Diet quality and mortality among Japanese men and Study · Diet quality and mortality among...

Confidential: For Review O

nly

Diet quality and mortality among Japanese men and

women: The Japan Public Health Center-based Prospective

Study

Journal: BMJ

Manuscript ID: BMJ.2015.028384

Article Type: Research

BMJ Journal: BMJ

Date Submitted by the Author: 28-Jul-2015

Complete List of Authors: Kurotani, Kayo; National Center for Global Health and Medicine, Department of Epidemiology and Prevention Akter, Shamima; National Center for Global Health and Medicine, Department of Epidemiology and Prevention Kashino, Ikuko; National Center for Global Health and Medicine, Department of Epidemiology and Prevention Goto, Atsushi; National Center for Global Health and Medicine, Diabetes and Metabolic Medicine Mizoue, Tetsuya; National Center for Global Health and Medicine, Department of Epidemiology and Prevention Noda, Mitsuhiko; National Center for Global Health and Medicine, Department of Diabetes and Metabolic Medicine

Sasazuki, Shizuka; National Cancer center, Epidemiology and Prevention Division Sawada, Norie; National Cancer center, Epidemiology and Prevention Division Tsugane, Shoichiro; Research Center for Cancer Prevention and Screening National Cancer Center, Epidemiology and Prevention Division

Keywords: diet quality, mortality, Dietary Guidelines, cancer, cardiovascular disease, heart disease, cerebrovascular disease, Japan

https://mc.manuscriptcentral.com/bmj

BMJ


nly1

Diet quality and mortality among Japanese men and women: The Japan Public Health

Center-based Prospective Study

Kayo Kurotani, Shamima Akter, Ikuko Kashino, Atsushi Goto, Tetsuya Mizoue, Mitsuhiko

Noda, Shizuka Sasazuki, Norie Sawada, and Shoichiro Tsugane for the Japan Public Health

Center-based Prospective Study Group

Kayo Kurotani, Department of Epidemiology and Prevention, National Center for Global

Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, Japan, 162-8655.

Senior researcher

Shamima Akter, Department of Epidemiology and Prevention, National Center for Global


Researcher

Ikuko Kashino, Department of Epidemiology and Prevention, National Center for Global


Researcher

Atsushi Goto, Department of Public Health, Tokyo Women’s University, 8-1 Kawadacho,

Shinjuku-ku, Tokyo, Japan, 162-8666

Assistant professor

Page 1 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly2

Tetsuya Mizoue, Department of Epidemiology and Prevention, National Center for Global


Director

Mitsuhiko Noda, Department of Diabetes Research, National Center for Global Health and

Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, Japan, 162-8655.

Director

Shizuka Sasazuki, Epidemiology and Prevention Group, Research Center for Cancer

Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku Tokyo, Japan,

104-0045.

Director

Norie Sawada, Epidemiology and Prevention Group, Research Center for Cancer Prevention

and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku Tokyo, Japan, 104-0045.

Section chief

Shoichiro Tsugane, Epidemiology and Prevention Group, Research Center for Cancer

Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku Tokyo, Japan,

104-0045.

Director of Research Center for Cancer Prevention and Screening

Page 2 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly3

Correspondence and reprint requests: Kayo Kurotani

Department of Epidemiology and Prevention, National Center for Global Health and

Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, Japan, 162-8655.

Telephone: +81-3-3202-7181, Fax: +81-3-3202-7364, E-mail: [email protected]

Page 3 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly4

ABSTRACT

Objective: To examine the association of adherence to the Japanese Food Guide Spinning Top

(ST) with total and cause-specific mortality in a large-scale, population-based cohort study in

Japan.

Design: Prospective cohort study with follow-up for a median of 15 years.

Setting: The Japan Public Health Center-based Prospective Study.

Participants: This five year, follow-up survey included 37,867 men and 44,351 women aged

45–75 years who had no history of cancer, stroke, ischemic heart disease or chronic liver

disease.

Main outcome measurements: Habitual dietary intakes were assessed using a validated

147-item food frequency questionnaire. Deaths and causes of death were identified using the

residential registry and death certificates.

Results: The Japanese Food Guide ST score was associated with lower total mortality in both

men and women [hazard ratio (HR): 0.80; 95% confidence interval (CI): 0.75, 0.86 in men;

HR: 0.89; 95% CI: 0.81, 0.97 in women] when lowest and highest quartiles were compared.

In both men and women, the Japanese Food Guide ST score was inversely associated with

CVD mortality (P-trend: <0.0001 in men; P-trend = 0.03 in women), especially

cerebrovascular mortality (HR: 0.75; 95% CI: 0.60, 0.93; P-trend = 0.008 in men; HR: 0.71;

95% CI: 0.55, 0.92; P-trend = 0.01 in women). Men in the highest quartile of the Japanese

Page 4 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly5

Food Guide ST score had a 15% lower risk of cancer mortality than men in the lowest quartile

(HR: 0.85; 95% CI: 0.76, 0.94).

Conclusion: A higher adherence to the Japanese dietary guideline had lower risks of total and

CVD mortality, especially cerebrovascular disease mortality (in men and women) and cancer

mortality (in men) in Japanese adults.

Page 5 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly6

INTRODUCTION 1

Recent assessments of diet focused on the overall diet quality rather than single 2

nutrients or foods.1 More than 25 a priori-defined dietary scoring systems have been 3

developed to assess diet quality based on adherence to dietary recommendations or guidelines 4

specific to the country where the tool was developed.2 For example, the Healthy Eating Index 5

(HEI)3 and the Alternate Healthy Eating Index (AHEI)

4 were developed in the US according 6

to Dietary Guidelines for Americans on the basis of nutrient and food intake. In Japan, the 7

Ministry of Health, Labour and Welfare and the Ministry of Agriculture, Forestry and 8

Fisheries of Japan jointly developed the Japanese Food Guide Spinning Top (ST) in 2005 9

(Figure 1).5 This guide attempts to illustrate the balance and quantity of food in the daily 10

Japanese diet.5 In 2009, Oba et al. developed a scoring system to measure the adherence to the 11

Japanese Food Guide ST based on intake of grain dishes, vegetable dishes, fish and meat 12

dishes, milk and fruits, as well as the total daily energy and energy from snacks and alcoholic 13

beverages.6 In recent years, several diet quality scores have been examined for associations 14

with health outcomes, including mortality.2 15

Of the epidemiological studies examining the association between diet quality and 16

mortality,6-21

most show that a higher diet quality score is associated with lower mortality.6-18

17

20 21 In studies that found these associations, all-cause mortality was reduced by 17–42 %,

6-18 18

20 21 cardiovascular disease (CVD) mortality by 18–53 %

7 10 15-17 20 21 and cancer mortality by 19

Page 6 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly7

13–30 %7 10-12 15 16 21

in the highest category of scores compared with the lowest. To our best 20

knowledge, only 2 Asian studies have examined this topic, showing that diet based on the 21

Japanese Food Guide ST and the Chinese Food Pagoda (CHFP) was associated with a lower 22

risk of mortality in Japan6 and China,

16 respectively. However, the Japanese study was 23

conducted in only one city6 and thus might not present results representative of Japan. 24

Additionally, although several dietary scoring systems assess fish and meat separately or 25

consider the quality of fat,2 which may be beneficial for CVD prevention,

22 the Japanese Food 26

Guide ST score does not separate fish and meat dishes into fish and meat.6 Through 27

modifications, the Japanese Food Guide ST score may be improved to include salient features 28

of other dietary scoring. 29

In the present study, we prospectively examined the association of the Japanese Food 30

Guide ST score and a modified Japanese Food Guide ST score with total and cause-specific 31

mortality using data from a large-scale, population-based cohort study in Japan. 32

