2024 Volume 1 Issue 4 Pages 43-54
Aomori Prefecture has the shortest lifespan among all the prefectures in Japan. As life expectancy is an important indicator of the comprehensive strength of a society, creating a social innovation that can carry a society as a whole is essential. To create social innovation, industries, government, academia, and citizens need to gather on a platform and collaborate (open innovation) by overcoming mutual barriers. Thus, the platform must be attractive to all of them. The formation of linkages between people and organizations on the platform enables the implementation of a health promotion methodology relevant to all parts of society. The authors believe that big data (including real-world data) obtained from the Iwaki Health Promotion Project can be a key element in making the platform attractive. Simultaneously, a social capital platform for social implementation is required. Furthermore, the authors are developing and disseminating the Quality-Of-Life Check-ups as a core tool for social implementation. In this paper, the authors outline the activities to overcome the shortest-lived prefectures in Japan by utilizing the data platform and social capital platform and introduce the quality of health check-ups as the central activity of social implementation.
As the fundamental premise of primary health care (PHC)1) states, “All people, everywhere, have the right to achieve the highest attainable level of health”. To bring services for health and well-being closer to communities, the following three components are essential.
1) Introducing integrated health services to meet health needs throughout people’s lives
2) Addressing the broader determinants of health through multisectoral policy and action
3) Empowering individuals, families, and communities to take charge of their health.
According to the author’s interpretation, PHC can be expressed as “health of the people, by the people, for the people”. In other words, everyone has the right to be healthy but must seize it themselves. To do that, citizens need to acquire the ability to strive for health promotion (empowerment). Thus, we need social capital—a social environment that supports promoting health activities for every citizen2,3). Health promotion can only be achieved when these conditions are met and the whole system starts to function.
However, those who are healthy and/or young (including children) have little motivation to improve their health, and empowerment is less effective. Additionally, it is difficult to draw attention to health promotion and other related actions in modern society, as they have low economic efficiency and a limited contribution to regional revitalization.
Our strategy and goals are outlined below (Fig. 1).
According to various statistics, the life expectancy of Aomori citizens is shortened for the following reasons4–7). Specifically, in addition to unhealthy lifestyle habits (smoking, obesity, heavy drinking, high salt intake, and insufficient vegetable intake), low rates of health check-ups, and delays in hospital visits. However, the roots of these phenomena lie in the state of society as a whole, which includes economic conditions, educational levels, culture, climate, and temperament.
Aomori residents are required to improve lifestyle habits, increase health check-up rates and hospital visits, and empower people to develop health promotion literacy and take action.
However, to promote the health of society as a whole, it is necessary for industries, government, academia, and citizens to become stakeholders in the health promotion of their own society and work together to promote these activities (open innovation).
To realize open innovation, we need a platform that brings together industries, government, academia, and citizens. However, in the real world, there is no platform on which industries, government, academia, and citizens can spontaneously gather. One main reason is that each party expects different results and has different goals, as shown below.
1) Industry (private sector)
• Enhancing corporate profits
• Social contribution ( corporate social responsibility )
• ESG investment
2) Government (local government)
• Promoting health among citizens
• Improving medical cost control
• Providing adequate social security
• Promoting the town and its development
3) Academia (universities)
• Deepening research and education
• Contributing socially as a university
4) Citizens (people)
• promoting health
• Reducing medical cost
• Adequately providing social security
• Revitalizing and collaborating with other citizens
Therefore, the platform must be sufficiently attractive to spontaneously attract industries, government, academia, and citizens. The author believes that big data makes it attractive.
Big data (including real-world data, RWD), a mixture of data from various fields, is indispensable for elucidating modern diseases that are becoming extremely multifactorial. The content of the analysis is not only limited to medical economics but also extends dramatically to a person’s life, with the ultimate goal of research being the improvement of a person’s QOL (quality of life), life purpose, or ultimate happiness. Scientists tend to focus too much on numbers, which leads to a narrow vision and rigid thinking. At first glance, big data is just a collection of numbers and feels inorganic. In other words, big data may provide the first opportunity for a comprehensive and detailed understanding of society as a whole. If so, there is a high possibility that new large-scale research and social activities will emerge, and a possibility that a paradigm shift will occur in all social activities (even in the fields of education and research).
