In the present special articles entitled “Evidence-based prevention of osteoporosis and osteoporotic fractures”, several preventive procedures for these diseases were evaluated for their effectiveness according to the best available evidence of literature. These procedures included optimization of calcium intake and physical activity as the primary prevention, bone density measurement as the screening, and prevention of falls in the elderly people. The present article described a method for the evaluation of preventive procedures for osteoporosis based on systematic review of the evidence, which was applicable for other preventive services of diseases. The next step to the review of evidence is how to communicate the evidence established to practitioners in the fields of preventive medicine and community health. One of the effective tools for this purpose is evidence-based preventive practice guideline. The Japanese Society for Hygiene should play a leading role in compiling a series of guidelines for the preventive procedures of various kinds of health problems such as lifestyle-related diseases.

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One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures in Japan is improvement in dietary calcium intake. However, virtually no randomized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan. In this study, we reviewed all the scientific papers currently available from medical literature databases to propose evidence-based recommendations on the preventive procedures for osteoporosis. The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender. The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life.

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According that osteoporosis is the common condition in an aging society such as in Japan, much progress has been made in understanding the treatment and prevention of osteoporosis. Among potential risk factors, exercise and physical activities have been recognized as lifestyle factors that might influence the risk of osteoporosis and osteoporotic fractures.
To assess the relationship between exercises including physical activities and the risk for low bone mass and osteoporosis-related fractures, a literature search over past 13 years was conducted. Accumulating evidence indicates that exercises decrease the risk for hip fractures among middle aged and older men and women. Exercises also help to maintain muscle strength, muscle volume, balance, and joint flexibility, which might prevent falls and fall-related fractures. One randomized controlled trial showed back-stretching exercise reduced the risk for vertebral fractures.
The literature search also indicates that high-impact and/or weight-bearing exercise might increase the bone density in the elderly and the peak bone mass among young women, while there is no association between moderate or lower-impact exercise and bone mineral density. Future research should be required to evaluate the types and quantity of physical activity needed for the prevention of osteoporosis.

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To review evidence on the benefits of screening women and men for osteoporosis, a Pub Med search was performed in English papers published between 1990 and 2002. We used data from a cohort study to estimate risk of fracture from bone mineral density.
Bone mineral density measured by dual X-ray absorptiometry (DXA) can predict bone fracture among elderly women, peri- and early post-menopausal women, and elderly men.
It is recommended that all white women older than 65 years be screened routinely for osteoporosis. We suggest that Japanese elderly women should receive BMD measurements as a screening, but we have still issues to be solved including age from when the screening should be started, methods, and how to treat the women found to have osteoporosis at the screening.
For peri- and postmenopausal women and elderly men, it might be beneficial to measure BMD as a screening and start treatment for those patients found to have osteoporosis. However, incidence of fractures for these people is lower than that for elderly women. One bone mass measurement can predict bone fracture risk for as long as over 10 years or more, but predictive ability of BMD decreases with time. Therefore, cost effectiveness needs to be reviewed to determine the benefits of screening among pen-menopausal women and men.
Although bone assessment by quantitative ultra sound (QUS) method by ultrasound can also predict future fractures, only a relatively small number of longitudinal studies have been conducted in the Western countries, and there is no established evidence by means of longitudinal studies among Japanese. It is necessary in Japan to seek such evidences, however, since this method is widely used for an osteoporosis examinations.

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This review aims to examine the effectiveness of fall-related strategies for fracture prevention among elderly population. Previous studies were reviewed using PubMed and Japan Centra Revuo Medicina databases. Our five research questions concerned prediction of fracture using history of accidental falls, fracture risk management, and effectiveness of exercise programs, home modification and usage of hip protector. We used “accidental falls” and “fractures” as search strategies. Obtained results were as follows: a) History of falls predicts future hip fracture. b) Exercise programs including balance training have positive effects for fracture prevention. c) Fracture risk evaluation and management reduce the number of hip fractures among elderly population. d) Environmental hazard assessment and necessary home modification are effective in preventing fractures especially among elderly population with the history of falls. e) The hip protector is a beneficial device for the prevention of hip fractures among elderly people at high risk of falling.