33

METHODS 34

Study design 35

The Japan Public Health Center-based Prospective (JPHC) Study was launched in 1990 36

for cohort I and in 1993 for cohort II.23

The participants of cohort I included residents of 5 37

Japanese public health center areas (Iwate, Akita, Nagano, Okinawa-Chubu and Tokyo) aged 38

Page 7 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly8

40-59 y. The participants of cohort II included residents of 6 public health center areas 39

(Ibaraki, Niigata, Kochi, Nagasaki, Okinawa-Miyako and Osaka) aged 40-69 y. A 40

questionnaire survey was conducted at baseline and at the 5- and 10-year follow-ups. 41

Information on medical histories and health-related lifestyles including smoking, drinking and 42

dietary habits was obtained at each survey. Because the questionnaire that was used for the 43

5-year follow-up survey (i.e. the second survey) provided more comprehensively information 44

about food intake than did the questionnaire that was used for the baseline survey, we used 45

data from the second survey as the baseline data for this analysis. Although we did not require 46

written informed consent, the study participants were informed of the objectives of the study, 47

and the participants who responded to the questionnaire survey were considered to have 48

consented to participating in the survey. This study was approved by the Institutional Review 49

Board of the National Cancer Center of Japan and the Ethics Committee of the National 50

Center for Global Health and Medicine, Japan. 51

52

Food frequency questionnaire 53

We used data from the second survey that included 147 food and beverage items and 9 54

frequency categories.24

For most food items, nine options were available for describing 55

consumption frequency: rarely (<once/month), 1-3 times/month, 1-2 times/week, 3-4 56

times/week, 5-6 times/week, once a day, 2-3 times/day, 4-6 times/day and ≥7 times/day. 57

Page 8 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly9

Regarding beverage intake, a standard portion size was specified for each food item and the 58

respondents were asked to assess their usual portion size relative to a standard specified for 59

each food item using three options (less than half, standard and more than 1.5 times). Daily 60

intake of most foods was calculated by multiplying the daily consumption frequency and the 61

standard portion size by the individual’s usual portion size. From the FFQ, total daily energy 62

intake and intake of each nutrient and food item were estimated according to the Japanese 63

Standard Tables of Food Composition.25

The validity and reproducibility of the FFQ had 64

already been established as reasonable.26-28

65

66

The Japanese Food Guide ST score and the modified Japanese Food Guide ST score 67

The Japanese Food Guide ST is based on the Dietary Guidelines for Japanese, released 68

in 2000, and guides people as to the types and amounts of food they should eat each day to 69

promote health. The Japanese Food Guide ST comprises five dish categories: grain dishes 70

(including rice, bread and noodles), vegetable dishes (including vegetables, mushrooms, 71

potatoes and seaweed), fish and meat dishes (including meat, fish, eggs and soybeans), milk 72

(milk and milk products) and fruits (fruit and 100% fruit juice [counted as half the weight]) 73

(Figure 1).5 In the Japanese Food Guide ST, the amount of dish that counts as one serving for 74

each dish category is estimated. One serving of a grain dish is composed of about 40 g 75

carbohydrates. In one serving of a vegetable dish, the main ingredient weighs about 70 g. One 76

Page 9 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly10

serving of fish and meat dish contains about 6 g protein, and one serving of milk contains 77

about 100 mg calcium. In one serving of fruits, the main ingredient weighs about 100 g. The 78

recommended amount of servings by category and the recommended total energy intake are 79

specified according to sex, age and physical activity level (Table 1). We modified the 80

recommended servings of vegetables dishes and fruits in the Japanese Food Guide ST from 81

equal to the recommended equivalents to ≥the recommended equivalents according to recent 82

diet quality scoring systems, including the AHEI-2010, HEI-2010 and CHFP.16, 21

In the 83

present study, participants were classified as having a moderate or high level of physical 84

activity if they engaged in manual labor or walked at least one hour per day. The remaining 85

participants were classified as sedentary. The Japanese Food Guide ST recommends that the 86

amount of energy intake from snacks and alcoholic beverages should be less than 200 87

kcal/day for everyone. 88

We determined the scores by measuring adherence to the Japanese Food Guide ST from 89

information in the FFQ. First, we calculated the number of servings according to the Japanese 90

Food Guide ST criteria. Grain dishes included rice, vitamin-enriched rice, rice with cereal, 91

bread, Japanese wheat noodles, buckwheat noodles, Okinawa noodles, Chinese noodles and 92

rice cakes. Vegetable dishes included carrots, spinach, pumpkins, cabbage, Chinese cabbage, 93

Chinese radishes, salted pickles of Chinese radishes, salted pickles of green leafy vegetables, 94

pickled plums, pickled Chinese cabbage, pickled cucumbers, pickled eggplant, sweet pepper, 95

Page 10 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly11

tomatoes, Chinese chives, garland chrysanthemums, komatsuna, broccoli, onions, cucumbers, 96

bean sprouts, snap beans, lettuce, pak choy, leaf mustard, bitter gourds, leaf beet, loofah, 97

mugwort, sweet potato, potato, taro, shiitake mushroom, hackberry, wakame seaweed, dark 98

edible seaweed, lavers, peanuts and tomato juice. Fish and meat dish included steak, grilled 99

and stewed beef, stir-fried pork, deep-fried pork, Western style stewed pork, Japanese style 100

stewed pork, pork in soup, pork liver, ham, sausage or Wiener sausage, bacon and luncheon 101

meats, chicken liver, grilled chicken, deep-fried chicken, egg, salmon, skipjack/tuna, 102

cod/flatfish, sea bream, horse mackerel/sardines, saury/mackerel, eel, squid, octopus, shrimp, 103

clams, pond snails, salted fish, dried fish, dried whitebait, salted fish roe, canned tuna, 104

fish-paste products (chikuwa and kamaboko), tofu, boiled tofu, fluffy tofu, freeze-dried tofu, 105

deep-fried tofu, fermented soybean (natto) and soymilk. Milk included cow's milk, cheese, 106

yoghurt, Japanese probiotic milk drink (Yakult), milk in tea and milk in coffee. Fruits included 107

papaya, mandarin oranges, other oranges, apples, persimmons, strawberries, grapes, melons, 108

watermelon, peaches, pears, kiwifruit, pineapple, bananas, 100% orange juice and 100% apple 109

juice. Snacks and alcoholic beverages included Japanese rice wine (sake), shochu, beer, 110

whiskey, wine, Japanese confectionaries, cake, biscuits, chocolate, canned coffee, coke, sugar 111

in tea and sugar in coffee. If individuals consumed the recommended amount of servings from 112

any of the five dish categories or the recommended total energy or energy from snacks and 113

alcoholic beverages, 10 points were given for that group. If individuals exceeded or fell short 114

Page 11 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly12

of the recommended servings or energy, the score was calculated proportionately between 0 115

and 10. When the calculation produced a negative score due to excess servings or energy, the 116

score was converted to 0. All group scores were summed to obtain a total Japanese Food 117

Guide ST score ranging from 0 (the lowest adherence) to 70 (the highest adherence). We 118

added the ratio of white to red meat as a new component to the Japanese Food Guide ST score, 119

creating the modified Japanese Food Guide ST score according to AHEI.4 White meat was 120

defined as grilled chicken, deep-fried chicken, salmon, skipjack/tuna, cod/flatfish, sea bream, 121

horse mackerel/sardine, saury/mackerel, eel, squid, octopus, shrimp, clam, pond snails, salted 122

fish, dried fish, dried whitebait, salted fish roe, canned tuna and fish-paste products. Red meat 123

was defined as steak, grilled and stewed beef, stir-fried pork, deep-fried pork, Western style 124

stewed pork, Japanese style stewed pork, pork in soup, pork liver, ham, sausage or Wiener 125

sausage, bacon and luncheon meats and chicken liver. Gram quantities were summed and 126

used to calculate the ratio. An ideal score of 10 was given for ratios ≥ 4:1, whereas a score of 127

