had >2-fold higher levels of DHA and EPA. DHA, but not EPA, had an inverse association with IMT in both Japanese and U.S. whites. The inverse association remained only in Japanese men after adjusting for risk and other factors. The significant difference in multivariable-adjusted IMT became nonsignificant after further adjusting for DHA (mean difference, 17 μm; 95% CI,-8 to 43; P=0.177) but not EPA. In this multivariable-adjusted model, DHA but not EPA was a significant predictor of IMT (P=-0.032 versus 0.863, respectively). Conclusions-These data suggest that DHA may have a more potent antiatherogenic effect than EPA, especially in levels observed in the Japanese, independent of risk factors. © 2011 American Heart Association. All rights reserved.

Although the causal relationships of high serum levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) with coronary artery disease (CAD) are well established, there have been few community-based epidemiologic studies of these relations in Japan. Furthermore, even when analysis is restricted to ischemic stroke, the relationship between dyslipidemia and stroke is very weak. Accordingly, it is difficult to perform cohort studies of dyslipidemia and cardiovascular disease. A series of studies, such as the NIPPON DATA (National Integrated Project for Prospective Observation of Non-communicable Disease and Its Trends in the Aged) cohort study of a representative sample of Japanese, have greatly increased existing evidence. NIPPON DATA80 revealed a clear positive relationship between TC and CAD, and indicated that reverse causality between hypocholesterolemia and liver disease may increase all-cause mortality in hypocholesterolemic Japanese. NIPPON DATA90 showed that serum high-density lipoprotein cholesterol (HDL-C) was inversely associated with all-cause mortality, even when HDL-C was very high. NIPPON DATA80 revealed that low-normal levels of serum albumin and TC are associated with a decline in activity during old age, especially in women. The Suita study-a unique cohort study of urban residents-showed that LDL-C and non-HDL-C were equally accurate in predicting the incidence of myocardial infarction. Further research of this quality is needed to ascertain the public health burden of dyslipidemia in Japan. © 2010 by the Japan Epidemiological Association.

Background: An immediate ambulance call offers the greatest opportunity for acute stroke therapy. Effectively using ambulance services requires strengthening the association between knowledge of early stroke symptoms and intention to call an ambulance at stroke onset, and encouraging the public to use ambulance services. Methods: The present study utilized data from the Acquisition of Stroke Knowledge (ASK) study, which administered multiple-choice, mail-in surveys regarding awareness of early stroke symptoms and response to a stroke attack before and after a 2-year stroke education campaign in two areas subject to intensive and moderate intervention, as well as in a control area, in Japan. In these three areas, 3833 individuals (1680, 1088 and 1065 participants in intensive intervention, moderate intervention, and control areas, respectively), aged 40 to 74 years, who responded appropriately to each survey were included in the present study. Results: After the intervention, the number of correctly identified symptoms significantly associated with intention to call an ambulance (P <0.05) increased (eg, from 4 to 5 correctly identified symptoms), without increasing choice of decoy symptoms in the intensive intervention area. Meanwhile, in other areas, rate of identification of not only correct symptoms but also decoy symptoms associated with intention to call an ambulance increased. Furthermore, the association between improvement in the knowledge of stroke symptoms and intention to call an ambulance was observed only in the intensive intervention area (P = 0.009). Conclusions: Our results indicate that intensive interventions are useful for strengthening the association between correct knowledge of early stroke symptoms and intention to call an ambulance, without strengthening the association between incorrect knowledge and intention to call an ambulance.

The influence of alcohol intake on hypertension may vary depending on the flushing response, but this relationship has not been confirmed. The relationship between alcohol intake and hypertension was examined according to the flushing response in a representative sample of the Japanese population. Participants in the National Health and Nutrition Survey in 2010 were asked to participate in the baseline survey of NIPPON DATA2010. Here, we investigated the relationship between alcohol intake and hypertension according to the flushing response. Statistical analyses were performed in a cross-sectional manner using multiple logistic regression models after adjusting for age, body mass index, smoking status, present illness of diabetes mellitus and present illness of dyslipidemia. Of the 1139 men and 1263 women, 659 and 463, respectively, had hypertension. Among the men, alcohol intake was positively associated with hypertension, regardless of the flushing response (P for linear trend both <0.05). This positive relationship was observed for both users and non-users of antihypertensive drugs. No interaction with the flushing response was observed (P for interaction=0.360). In women, although the direction differed between flushers and non-flushers, the association between alcohol intake and hypertension was not significant, regardless of flushing response. In conclusion, In Japanese men, alcohol intake was positively associated with hypertension in a manner that was not influenced by the flushing response.