However, big data alone cannot drive all activities. To collect big data and implement its results in society, it is necessary to have a platform with strong social capital.
When the two platforms of data and social capital are developed and integrated, the foundation for conducting activities to realize health and well-being is established.
As an important tool for promoting the above activities, we developed a QOLC (Quality-Of-Life Check-up) and implemented it in society.
The author’s health promotion activities based on the above principles are described below.
2. Activity motivation: analysis of Aomori PrefectureAomori Prefecture has the shortest lifespan among the prefectures in Japan4). Since 1965, the prefecture has never risen above the bottom rank since the first prefecture rankings for life expectancy for men and women were published in Japan. Thus, increasing the lifespan is one great wish of the prefectural citizens.
Based on a comparison of death statistics in Aomori Prefecture and Nagano Prefecture, which has the longest life expectancy of all of Japan’s prefectures, we obtained the following conclusions5):
1) The mortality rate in Aomori Prefecture is higher than the Nagano Prefecture for all generations (especially those in their 40s and 50s). In other words, we can conclude that the 2.5-year difference in average life expectancy between the two prefectures is not the difference that occurs at the end of life.
2) The mortality rate of the major causes of death (three major lifestyle-related diseases—cancer, heart disease, and stroke) is high in Aomori Prefecture. Additionally, the incidence and mortality rates of diabetes, which is considered the root cause of many diseases, and the suicide rate in Aomori are among the highest in Japan.
The three major lifestyle-related diseases, which account for approximately 70% of adult deaths in Japan, have a long incubation period (usually 30–40 years). This means, for example, that people who contract or die from these diseases in their 40s and 50s are influenced by the lifestyles of teenagers, infants, and even toddlers. Therefore, the targets of health promotion activities are expanding to include not only adults and the older adults but also children, including preschoolers, and young workers.
The authors devised a system (QOLC) that allows people to get their results immediately after a health check-up and obtain important knowledge about health. QOLC was developed as a tool to support health promotion activities. This paper introduces it as a protocol paper.
The author will explain the principles of the author’s activities from a different angle.
As shown in Fig. 2, there is a sequence (history) of primordial prevention, primary prevention, secondary prevention, and medical care up to the average lifespan that the authors are targeting. Average life expectancy is calculated after death occurs, so it is the medical care that most affects death. The next factor that affects average lifespan is secondary prevention (health checkups). On the other hand, primary prevention is the basis for extending the average lifespan (health promotion) and is of great significance because it targets all citizens, but it takes several decades to reach “death” (average lifespan). In order to develop primary prevention, it is essential to enhance primordial prevention as the foundation. To date, the authors have been working to primordial prevention by building the data platform and human platform described below. However, even if we say that we are developing primary prevention based on primordial prevention, it is difficult to link them together. Therefore, the authors developed a QOLC checkup to serve as a bridge between primordial prevention and primary prevention.
Primordial prevention is an idea that originally emerged from research into the prevention of cardiovascular diseases. In the 1970s, Blackburn proposed the idea that not only individual risk factors but also social and cultural factors are important for disease prevention8).
In 1982, the World Health Organization (WHO) proposed the idea of “primordial prevention, in a report on cardiovascular diseases. Subsequently, in 1998, WHO identified social determinants of health (SDH) as “social disparities”, “stress”, “early childhood”, “social exclusion”, “labor”, “unemployment”, and “social support”. They announced 10 social determinants of health: drug dependence, food, and transportation. Since then, social and environmental measures that lead to health have become more important year by year. Furthermore, WHO once again referred to “primordial prevention” in its “Basic Epidemiology (2nd edition)” published in 20069).
1. Big data platformIn recent years, the collection of big data has become more available and possible with the advancement of digital networks and technology in analysis.
Big data has been causing a paradigm shift, not only in research but also in activities across all fields.
The big data targeted by the author consists of four types, and its collection is currently in progress.