0 was given for a ratio of 0. Intermediate intakes were scored proportionately between 0 and 128

10. The Japanese Food Guide ST score and the ratio of white to red meat score were summed 129

to obtain the modified Japanese Food Guide ST score ranging from 0 (worst) to 80 (best). 130

131

Study population 132

Of the potential subjects at baseline (n = 140 420), 103 450 participants responded to 133

Page 12 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly13

the second survey; of these, 102 364 completed the FFQ at the second survey. Of these 134

participants, we excluded 10 227 participants due to missing information regarding the 135

number of rice bowls consumed and the frequency of intake of the following: more than half 136

of the vegetable items, more than half of the fish and meat items, milk, more than half of the 137

fruit items, all snack items and alcoholic beverage items. Of 92 137 participants, we excluded 138

6215 participants who reported extreme intake of foods in one category (grains dishes, 139

vegetable dishes, fish and meat dishes, milk, fruits, as well and energy from snack and alcohol 140

intake) or total energy intake (upper and lower 1% according to sex). We also excluded 3704 141

participants who reported a history of cancer, stroke, ischemic heart disease or chronic liver 142

disease in the second survey. Ultimately, a total of 82 218 participants (37 867 men and 44 143

351 women) remained in this analysis. 144

145

Follow-up and outcome 146

The participants’ residency and vital status were followed up using the residential 147

registry. Causes of deaths were confirmed via death certificates (with permission) and were 148

defined according to the ICD-10.29

The major endpoint of the present study was mortality 149

from all causes, cancer (ICD-10: C00 to C97), CVD (ICD-10: I00 to I99), heart disease 150

(ICD-10: I20 to I52) and cerebrovascular disease (ICD-10: I60 to I69). 151

152

Page 13 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly14

Statistical analysis 153

We calculated person-years of follow-up for each person starting from the date of 154

response to the second survey questionnaire until the date of death, emigration from Japan or 155

31 December 2012, whichever came first. For individuals who were lost to follow-up, the last 156

confirmed date of their participation in the study area was used as the censoring date. 157

Participants were divided into quartiles of total Japanese Food Guide ST scores and the 158

modified Japanese Food Guide ST scores based on the distribution for men and women, 159

separately. Confounding variables considered were as follows: age (years, continuous), study 160

area (11 areas), body mass index (BMI <21, 21.0–22.9, 23.0–24.9, 25.0–26.9 or ≥27.0 kg/m2), 161

smoking status (lifetime non-smoker, former smoker or current smoker with a consumption of 162

either <20 or ≥20 cigarettes/day), total physical activity (metabolic equivalent task h/day, 163

quartiles), history of diabetes mellitus (yes or no), history of hypertension (yes or no), history 164

of dyslipidemia (yes or no), coffee consumption (almost never, < 1, 1 or ≥ 2 cups/day; 1 cup = 165

120 mL), green tea consumption (almost never, < 1, 1, 2–3 or ≥ 4 cups/day) and menopausal 166

status (premenopausal or postmenopausal) for women. An indicator variable for missing data 167

was created for each covariate. 168

We used Cox proportional hazard regression analysis to estimate hazard ratios (HRs) 169

and 95% confidence intervals of mortality from total and cause-specific mortality for quartiles 170

of the Japanese Food Guide ST scores and the modified Japanese Food Guide ST scores, 171

Page 14 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly15

using the lowest quartile category as a reference. The first model was adjusted for age and 172

study area, and the second model was further adjusted for BMI, smoking status, total physical 173

activity, history of diabetes mellitus, history of hypertension, history of dyslipidemia, coffee 174

consumption, green tea consumption and menopausal status for women. For estimating the 175

impact of total and cause-specific mortality on each group score, we further adjusted for each 176

group score. Trend association was assessed by assigning ordinal numbers (0–3) to quartile 177

categories of the Japanese Food Guide ST scores and the modified Japanese Food Guide ST 178

scores. We also analysed the data with respect to BMI (<25 kg/m2 or ≥25 kg/m

2) for both men 179

and women, smoking status (non-smoker or current smoker) in men and menopausal status 180

(premenopausal or postmenopausal) in women. We conducted multiple sensitivity analyses by 181

excluding individuals with a history of diabetes mellitus, hypertension or dyslipidemia and 182

those who died during the first three years of follow-up. All analyses were performed using 183

SAS version 9.3 for Windows. 184

185

RESULTS 186

At baseline (the time of the second survey), the mean (±SD) Japanese Food Guide ST 187

and modified Japanese Food Guide ST scores were 42.4 ± 9.2 and 47.8 ± 9.9, respectively, in 188

men and 47.4 ± 7.6 and 53.0 ± 8.3, respectively, in women. As shown in Table 2, both men 189

and women with higher Japanese Food Guide ST scores were less likely to be young, a 190

Page 15 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly16

current smoker or a weekly alcohol drinker and more likely to have a history of dyslipidemia, 191

to drink green tea and to have a higher energy intake than those with lower scores. Men with 192

higher scores were more likely to consume coffee and to have a history of diabetes and less 193

likely to have a history of hypertension. Women with higher scores were more likely to report 194

higher levels of physical activity at work or during leisure time, postmenopausal status and 195

were less likely to consume coffee. 196

During the mean (±SD) follow-up time of 14.5 ± 3.7 years for men and 15.2 ± 3.0 years 197

for women, deaths due to total causes, cancer, CVD, heart disease and cerebrovascular disease 198

included 6835 men and 3967 women, 2855 men and 1591 women, 1668 men and 1076 199

women, 893 men and 544 women and 640 men and 443 women, respectively. After 200

adjustment for potential confounding variables, higher Japanese Food Guide ST scores were 201

associated with lower total mortality in both men and women; the multivariate adjusted HRs 202

of total mortality for the lowest through highest quartile scores were 1.00, 0.91, 0.85 and 0.80 203

(P for trend < 0.0001) in men and 1.00, 0.93, 0.89 and 0.89 (P for trend = 0.005) in women 204

(Table 3). For cause-specific mortality, CVD mortality (especially cerebrovascular mortality) 205

was inversely associated with the Japanese Food Guide ST score in both men and women; the 206

multivariate adjusted HRs of CVD mortality for the lowest through highest quartile category 207

of score were 1.00, 0.95, 0.77 and 0.82 (P for trend = 0.02) in men and 1.00, 0.93, 0.82 and 208

0.85 (P for trend = 0.03) in women. The corresponding values for cerebrovascular mortality 209

Page 16 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly17

were 1.00, 0.82, 0.74 and 0.75 (P for trend = 0.008) in men and 1.00, 0.77, 0.73 and 0.71 (P 210

for trend = 0.01) in women. Men in the highest quartile of the Japanese Food Guide ST score 211

had a 15% lower risk of cancer mortality than did men in the lowest quartile (HR = 0.85; 95% 212

CI: 0.76, 0.94; P for trend = 0.002). However, women with higher Japanese Food Guide ST 213

scores had no reduction in the risk of cancer mortality. In addition, heart disease mortality was 214

not associated with the Japanese Food Guide ST score for either men or women. 215

Similar to the Japanese Food Guide ST score, higher modified Japanese Food Guide ST 216

scores were associated with a lower risk of total, CVD and cerebrovascular disease mortality 217

in men and women and cancer mortality in men (Table 4); the multivariate adjusted HRs of 218

total, CVD and cerebrovascular disease mortality for the highest quartile scores compared 219

with the lowest was 0.82 (95% CI: 0.76, 0.87; P for trend < 0.0001), 0.80 (95% CI: 0.70, 0.92; 220