© 2019 S. Karger AG, Basel. Background: While water intake is frequently recommended to prevent cerebral infarction (CI), only few studies have been published on this topic. Objectives: This study retrospectively estimated the daily non-alcohol drink (NAD) intake in CI patients before CI onset and compared it with NAD in healthy subjects. Methods: We performed a cross-sectional study on CI patients in 3 hospitals and healthy subjects in the Kobe Orthopedic and Biomedical Epidemiologic (KOBE) study. Data from 1,287 subjects (274 CI patients and 1,013 healthy subjects) were used for the analyses. By dividing the CI patients into "increased", "unchanged", and "decreased" groups according to their current NAD intake, we compared the NAD intake between these 3 groups and healthy subjects by analyses of covariance and the post hoc test, adjusting for sex, age, surveyed month, body mass index, alcohol drinking history, and smoking history. Under the assumption that the NAD intake in the "unchanged" group was equal to the NAD intake before CI onset, the OR of less NAD intake for CI adjusting for the relevant variables in the "unchanged" group and the healthy subjects was calculated; the cut-off point was chosen using Youden's index. Results: The mean age (mean ± SD) of the participants was 62.8 ± 9.3 years. One hundred and fifty-one patients (36 women) were included in the "increased" group; 105 (30 women), in the "unchanged" group; 18 (2 women), in the "decreased" group; and 1,013 (706 women), in the "healthy" group. The mean NAD intake was 1,702.5 ± 670.2 mL in the "increased" group, 1,494.2 ± 611.2 mL in the "unchanged" group, 1,268.0 ± 596.1 mL in the "decreased" group, and 1,720.6 ± 686.0 mL in the "healthy" group. After adjusting for the relevant variables, a significant difference in NAD intake between the groups was observed (F = 6.1, p < 0.001), and a post hoc test demonstrated significant differences (p < 0.05) in NAD intake between the "healthy" and "unchanged" groups, and between the "increased" and "unchanged" groups. The OR of less NAD intake (<1,570 mL/day, chosen using Youden's index) for CI was 2.48 (95% CI 1.52-4.07). Conclusion: This study showed that daily NAD intake before CI onset in CI patients was less than that in healthy persons, indicating that sufficient intake of NAD may be protective for CI.

Aims/hypothesis: At the same level of BMI, white people have less visceral adipose tissue (VAT) and are less susceptible to developing type 2 diabetes than Japanese people. No previous population-based studies have compared insulin resistance and insulin secretion between these two races in a standardised manner that accounts for VAT. We compared HOMA-IR, HOMA of beta cell function (HOMA-β%) and disposition index (DI) in US white men and Japanese men in Japan.Methods: We conducted a population-based, cross-sectional study, comprising 298 white men and 294 Japanese men aged 40–49 years without diabetes. Insulin, glucose, VAT and other measurements were performed at the University of Pittsburgh. We used ANCOVA to compare geometric means of HOMA-IR, HOMA-β% and DI, adjusting for VAT and other covariates.Results: White men had higher HOMA-IR, HOMA-β% and DI than Japanese men, and the difference remained significant (p < 0.01) after adjusting for VAT (geometric mean [95% CI]): 3.1 (2.9, 3.2) vs 2.5 (2.4, 2.6), 130.8 (124.6, 137.3) vs 86.7 (82.5, 91.0), and 42.4 (41.0, 44.0) vs 34.8 (33.6, 36.0), respectively. Moreover, HOMA-IR, HOMA-β% and DI were significantly higher in white men even after further adjustment for BMI, impaired fasting glucose and other risk factors.Conclusions/interpretation: The higher VAT-adjusted DI in white men than Japanese men may partly explain lower susceptibility of white people than Japanese people to developing type 2 diabetes. The results, however, should be interpreted with caution because the assessment of insulin indices was made using fasting samples and adjustment was not made for baseline glucose tolerance. Further studies using formal methods to evaluate insulin indices are warranted.