1) Iwaki Health Promotion Project10,11): This project, which started in 2005, is a multipurpose survey and research activity that conducts comprehensive health assessments and is now in its 19th year. Data from the Iwaki Health Promotion Project form the core of the RWD used in this study. The outline of the project is as follows: A large-scale health survey is conducted for 10 consecutive days in June every year targeting residents aged 20 years and older in the Iwaki district of Hirosaki City, Aomori Prefecture (population: approximately 9,000). Approximately 1,000 applicants participate each year. The number of survey items has been increasing yearly, and the number of measurement items per person in 2005 was approximately 600; however, the number grew to approximately 3,000 or more by 2019. Table 1 summarizes the measurements collected from 2005 to 2022. The big data of the Iwaki Health Promotion Project have the following characteristics.
| 1. | Questionnaire: Family structure, educational history, medical history, family history, current medication, lifestyle (smoking, alcohol, exercise), motion and time study, Perceived Health Competence Scale, daily activities, oral hygiene, menstruation status, number of pregnancies or deliveries, bone fracture history |
| 2. | Diet: Food Frequency Questionnaire |
| 3. | Body composition: percentage of fat, muscle volume, visceral fat volume, etc. |
| 4. | Bone density (using ultrasonography) |
| 5. | Cardiovascular-related items: Blood pressure, electrocardiography, echocardiography, brachial-ankle pulse wave velocity, ABI (Ankle Brachial Index), fundus examination |
| 6. | Abdominal ultrasonography (for liver, pancreas, gall bladder, etc.) |
| 7. | Pulmonary function (using spirometer) |
| 8. | Physical fitness (20 items): Grip strength, sit-and-reach, lateral jumps, long jump with standing, standing balance with opened eyes, bar gripping reaction time, etc. |
| 9. | Blood examination: |
| ① Basic items (50 items): Leukocyte number, platelet number, hemoglobin, liver function, renal function | |
| ② Immunoglobulins, complements, uric acid, electrodes, etc. | |
| ③ Trace elements (14 items): Manganese, zinc, selenium, chrome, nickel, etc. | |
| ④ Glucose, lipid, and bone metabolism: HbA1c, blood glucose, LDL-/HDL-cholesterol, triglyceride, etc. | |
| ⑤ Amino acids (36 types), fatty acids (21 types) | |
| ⑥ Hormones (15 types), cytokines (seven types), and vitamins (10 types) | |
| ⑦ Neutrophil function: Reactive oxygen production capability, phagocytic activity, serum opsonin activity | |
| 10. | Cognitive function: Mini-Mental State Examination, Wechsler Memory Scale-Revised |
| 11. | Depressive state: Center for Epidemiologic Studies Depression Scale |
| 12. | Feces: Microbiota (16S-rRNA × MiSeqb method, shotgun analysis method) |
| 13. | Urine (10 items): 8-OHdG, trace albumin, cortisol, aldosterone, equol, etc. |
| 14. | Hearing, vision, and olfactory tests |
| 15. | Sleeping status: Pittsburgh Sleep Quality Index, polysomnography |
| 16. | Oral cavity: Oral flora, microbiota (16S-rRNA × MiSeqb method, shotgun analysis method), number of remaining teeth, periodontal disease, occlusal function, etc. |
| 17. | Orthopedic findings (20 items): Joint movable range (knee, hip joint), hydrarthrosis (knee), joint fissure (carpal tunnel), MRI images (knee, cervical vertebra, lumbar vertebra), etc. |
| 18. | Skin (five items): Transepidermal water loss, horny layer moisture, carotenoids, PH, skin typing |
| 19. | Advanced glycation end products |
| 20. | Exhaled gas (six types): NO CO, H2, CH4, etc. |
| 21. | Whole genome analysis |
| 22. | Metabolome analysis (blood) |
a. It is the world’s most comprehensive health database, with over 3,000 items per person.
b. It is characterized by data openness. Companies and researchers participating in the Iwaki Health Promotion Project may use the data if they comply with certain rules and regulations. This allows many research organizations and companies to come together. Researchers and companies conduct measurements in the Iwaki Health Promotion Project based on their interests. The items they measure have also been added to the data, making big data even larger.