P for trend = 0.0003) and 0.72 (95% CI: 0.58, 0.90; P for trend = 0.002), respectively, in men 221

and 0.88 (95% CI: 0.80, 0.96; P for trend = 0.008), 0.80 (95% CI: 0.67, 0.96; P for trend = 222

0.045) and 0.71 (95% CI: 0.54, 0.94; P for trend = 0.03), respectively, in women. The 223

corresponding value for cancer mortality in men was 0.87 (95% CI: 0.78, 0.96; P for trend = 224

0.006) 225

For the Japanese Food Guide ST score, group scores that attenuated point estimates 226

of the multivariate model 2 by ten percent or more included milk for CVD mortality (13.4 %) 227

and for cerebrovascular disease mortality (14.7 %) in men and fruits for cerebrovascular 228

Page 17 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly18

disease mortality (12.7 %) in women. 229

In stratified analysis by BMI, both the Japanese Food Guide ST score and the modified 230

Japanese Food Guide ST score were significantly associated with the odds of total, CVD and 231

cerebrovascular disease mortality in men of normal weight (BMI <25 kg/m2) (P for trend 232

<0.001). In contrast, no such association was observed among overweight men (BMI ≥25 233

kg/m2) (P for interaction <0.10). In stratified analysis by smoking status in men, both the 234

Japanese Food Guide ST and the modified Japanese Food Guide ST scores were more 235

strongly associated with total mortality in current smokers than in non-smokers; the 236

multivariate adjusted HRs of total mortality for the highest quartile of the Japanese Food 237

Guide ST score compared to the lowest was 0.74 (95% CI: 0.67, 0.81; P for trend < 0.0001) in 238

current smokers and 0.87 (95% CI: 0.78, 0.96; P for trend = 0.002) in non-smokers (P for 239

interaction= 0.009). Both scores were significantly associated with the risk of CVD mortality 240

in current smokers, whereas no clear associations were observed between CVD mortality and 241

either score among non-smokers (P for interaction <0.10). There were no differential 242

associations of BMI and menopausal status in women. 243

In the sensitivity analysis, the observed associations in all participants did not changed 244

after exclusion of total deaths during the first three years of follow-up. Exclusion of 245

individuals with a history of diabetes, hypertension, or dyslipidemia (n= 9359 in men and n= 246

11 128 in women) strengthened the observed associations of total, CVD and cerebrovascular 247

Page 18 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly19

disease mortality in men; the multivariate adjusted HRs of total, CVD and cerebrovascular 248

disease mortality for the highest quartile compared with the lowest was 0.75 (95% CI: 0.69, 249

0.82; P for trend < 0.0001), 0.69 (95% CI: 0.57, 0.82; P for trend < 0.0001) and 0.62 (95% CI: 250

0.47, 0.83; P for trend = 0.001), respectively, for the Japanese Food Guide ST score and 0.79 251

(95% CI: 0.73, 0.88; P for trend < 0.0001), 0.70 (95% CI: 0.58, 0.84; P for trend < 0.0001) 252

and 0.61 (95% CI: 0.45, 0.81; P for trend = 0.0007), respectively, for the modified Japanese 253

Food Guide ST score. However, the observed associations in women did not change after 254

excluding individuals with a history of diabetes, hypertension or dyslipidemia. 255

256

DISCUSSION 257

In this large prospective cohort, men and women with higher adherence to the Japanese 258

Food Guide ST had a 20% and 11% lower risk of total mortality, respectively. This protective 259

association was typically attributable to a strong reduction in cerebrovascular mortality in 260

both men and women. The Japanese Food Guide ST scores predicted a risk of cancer 261

mortality in men but not in women. We also modified the Japanese Food Guide ST score 262

considering the quality of fish and meat consumed. Similar to the Japanese Food Guide ST 263

score, the modified Japanese Food Guide ST score was inversely associated with total and 264

cause-specific mortality. The associations of both scores with total, CVD and cerebrovascular 265

disease mortality were particularly pronounced in normal-weight men. Those with total and 266

Page 19 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly20

CVD mortality were also pronounced in current male smokers. This study is one of the few to 267

examine the association between adherence to dietary recommendations or guidelines and 268

mortality in Asian countries. 269

270

Findings in relation to other studies 271

Our findings are in agreement with those from other studies, which reported that higher 272

diet-quality scores were associated with reduced total mortality.6-18 20 21

In China, the CHFP 273

score assesses the adherence to the CHFP, which is based on food groups according to the 274

Dietary Guidelines for Chinese.16

The concept of the CHFP score is similar to that of the 275

Japanese Food Guide ST. In the Shanghai Men’s Health Study (n = 61 239) and the Shanghai 276

Women’s Health Study (n = 73 216), the highest CHFP score was associated with a 33% and 277

13% lower risk of total mortality in men and women, respectively, using individuals in the 278

lowest score quartile as the reference.16

In the Iowa Women’s Health Study15

and the 279

Whitehall II cohort,20

the highest category of AHEI, which includes components similar to 280

those of the Japanese Food Guide ST, predicted 18% and 25% lower risk of total mortality, 281

respectively. In the Multiethnic Cohort,21

the highest diet-quality score, including HEI-2010 282

and AHEI-2010, was associated with 22–25% and 21–22% lower risk of total mortality in 283

men and women, respectively. This epidemiological evidence, including the present findings, 284

suggests that individuals with higher adherence to country-specific dietary recommendations 285

Page 20 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly21

have a lower risk of total mortality. 286

We found that a higher Japanese Food Guide ST score was associated with a lower risk 287

of total mortality over 15 years of follow-up in both men and women. The Japanese Food 288

Guide ST score used in this study was based on the score developed by Oba et al., who found 289

no clear association between the Japanese Food Guide ST scores and total mortality risk over 290

seven years of follow-up among men from Japan, whereas a significant inverse association 291

was observed among women.6 We have no clear explanation for the observed difference in 292

men between the present study and the previous study,6 but this difference might be 293

attributable to the different scoring of vegetable dishes and fruits used in each study. When 294

individuals consumed greater than the recommended equivalents of vegetable dishes or fruits, 295

their scores for these foods were deducted in the previous Japanese study. In contrast, we 296

assigned the highest score (10 points) to individuals who consumed higher than the 297

recommended amounts of vegetable dishes or fruits. Given that higher intake of vegetables 298

and fruits has been associated with a lower risk of mortality,30

the previous study6 might have 299

underestimated this association. 300

In most studies, diet-quality scores have been more strongly associated with reduced 301

mortality from CVD than from cancers.7 15-17 20 21 31

We also found that women with the 302

highest scores for the Japanese Food Guide ST were associated with a 15% lower risk of 303

CVD mortality but no risk reduction for cancer mortality using individuals in the lowest score 304

Page 21 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly22

quartile as the reference. Because cancer is a heterogeneous endpoint and diet might be 305

involved in the pathogenesis of certain cancers,32

weak associations might be observed 306

between cancer mortality and diet-quality scores. However, we found that men with the 307

highest Japanese Food Guide ST scores were associated with an 18% risk reduction for CVD 308

and a 15% risk reduction for cancers compared with those with the lowest scores. This result 309

might be related to the mortality from cancers according to sites of cancer in Japanese males. 310

Compared with Western countries and female populations in Japan, gastrointestinal cancer 311

mortality rates are higher in male populations in Japan.33 34

The 2007 World Cancer Research 312

Fund/American Institute for Cancer Research report35

suggested that vegetables and fruits 313

probably protect against stomach cancer and milk probably protects against colorectal cancer. 314

These foods are components of the Japanese Food Guide ST scores. Given that the Japanese 315

Food Guide ST includes the components that are protective against cancers with high 316

mortality in Japan, our findings suggest that adherence to the Japanese Food Guide ST might 317

decrease the risk of CVD and cancer mortality in the Japanese population. 318

A recent randomized controlled trial suggested that improving the quality of fat in the 319

diet might have primary benefits on CVD.22

However, the Japanese Food Guide ST score did 320

not consider the quality of fat, treating meat and fish as a same component. In the present 321

study, we modified the Japanese Food Guide ST score by adding the ratio of white to red meat 322

according to AHEI.4 White meat, including fish and poultry, is rich in polyunsaturated fatty 323

Page 22 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly23

acids, whereas red meat, including beef and pork, is rich in saturated fatty acids.36

In the 324

present study, the observed inverse associations of total and cause-specific mortality with the 325

Japanese Food Guide ST scores did not change after modification of the scores. This 326

observation could be explained by the higher consumption of fish37 38

and lower consumption 327

of beef and pork38 39

in Japanese populations compared with Westerners, leading to a 328

relatively ideal balance of white and red meat intake. Additionally, our previous studies 329

showed that a high intake of fish and n-3 polyunsaturated fatty acids was associated with a 330

decreased risk of myocardial infarction40

and that a high intake of saturated fatty acids was 331

associated with a decreased risk of stroke.41

Thus, the ratio of white to red meat as a score 332

component might not have a large effect on mortality risk in the present study. Our findings 333

suggest that the original Japanese Food Guide ST score could be accurate enough to predict 334

mortality risk in Japanese men and women. 335

We observed a more pronounced association between the Japanese Food Guide ST, the 336

modified Japanese Food Guide ST scores and total and CVD mortality in normal weight men 337

and smoking men. Large prospective studies of Japanese, including our study, have reported a 338

reverse-J pattern for total mortality according to BMI levels and a >11 % elevated risk of total 339

mortality for low BMI (<23 kg/m2) compared with BMI 23–<25 kg/m

2.42

Our previous study 340

showed that male current smokers had a 55% higher risk of total mortality compared with 341

never smokers.43

The beneficial effect of the adherence to the Japanese Food Guide ST on 342

Page 23 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly24

mortality risk might be more pronounced in populations at high risk of mortality, such as 343

individuals with low BMI and smokers. 344

In the present study, milk intake, which was evaluated on the basis of dairy calcium 345

intake, largely explained the associations between CVD, cerebrovascular disease mortality 346

and the Japanese Food Guide ST score in men. In a Japanese study, a 47% lower mortality 347

from total stroke for the highest versus the lowest quintile of dairy calcium intake was 348

observed in men.44

In addition, a 31% reduction in stroke risk was observed in individuals 349

with higher intake of dairy calcium compared with those with lower intake in our previous 350

report.45

As for women in the present study, we found that the association with 351

cerebrovascular disease mortality was largely explained by fruit intake. In a meta-analysis of 352

six prospective studies, a 5% lower mortality from CVD for the highest versus the lowest 353

quintile of fruit intake was observed.46

Additionally, our previous study showed that fruit 354

intake was inversely associated with CVD risk in women.47

Of the Japanese Food Guide ST 355

components, milk and fruits might have a large impact on CVD mortality, especially 356

cerebrovascular disease mortality. 357

358

Strengths and limitations 359

The strengths of the present study were its population-based prospective design 360

involving a large cohort and the use of a validated FFQ. Our study also has several limitations. 361

Page 24 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly25

First, the FFQ was not developed for the purpose of estimating the adherence to the Japanese 362

Food Guide ST. However, we used 125 of 147 (85%) food and beverages in the validated 363

FFQ, and we retrospectively calculated dish servings according to the Japanese Food Guide 364

ST criteria and the Japanese Food Guide ST score. Thus, well-designed FFQs could be used 365

to estimate dish servings and calculate the Japanese Food Guide ST score. Second, dietary 366

intake was assessed at baseline only and may not represent long-term habitual intake relevant 367

to mortality. Repeated assessment of diet over a long period of time before death will likely 368

provide a better estimate of dietary status. Third, the present analysis included individuals 369

with a history of diabetes, hypertension or dyslipidemia, who were advised to follow the 370

guidelines of each disease. After excluding for these individuals, however, similar results 371

were observed. Finally, effects of confounding by unmeasured and residual variables cannot 372

be totally ruled out. 373

374

Conclusion 375

In summary, Japanese individuals with higher adherence to the Japanese dietary 376

guideline had lower risks of total and CVD mortality, especially cerebrovascular disease, (in 377

men and women) and cancer mortality (in men). Our findings suggest that appropriate 378

consumption of energy, grains, vegetables, fruits, meat, fish, eggs, soy products, dairy 379

products, confectionaries and alcoholic beverages might have benefits on mortality. 380

381

Page 25 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly26

What is already known on this topic. 382

Epidemiological studies have shown that higher diet quality scores were associated with 383

lower mortality from chronic diseases in Western populations. However, few studies have 384

examined the association between diet quality and mortality in Asian countries. 385

386

What this study adds. 387

Higher adherence to the Japanese Dietary Guideline with appropriate consumption of energy, 388

grains, vegetables, fruits, meat, fish, eggs, soy products, dairy products, confectionaries and 389

alcoholic beverages is associated with lower risk of total and CVD mortality, especially 390

cerebrovascular disease mortality and cancer mortality in the Japanese population. 391

392

Funding: This study was supported by National Cancer Center Research and Development 393

Fund (23-A-31[toku] and 26-A-2) (since 2011) and a Grant-in-Aid for Cancer Research from 394

the Ministry of Health, Labour and Welfare of Japan (from 1989 to 2010) and Practical 395

Research Project for Life-Style related Diseases including Cardiovascular Diseases and 396

Diabetes Mellitus (15ek0210021h0002) from the Japan Agency for Medical Research and 397

Development. 398

399

400

Page 26 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly27

Competing Interests：：：：All authors have completed the ICMJE uniform disclosure form at 401

www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the 402

submitted work; no financial relationships with any organisations that might have an interest 403

in the submitted work in the previous three years; no other relationships or activities that 404

could appear to have influenced the submitted work. 405

406

Authorship：：：：ST was involved in the design of study as the principal investigator; ST, NS, and 407

SS conducted the survey; KK, SA, IK, AG, TM, and MN drafted the plan for the data 408

analyses; KK conducted data analysis; TM provided statistical expertise; and KK drafted the 409

manuscript; KK and TM had primary responsibility for final content; and all authors were 410

involved in interpretation of the results and revision of the manuscript and approved the final 411

version of the manuscripts. 412

413

We are indebted to the Aomori, Iwate, Ibaraki, Niigata, Osaka, Kochi, Nagasaki, and Okinawa 414

Cancer Registries for providing their incidence data. 415

Members of the Japan Public Health Center-based Prospective Study (JPHC Study, principal 416

investigator: S. Tsugane) Group are: S. Tsugane, N. Sawada, M. Iwasaki, S. Sasazuki, T. 417

Yamaji, T. Shimazu and T. Hanaoka, National Cancer Center, Tokyo; J. Ogata, S. Baba, T. 418

Mannami, A. Okayama, and Y. Kokubo, National Cerebral and 419

Page 27 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly28

Cardiovascular Center, Osaka; K. Miyakawa, F. Saito, A. Koizumi, Y. Sano, I. Hashimoto, T. 420

Ikuta, Y. Tanaba, H. Sato, Y. Roppongi, T. Takashima and H. Suzuki, Iwate Prefectural Ninohe 421

Public Health Center, Iwate; Y. Miyajima, N. Suzuki, S. Nagasawa, Y. Furusugi, N. Nagai, Y. 422

Ito, S. Komatsu and T. Minamizono, Akita Prefectural Yokote Public Health Center, Akita; H. 423

Sanada, Y. Hatayama, F. Kobayashi, H. Uchino, Y. Shirai, T. Kondo, R. Sasaki, Y. Watanabe, 424