2) Data collaboration with other universities: Health data were integrated from 13 universities across Japan (e.g., Kyoto Prefectural University of Medicine, Wakayama Medical University, and Meio University).
3) QOLC: Explained later in the manuscript.
4) Utilization of the “Next-Generation Medical Infrastructure Law”. We began utilizing the Next-Generation Medical Infrastructure Law in cooperation with Hirosaki City. This information includes medical receipts, which enables medical economic analysis.
5) The big data collected in this manner will be managed and operated in cooperation with data scientists and supercomputers at the University of Tokyo and Kyoto University.
2. Social capital platformData platforms alone cannot create a social innovation for health promotion. It is equally important to develop an appropriate social environment (network) that supports the realization of activity flows, such as data collection and social implementation of results obtained from big data.
1) Hirosaki University Graduate School of Medicine Health Future Innovation Center: a core organization for creating regional health innovations at Hirosaki University.
2) Aomori Medical Association Health Promotion Center: Since 2016, Aomori Prefecture, Aomori Medical Association, Hirosaki University COI11), and two local private banks have collaborated to train health promotion leaders and provide advice on health promotion. By the end of March 2023, nearly 7,000 health trainers have been trained.
3) In 2019, the mayors of all 40 municipalities in Aomori Prefecture issued health declarations.
4) Aomori Health and Productivity Management Certification Office System (2017 onwards): a system in which administrators declare their health, and companies and organizations that meet the requirements are certified as “Aomori Health and Productivity Management Offices”. By the end of March 2023, 398 companies have been certified.
5) Health education in elementary and junior high schools: approximately 100 elementary and junior high schools, which account for approximately 25% of Aomori Prefecture, supported the development of systematic and comprehensive health education.
3. QOLCThe authors have developed and are currently disseminating QOLC to grasp the current state of the body or acquire health literacy information by obtaining the results of medical examinations on the spot.
The main purpose of the health examinations is to detect diseases early and prevent death. Although health check-ups are the best opportunity to learn about health, the current health check-ups do not provide health education. Additionally, health guidance is uniform and uninteresting and does not lead to improved motivation or behavioral changes in the recipient.
One reason for this is that in a regular health check-up in Japan, recipients will receive written results and explanations in about a month.
Therefore, the authors devised a system (QOLC) that allows people to get their results immediately after a health check-up and obtain important knowledge about health.
The QOLC is as follows (Fig. 3).
Unlike a traditional health check-up, QOLC involves a comprehensive list of evaluations, including oral hygiene, frailty, depression, and dementia. The specific measurement items are listed below (Fig. 4):
1) Interviews (history of current illness, medical history, family history, lifestyle habits, etc.)
2) Measurement of factors related to metabolic syndrome (body composition, blood pressure, serum lipids, blood sugar, HbA1c, etc.)
3) Oral hygiene examination
4) Frailty-related survey (bone density, physical fitness measurement)
5) Dementia and depression tests
The check-up takes about one hour from start to finish; the test results are available one hour later, after which examinees attend the health education program (Fig. 5).
We are also implementing a simplified version with a reduced number of measurement items. This version requires less time and staff.
The QOLC has the following benefits.
1) Emphasis on QOL level measurement items: this can give examinees awareness and encouragement of behavioral change. It can also provoke a strong awareness of their health, which subsequently leads to behavioral changes and the acquisition of deeper health literacy. We introduced measurement items at the level of daily living that would be as interesting and relatable as possible to the recipients. For example, the estimation of green and yellow vegetable intake, oral hygiene examination, intra-abdominal fat measurement, and physical strength measurement.
2) Immediateness: all the test results described in the “results table” are sent to the examinee after about one hour, whereas normal health check-ups may take several months. The fact that it only takes an hour to receive the health check-up results has an empowering effect on examinees.
3) Enlightenment: citizens can participate in health education programs based on their results. It is easier to acquire health literacy by referring to personal results. Additionally, examinees can take the health promotion challenge program (online or flyer) monthly until the next QOLC (usually one year later).