Y. Miyagawa, Y. Kobayashi, M. Machida, K. Kobayashi and M. Tsukada, Nagano Prefectural 425

Saku Public Health Center, Nagano; Y. Kishimoto, E. Takara, T. Fukuyama, M. Kinjo, M. Irei, 426

and H. Sakiyama, Okinawa Prefectural Chubu Public Health Center, Okinawa; K. Imoto, H. 427

Yazawa, T. Seo, A. Seiko, F. Ito, F. Shoji and R. Saito, Katsushika Public Health Center, 428

Tokyo; A. Murata, K. Minato, K. Motegi, T. Fujieda and S. Yamato, Ibaraki Prefectural Mito 429

Public Health Center, Ibaraki; K. Matsui, T. Abe, M. Katagiri, M. Suzuki, K. and Matsui, 430

Niigata Prefectural Kashiwazaki and Nagaoka Public Health Center, Niigata; M. Doi, A. 431

Terao, Y. Ishikawa, and T. Tagami, Kochi Prefectural Chuo-higashi Public Health Center, 432

Kochi; H. Sueta, H. Doi, M. Urata, N. Okamoto, F. Ide, H. Goto and R Fujita, Nagasaki 433

Prefectural Kamigoto Public Health Center, Nagasaki; H. Sakiyama, N. Onga, H. Takaesu, M. 434

Uehara, T. Nakasone and M. Yamakawa, Okinawa Prefectural Miyako Public Health Center, 435

Okinawa; F. Horii, I. Asano, H. Yamaguchi, K. Aoki, S. Maruyama, M. Ichii, and M. Takano, 436

Osaka Prefectural Suita Public Health Center, Osaka; Y. Tsubono, Tohoku University, Miyagi; 437

K. Suzuki, Research Institute for Brain and Blood Vessels Akita, Akita; Y. Honda, K. 438

Page 28 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly29

Yamagishi, S. Sakurai and N. Tsuchiya, University of Tsukuba, Ibaraki; M. Kabuto, National 439

Institute for Environmental Studies, Ibaraki; M. Yamaguchi, Y. Matsumura, S. Sasaki, and S. 440

Watanabe, National Institute of Health and Nutrition, Tokyo; M. Akabane, Tokyo University 441

of Agriculture, Tokyo; T. Kadowaki and M. Inoue, The University of Tokyo, Tokyo; M. Noda 442

and T. Mizoue, National Center for Global Health and Medicine, Tokyo; Y. Kawaguchi, 443

Tokyo Medical and Dental University, Tokyo; Y. Takashima and Y. Yoshida, Kyorin 444

University, Tokyo; K. Nakamura and R. Takachi, Niigata University, Niigata; J. Ishihara, 445

Sagami Women’s University, Kanagawa; S. Matsushima and S. Natsukawa, Saku General 446

Hospital, Nagano; H. Shimizu, Sakihae Institute, Gifu; H. Sugimura, Hamamatsu University 447

School of Medicine, Shizuoka; S. Tominaga, Aichi Cancer Center, Aichi; N. Hamajima, 448

Nagoya University, Aichi; H. Iso and T. Sobue, Osaka University, Osaka; M. Iida, W. Ajiki, 449

and A. Ioka, Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka; S. Sato, 450

Chiba Prefectural Institute of Public Health, Chiba; E. Maruyama, Kobe University, Hyogo; 451

M. Konishi, K. Okada, and I. Saito, Ehime University, Ehime; N. Yasuda, Kochi University, 452

Kochi; S. Kono, Kyushu University, Fukuoka; S. Akiba, Kagoshima University, Kagoshima; 453

T. Isobe, Keio University; Y. Sato, Tokyo Gakugei University. 454

455

Data sharing：：：：no additional data available. 456

457

Page 29 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly30

Ethical approval：：：：The Institutional Review Board of the National Cancer Center of Japan 458

and the Ethics Committee of the National Center for Global Health and Medicine, Japan. 459

460

Copyright：：：：The Corresponding Author has the right to grant on behalf of all authors and does 461

grant on behalf of all authors, an exclusive licence on a worldwide basis to the BMJ 462

Publishing Group Ltd to permit this article (if accepted) to be published in BMJ editions and 463

any other BMJPGL products and sublicences such use and exploit all subsidiary rights, as set 464

out in our licence. 465

466

Page 30 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly31

References

1. Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr. Opin.

Lipidol. 2002;13:3-9.

2. Wirt A, Collins CE. Diet quality--what is it and does it matter? Public Health Nutr

2009;12:2473-92.

3. Kennedy E, Meyers L, Layden W. The 1995 dietary guidelines for Americans: an overview.

J. Am. Diet. Assoc. 1996;96:234-7.

4. McCullough ML, Feskanich D, Stampfer MJ, Giovannucci EL, Rimm EB, Hu FB, et al.

Diet quality and major chronic disease risk in men and women: moving toward

improved dietary guidance. Am. J. Clin. Nutr. 2002;76:1261-71.

5. Yoshiike N, Hayashi F, Takemi Y, Mizoguchi K, Seino F. A new food guide in Japan: the

Japanese food guide Spinning Top. Nutr. Rev. 2007;65:149-54.

6. Oba S, Nagata C, Nakamura K, Fujii K, Kawachi T, Takatsuka N, 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;109:1540-7.

7. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet

and survival in a Greek population. N. Engl. J. Med. 2003;348:2599-608.

8. Trichopoulou A, Kourisblazos A, Wahlqvist ML, Gnardellis C, Lagiou P, Polychronopoulos

E, et al. Diet and Overall Survival in Elderly People. Br. Med. J. 1995;311:1457-60.

Page 31 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly32

9. Osler M, Schroll M. Diet and mortality in a cohort of elderly people in a north European

community. Int. J. Epidemiol. 1997;26:155-9.

10. Kant AK, Schatzkin A, Graubard BI, Schairer C. A prospective study of diet quality and

mortality in women. JAMA 2000;283:2109-15.

11. Mai V, Kant AK, Flood A, Lacey JV, Schairer C, Schatzkin A. Diet quality and subsequent

cancer incidence and mortality in a prospective cohort of women. Int. J. Epidemiol.

2005;34:54-60.

12. Michels KB, Wolk A. A prospective study of variety of healthy foods and mortality in

women. Int. J. Epidemiol. 2002;31:847-54.

13. Knoops KT, Groot de LC, Fidanza F, Alberti-Fidanza A, Kromhout D, van Staveren WA.

Comparison of three different dietary scores in relation to 10-year mortality in elderly

European subjects: the HALE project. Eur. J. Clin. Nutr. 2006;60:746-55.

14. Santaren ID, Watkins SM, Liese AD, Wagenknecht LE, Rewers MJ, Haffner SM, et al.

Serum pentadecanoic acid (15:0), a short-term marker of dairy food intake, is

inversely associated with incident type 2 diabetes and its underlying disorders. Am. J.

Clin. Nutr. 2014;100:1532-40.

15. Mursu J, Steffen LM, Meyer KA, Duprez D, Jacobs DR, Jr. Diet quality indexes and

mortality in postmenopausal women: the Iowa Women's Health Study. Am. J. Clin.

Nutr. 2013;98:444-53.

Page 32 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly33

16. Yu D, Zhang X, Xiang YB, Yang G, Li H, Gao YT, et al. Adherence to dietary guidelines

and mortality: a report from prospective cohort studies of 134,000 Chinese adults in

urban Shanghai. Am. J. Clin. Nutr. 2014;100:693-700.

17. Seymour JD, Calle EE, Flagg EW, Coates RJ, Ford ES, Thun MJ. Diet Quality Index as a

Predictor of Short-term Mortality in the American Cancer Society Cancer Prevention

Study II Nutrition Cohort. Am. J. Epidemiol. 2003;157:980-88.

18. Bazelmans C, De Henauw S, Matthys C, Dramaix M, Kornitzer M, De Backer G, et al.

Healthy food and nutrient index and all cause mortality. Eur. J. Epidemiol.

2006;21:145-52.

19. Lagiou P, Trichopoulos D, Sandin S, Lagiou A, Mucci L, Wolk A, et al. Mediterranean

dietary pattern and mortality among young women: a cohort study in Sweden. Br. J.

Nutr. 2006;96:384-92.

20. Akbaraly TN, Ferrie JE, Berr C, Brunner EJ, Head J, Marmot MG, et al. Alternative

Healthy Eating Index and mortality over 18 y of follow-up: results from the Whitehall

II cohort. Am. J. Clin. Nutr. 2011;94:247-53.

21. Harmon BE, Boushey CJ, Shvetsov YB, Ettienne R, Reedy J, Wilkens LR, et al.

Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: the

Dietary Patterns Methods Project. Am. J. Clin. Nutr. 2015;101:587-97.

22. Reidlinger DP, Darzi J, Hall WL, Seed PT, Chowienczyk PJ, Sanders TA. How effective

Page 33 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly34

are current dietary guidelines for cardiovascular disease prevention in healthy

middle-aged and older men and women? A randomized controlled trial. Am. J. Clin.

Nutr. 2015;101:922-30.

23. Tsugane S, Sobue T. Baseline survey of JPHC study--design and participation rate. Japan

Public Health Center-based Prospective Study on Cancer and Cardiovascular Diseases.

J. Epidemiol. 2001;11:S24-9.

24. Sasaki S, Kobayashi M, Ishihara J, Tsugane S. Self-administered food frequency

questionnaire used in the 5-year follow-up survey of the JPHC Study: questionnaire

structure, computation algorithms, and area-based mean intake. J. Epidemiol.

2003;13:S13-22.

25. Science and Technology, Agency. [Standard Tables of Food Composition in Japan] 5th

revised and enlarged. Tokyo, Japan: Printing Bureau of the Ministry of Finance, 2005.

26. Ishihara J, Sobue T, Yamamoto S, Yoshimi I, Sasaki S, Kobayashi M, et al. Validity and

reproducibility of a self-administered food frequency questionnaire in the JPHC Study

Cohort II: study design, participant profile and results in comparison with Cohort I. J.

Epidemiol. 2003;13:S134-47.

27. Sasaki S, Ishihara J, Tsugane S. Reproducibility of a self-administered food frequency

questionnaire used in the 5-year follow-up survey of the JPHC Study Cohort I to

assess food and nutrient intake. J. Epidemiol. 2003;13:S115-24.

Page 34 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly35

28. Sasaki S, Kobayashi M, Tsugane S. Validity of a self-administered food frequency

questionnaire used in the 5-year follow-up survey of the JPHC Study Cohort I:

comparison with dietary records for food groups. J. Epidemiol. 2003;13:S57-63.

29. World Health Organization. International Statistical Classification of Diseases and Related

Health Problems 10th Revision.

http://apps.who.int/classifications/icd10/browse/2015/en. 2015 (1 May, 2015).

30. Wang XX, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, et al. Fruit and vegetable

consumption and mortality from all causes, cardiovascular disease, and cancer:

systematic review and dose-response meta-analysis of prospective cohort studies. BMJ

2014;349:g4490.

31. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the

Mediterranean diet on health: an updated systematic review and meta-analysis. Am. J.

Clin. Nutr. 2010;92:1189-96.

32. Chiuve SE, Fung TT, Rimm EB, Hu FB, McCullough ML, Wang M, et al. Alternative

Dietary Indices Both Strongly Predict Risk of Chronic Disease. J. Nutr.

2012;142:1009-18.

33. Ministry of Health, Labour, and Welfare, Japan. Vital statistics of Japan.

http://www.e-stat.go.jp/SG1/estat/ListE.do?lid=000001108740. Vital , Health and

Social Statistics Division, Statistics and Information Department, Minister's

Page 35 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly36

Secretariat, Ministry of Health, Labour and Welfare, 2013

34. Boyle P, Levin B. World cancer report 2008.

http://www.iarc.fr/en/publications/pdfs-online/wcr/2008/wcr_2008.pdf. International

Agency for Research on Cancer, 2008

35. World Cancer Research, Fund, American Institute for Cancer, Research. Food, Nutrition,

Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington,

DC: AICR, 2007.

36. Science and Technology, Agency. [Standard Tables of Food Composition in Japan, fatty

acids section.] 5th revised and enlarged ed. Tokyo, Japan: Printing Bureau of the

Ministry of Finance, 2005.

37. FAOSTAT. Fish, Seafood. http://faostat.fao.org/. Food and agriculture organization of the

united nations statistics division, 2013

38. Kenko Eiyo Joho K. The National Health and Nutrition Survey in Japan, 2010. Tokyo:

Daiichi-shuppan, 2013.

39. Daniel CR, Cross AJ, Koebnick C, Sinha R. Trends in meat consumption in the USA.

Public Health Nutr 2011;14:575-83.

40. Iso H, Kobayashi M, Ishihara J, Sasaki S, Okada K, Kita Y, et al. Intake of Fish and n3

Fatty Acids and Risk of Coronary Heart Disease Among Japanese: The Japan Public

Health Center-Based (JPHC) Study Cohort I. Circulation 2006;113:195-202.

Page 36 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly37

41. Yamagishi K, Iso H, Kokubo Y, Saito I, Yatsuya H, Ishihara J, et al. Dietary intake of

saturated fatty acids and incident stroke and coronary heart disease in Japanese

communities: the JPHC Study. Eur. Heart J. 2013;34:1225.

42. Sasazuki S, Inoue M, Tsuji I, Sugawara Y, Tamakoshi A, Matsuo K, et al. Body Mass

Index and Mortality From All Causes and Major Causes in Japanese: Results of a

Pooled Analysis of 7 Large-Scale Cohort Studies. J. Epidemiol. 2011;21:417-30.

43. Hara M, Sobue T, Sasaki S, Tsugane S. Smoking and risk of premature death among

middle-aged Japanese: Ten-year follow-up of the Japan Public Health Center-based

prospective study on cancer and cardiovascular diseases (JPHC study) Cohort I. Jpn. J.

Cancer Res. 2002;93:6-14.

44. Umesawa M, Iso H, Date C, Yamamoto A, Toyoshima H, Watanabe Y, et al. Dietary

Intake of Calcium in Relation to Mortality From Cardiovascular Disease: The JACC

Study. Stroke 2006;37:20-26.

45. Umesawa M, Iso H, Ishihara J, Saito I, Kokubo Y, Inoue M, et al. Dietary Calcium Intake

and Risks of Stroke, Its Subtypes, and Coronary Heart Disease in Japanese: The JPHC

Study Cohort I. Stroke 2008;39:2449-56.

46. Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, et al. Fruit and vegetable consumption

and mortality from all causes, cardiovascular disease, and cancer: systematic review

and dose-response meta-analysis of prospective cohort studies. BMJ 2014;349:g4490.

Page 37 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly38

47. Takachi R, Inoue M, Ishihara J, Kurahashi N, Iwasaki M, Sasazuki S, et al. Fruit and

vegetable intake and risk of total cancer and cardiovascular disease: Japan Public

Health Center-Based Prospective Study. Am. J. Epidemiol. 2008;167:59-70.