4) Enjoyment: measuring QOL levels, obtaining immediate health check-up results, new measurement items using Dx, etc., and future predictions of health levels and diseases will increase examinee’s interest in health and motivation to go for health check-ups. Additionally, the introduction of new Dx equipment by companies will have economic effects, which will lead to the spread and continuation of this health check-up in the future.
The main measurement items at present are as follows;
1) Height, body weight, and BMI (body mass index)
2) Visceral fat: visceral fat area (VFA) was measured non-invasively using a bioimpedance-type visceral fat meter (EW-FA90; Panasonic Corporation, Osaka, Japan), which is a certified medical device in Japan (No. 22500BZX00522000) 10). Measurements obtained using this device were reported to have a strong correlation with those obtained using computed tomography, which is the standard for VFA measurement12,13).
3) Body composition: body composition was measured by bioelectrical impedance analysis (BIA) using an MC-190 (Tanita, Tokyo, Japan) in a standing position. The BIA is a multi-frequency, 8-electrode system that can provide estimates of muscle mass and body fat content for the entire body, trunk, and extremities14).
4) Urinary Na/K ratio: the urinary Na/K ratio, which has already been reported to be associated with blood pressure15), was measured using a urinary Na/K ratio-measuring device called HEU-001F (OMRON Healthcare Co., Ltd., Kyoto, Japan)16).
5) Vegetable intake check: the level of carotenoid on participant’s skin was measured using a Multiple Spatially Resolved Reflection Spectroscopy Sensor (Biozoom Services GmbH, Kassel, Germany) based on the reflection spectroscopy method17). A wavelength of 350–1,000 nm was provided via 118 LED light emitters in 16 steps, and the sensor detected the light reflected by the skin at 152 light-sensitive areas. Algorithms representing the skin carotenoid levels (0.1–12.0) were designed to ensure optimal correlation with the measured Resonance Raman Spectroscopy values. It was measured (once per person) on the thumb, completely covering the sensor without allowing stray light to enter. The measurement was repeated when an error message was shown.
6) Two-step test and stand-up test: this test is used as the criteria for determining locomotive syndrome by the Japanese Orthopedic Association. The stand-up test quantifies muscle strength and flexibility in the lower extremities, as well as balance, by assessing an individual’s ability to stand up on one or both legs from stools of four specified heights of 10, 20, 30, and 40 cm18,19). The two-step test measures stride length to assess walking ability, including muscle strength and flexibility in the lower extremities and balance20).
7) Hand grip power: grip strength reflects the muscle strength of the whole body.
8) Test for oral hygiene: a salivary sample was collected with 3 ml of mouthwash liquid and immediately evaluated using a commercially available test kit, the Salivary Multi-Test (SMT) (LION Dental Products Co., Ltd., Tokyo, Japan)21). SMT evaluated each level of cariogenic bacteria, acidity, buffer capacity, occult blood, leukocyte count, protein, and ammonia in saliva. This system consists of test strips and a measuring device. It detects color changes in the test strip and measures the reflectance at a specified wavelength. The cariogenic bacteria reflect the reduction ability of resazurin sodium by gram-positive bacteria, and the acidity demonstrates a change in the coloration of a pH indicator. The acid buffering capacity reflects the coloration change of the compound pH indicator under a fixed quantity of acid. Occult blood was detected by determining the hemoglobin pseudo-peroxidase activity as an index. Leukocyte levels were detected by measuring esterase activity in the isolated salivary leukocytes. The protein-error error of the indicator reactions was used to determine protein levels. Ammonia was detected by a color change in bromocresol green22–24). The values of the test results were expressed as relative values (percentage; 0–100% within the detection range), and the final three classifications (high, average, or low) were achieved according to the reference value established by the manufacturer21).
9) Bone mineral density (BMD): heel BMD was evaluated using the osteo sono-assessment index after ultrasonographic (AOS-100NW; Hitachi-Aloka Medical, Ltd., Tokyo, Japan) examination of the calcaneus25,26). The Z-score describes the standard deviation by which the heel BMD in an individual differs from the mean value expected for that individual’s age and sex, and the T-score describes the standard deviation of an individual’s BMD compared with the mean value of a young healthy reference population (20–44 years old), with the difference expressed in standard deviations27).