Page 38 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

Confidential: For Review Only

- 39 -

Table 1

The recommended amount of servings by dish category, total energy, and energy from snacks and alcoholic beverages

1We modified the recommended servings of vegetables dishes and fruits in the Japanese Food Guide ST from equal to the recommended

equivalents to greater than or equal to the recommended equivalents

Age and physical activity level Grain

dishes

(serving/d)

Vegetable

dishes1

(serving/d)

Fish and

meat dishes

(serving/d)

Milk

(serving/d)

Fruits1

(serving/d)

Total

energy

(kcal/d)

Snacks

and

alcoholic

beverages

(kcal/d)

Men Women

70 y or older

70 y or older or

18-69 y with low

physical activity

4-5 ≥5 3-4 2 ≥2 1800±200 0-200

18-69 y with low

physical activity

18-69 y with

moderate or higher

physical activity

5-7 ≥5 3-5 2 ≥2 2200±200 0-200

18-69 y with moderate or

higher physical activity ― 7-8 ≥6 4-6 2-3 ≥2 2600±200 0-200

Page 39 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 40 -

Table 2

Baseline characteristics of subjects according to categories of the score on adherence to the Japanese Food Guide Spinning Top

(continued)

Quartiles of the score

Q1 (low) Q2 Q3 Q4 (high)

Men

n 9573 9544 8377 10073

Median score 32.0 40.0 46.0 54.0

Age (y)1 49.7±7.4 50.6±7.6 51.4±7.7 52.2±7.7

BMI (kg/m2)2,3

23.5±0.03 23.6±0.03 23.6±0.03 23.6±0.03

Total physical activity (metabolic equivalents-h/day)2,3

33.6±0.07 33.6±0.07 33.5±0.08 33.5±0.07

Current smoker (%)3,4

56.9 49.7 43.3 37.4

Alcohol consumption ≥1 d/wk (%)4 85.0 73.2 63.2 50.2

History of hypertension (%)4 17.9 17.1 16.8 14.8

History of diabetes (%)4 6.0 6.2 7.3 7.6

History of dyslipidemia (%)4 3.1 3.5 3.8 4.1

Energy (kcal/d)2 2063±6.3 2181±6.2 2189±6.8 2232±6.2

Coffee consumption (≥1 cups/day, %)3,4

30.5 34.0 34.6 33.2

Green tea consumption (≥1 cups/day, %)3,4

47.1 55.2 58.6 63.8

Page 40 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 41 -

Table 2 continued

1Mean±SD

2Age adjusted mean±SE

3Subjects with missing information were excluded (BMI: n = 599 in men, n = 759 in women; smoking status: n = 611 in men, n = 1877 in

women; total physical activity: n = 5382 in men, n = 6328 in women; coffee consumption: n = 751 in men, n = 851 in women; green tea

consumption: n = 631 in men, n = 826 in women). 4Age adjusted proportion

Quartiles of the score


Women

n 10921 10200 11420 11810

Median score 42.0 48.0 53.0 59.0

Age (y)1 50.9±8.0 51.0±7.7 51.4±7.6 51.6±7.6

BMI (kg/m2)2,3

23.5±0.03 23.5±0.03 23.4±0.03 23.4±0.03

Total physical activity (metabolic equivalents-h/day)2,3

32.4±0.06 32.5±0.06 32.7±0.06 33.0±0.06

Current smoker (%)3,4

9.2 5.4 3.8 2.9

Alcohol consumption ≥1 d/wk (%)4 16.7 12.5 10.8 9.3

History of hypertension (%)4 16.6 17.1 16.7 16.5

History of diabetes (%)4 3.2 3.3 3.1 3.0

History of dyslipidemia (%)4 4.8 6.2 6.6 6.9

Postmenopausal status (%)4 82.0 84.6 85.2 86.3

Energy (kcal/d)2 1752±5.2 1869±5.4 1911±5.1 1928±5.0

Coffee consumption (≥1 cups/day, %)3,4

38.1 37.3 35.5 32.7

Green tea consumption (≥1 cups/day, %)3,4

50.5 58.6 63.1 66.7

Page 41 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 42 -

Table 3

Multivariate adjusted hazard ratios (HR (95% confidence interval)) of mortality according to categories of the score on adherence to the Japanese

Food Guide Spinning Top

Quartiles of the score P trend

1


Men

Median score 32.0 40.0 46.0 54.0

Person-years 136594 142320 121670 147411

Total mortality

No. death 1785 1780 1487 1783

Rate/1000 person-years 13.1 12.5 12.2 12.1

Age and area adjusted HR (95% CI)2 1.00 (ref) 0.85 (0.80-0.91) 0.77 (0.71-0.82) 0.69 (0.64-0.73) <0.0001

Multivariate adjusted HR (95% CI)3 1.00 (ref) 0.91 (0.86-0.98) 0.85 (0.79-0.91) 0.80 (0.75-0.86) <0.0001

Cancer mortality

No. death 731 738 633 753



Multivariate adjusted HR (95% CI)3 1.00 (ref) 0.93 (0.84-1.03) 0.89 (0.80-0.996) 0.85 (0.76-0.94) 0.002

Cardiovascular disease mortality

No. death 434 450 333 450




(continued)

Page 42 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 43 -

Table 3 continued

Heart disease mortality

No. death 216 252 175 250


Age and area adjusted HR (95% CI)2 1.00 (ref) 0.99 (0.82-1.18) 0.73 (0.60-0.90) 0.78 (0.65-0.94) 0.0008


Cerebrovascular disease mortality

No. death 179 160 131 170




Women

Median score 42.0 48.0 53.0 59.0

Person-years 163066 154448 174371 181228

Total mortality

No. death 1092 897 977 1001




(continued)

Page 43 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 44 -

(continued)

Table 3 continued

Cancer mortality

No. death 386 352 413 440





No. death 310 247 253 266





No. death 157 133 120 134





No. death 137 95 106 105




Page 44 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 45 -

Table 3 continued

1To test the linear trend with mortality, ordinal numbers 0-3 to categories of the score was used.

2Adjusted for age and public health center area.

3Additionally adjusted for body mass index, smoking status, total physical activity, history of hypertension, history of diabetes, history of

dyslipidemia, coffee consumption, green tea consumption and menopausal status (only in women).

Page 45 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 46 -

Table 4

Multivariate adjusted hazard ratios (HR (95% confidence interval)) of mortality according to categories of the score on adherence to the modified

Japanese Food Guide Spinning Top

Quartiles of the score P trend

1


Men

Median score 37.0 45.0 52.0 61.0

Person-years 137839 132053 134243 143860

Total mortality

No. death 1736 1631 1643 1825



Multivariate adjusted HR (95% CI)3 1.00 (ref) 0.92 (0.86-0.99) 0.85 (0.79-0.91) 0.82 (0.76-0.87) <0.0001

Cancer mortality

No. death 711 682 703 759





No. death 422 411 376 459




(continued)

Page 46 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 47 -

Table 4 continued


No. death 214 219 211 249





No. death 175 152 137 176




Women

Median score 46.0 54.0 59.0 66.0

Person-years 164644 164008 182429 162030

Total mortality

No. death 1069 933 1045 920




(continued)

Page 47 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 48 -

(continued)

Table 4 continued

Cancer mortality

No. death 384 371 429 407





No. death 287 256 306 227





No. death 148 136 154 106





No. death 125 102 119 97




Page 48 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


- 49 -

Table 4 continued

1To test the linear trend with mortality, ordinal numbers 0-3 to categories of the score was used.

2Adjusted for age and public health center area.

3Additionally adjusted for body mass index, smoking status, total physical activity, history of hypertension, history of diabetes, history of

dyslipidemia, coffee consumption, green tea consumption and menopausal status (only in women).

Page 49 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly

- 50 -

Figure 1

The Japanese Food Guide Spinning Top

Page 50 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960


nly

187x180mm (600 x 600 DPI)

Page 51 of 51


BMJ

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

Date post:	11-Oct-2020
Category:	Documents
Upload:	others
View:	2 times
Download:	0 times

Diet quality and mortality among Japanese men and Study · Diet quality and mortality among...

Documents