We plan to actively introduce health measurement equipment utilizing Dx that will be developed in the near future. In the near future, we would like to create prediction formulas for various diseases based on the results of QOLC from the data of the QOLC themselves and the big data collected by the authors, and show them to the examinees. As a result, the effect of QOLC on increasing the health motivation of examinees should become more pronounced.
The classification of normal values and abnormal values for the above measurement items was based on the supporting papers shown in each section.
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Hirosaki University Graduate School of Medicine (2018-083, 2019-053-1, 2020-101, 2020-100 and 2021-016).
At the end of March 2023, approximately 10,000 people underwent QOLC. Although the targets are companies and local governments, we would like to use them for health education in schools in the future.
Additionally, since 2019, we have been conducting QOLC in Hai Phong City, Vietnam, with Japan International Cooperation Agency’s grassroots support. In 2019, approximately 100 employees at two companies underwent QOLC.
We expect the following results over the next five years.
1) Conduct a total of 1,000 QOLCs (average of 200 per year) in the next five years at local governments and companies in Aomori Prefecture. The target population is estimated to be 40,000 in total (approximately 3.4% of Aomori Prefecture’s population).
2) Health indicators published by Aomori Prefecture once every five years will be used as interim evaluation indicators. Specifically, these include tobacco smoking prevalence, alcohol consumption rate, obesity rate, health checkup rate, vegetable intake, and salt intake. In addition, changes in health literacy and motivation for health promotion, which are always asked in QOLC, are also used as intermediate indicators.
3) The final evaluation indicators will be the mortality rates by prefecture (mortality rates by age and gender, crude mortality rates, and age-adjusted mortality rates) and average life expectancy published by the Ministry of Health, Labor and Welfare once every five years.
This research is jointly managed by the Innovation Center for Health Promotion (activity mnagement) and the Health and Medical Data Science Research Center (data management).
QOLC has an element of enjoyment, and many people can easily access it because there are many items to be measured on the level of living and non-invasively. To promote health, each citizen must gain an interest in health and increase their motivation to improve their health with knowledge about their health, and the QOLC can support this. Additionally, the QOLC allows examinees to obtain their results one hour later. The author believes that it is essential to have knowledge correctly organized in the mind to cause behavioral change. Behavioral change is difficult even with knowledge but cannot occur without knowledge.
To date, health check-ups have aimed to detect diseases earlier and prevent them from leading to death. Although it has the potential to be useful for primary prevention, it has not been able to make the most of its potential. QOLC emphasizes health education for primary prevention while maintaining its role as secondary prevention. In today’s world, where medical expenses are increasing every year owing to advances in medical technology, the authors believe that the enhancement of primary prevention through QOLC will be a savior.
The problem with the QOL check-up is that it requires the examinee to spend approximately two hours and the cost of equipment and staff. Currently, the trial is underway. Thus, the price is set at a low price. However, to continue, it is necessary to set a suitable price (establishing a proper balance between securing profits for business continuity and being affordable for patients) and shorten the required time.
In its truest sense, the era of big data has now arrived, and its overwhelming potential has caused a paradigm shift in activities in all fields, not just research and education. However, the foundation of health promotion is based on the development of empowerment toward health promotion by each citizen. QOLC is a tool that greatly assists in this process. Although verification of the effects of this health check-up is yet to be completed, this article introduces it as a protocol paper.
In the future, I would like to spread this QOLC to all who need health literacy and behavioral changes for health promotion.
The authors would like to thank the staff of Hirosaki University COI for their consistent cooperation from the design to the completion of this study. We would also like to thank Lion Corporation, Kao Corporation, KAGOME CO., LTD., and Maruman Computer Service Co., Ltd. for their assistance in providing the equipment and building the system. This work was supported by JST, Center of Innovation Program and Center of Innovation Next Program (JPMJCE1302, JPMJCA2201 and JPMJPF2210).
Shigeyuki Nakaji supervised the research. Other authors designed the research and carried out QOL check-ups.
This work was supported by JST COI [grant number: JPMJCE1302].
The authors declare no conflicts of interest.