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Objectives: In order to clarify the characteristics of medical institutions visited by patients with selected intractable diseases, we analyzed data from the fourth nationwide survey in 1997.
Methods: We asked 47 prefectural governments to provide data concerning every patient receiving financial aid for treatment of 39 selected intractable diseases from April 1997 to March 1998. Out of 399, 719 whose information was reported by prefectural governments, we analysed data of 370, 232 patients whose medical institutions were reported. We performed detailed analysis on the relation between patients' residences and locations of medical institution which the patients visited, and on the characteristics of medical institutions. These analyses were respectively compared by sex and age, the beginning year of the financial aid, whether the patients were inpatients or outpatients, type of insurance, and clinical division where the patient was treated.
Results: 1. Analysis showed that 7.4% of all patients were treated in medical institutions outside the prefectures where they lived. Patients who lived in the neighboring prefectures of huge cities like Tokyo, tended to be treated in the medical institutions there. 2. We found that 23.5% of patients were treated in university hospitals, and 11.9% were seen in clinics. 3. There was a difference between patients with SMON and patients with myastenia gravis, pemphigus, epidermolysis bullosa or primary pulmonary hypertension. Of the two groups, the former preferred to visit clinics and be treated in medical institutions located in the same cities, towns, and villages where they lived. On the contrary, patients with the latter 4 diseases tended to visit large hospitals and be treated in those outside their prefectures. 4. Elderly patients over 70 years old tended to be treated in clinics or hospitals located in their neighborhoods. 5. Compared with past surveys, the percentage of patients treated in university hospitals had decreased, and that of patients treated in clinics had increased year by year. No change was found in the proportion of patients treated in medical insitutions outside their prefectures.
Conclusions: By the present analysis of a nationwide survey taken in fiscal year 1997, we were able to clarify the chracteristics of medical institutions visited by patients with selected intractable diseases. This kind of analysis should be continued to obtain important information on the epidemiology of intractable diseases.

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Objectives: In order to evaluate the relationship of quality of life (QOL) with physical fitness, competence and stress response in the elderly population in Japan, a cross sectional field survey of elderly subjects was conducted.
Methods: This survey was taken in Naguri village, Saitama. The data collected included physical fitness, competence, stress response and QOL in addition to demographic variables. As for physicl fitness indexes, grip strength (GS), single leg balance with eyes closed (SLB), bar grip ping reaction time (RT), trunk flexion (RF), ten-meter walking time (WT) and vital capacity (VC) were measured. The SF-36 was used for QOL assessment.
Results: A total of 120 elderly subjected participated to the survey. There were 42 males (73.5±5.74 years) and 78 females (74.2±6.17 years). The associations between physical health parameters in SF-36 and WT were highly significant: physicl functioning (β=-2.96, p<0.001), role physical (β=-3.64, p<0.001), bodily pain (β=-3.27, p<0.001) and general health (β=-3.14, p=0.001). Psychological stress response had a negative correlation with social functioning (β=-0.74, p=0.024), role-emotional (β=-2.34, p<0.007) and mental health (β=-0.97, p=0.024) as determined by multiple regression analysis. The goodness-of-fit indexes of the structural equation model describing the relationships among physical fitness, competence, stress response and QOL indicated excellent fit to the data with GFI=0.95 and AGFI=0.88. Stress response showed relatively stronger influence on QOL than physical fitness or competence.
Conclusion: Although there were slight differences in degree of influence, physical fitness, stress response and competence were found to be clearly related to QOL in elderly subjects. To keep good QOL status, it is important to maintain good physical fitness and level of competence and to reduce stress response.

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Objectives: The theoretical maximum intake values of pesticides by body weight (TMI) were estimated for school children and the differences in district and age-group were compared. Furthermore TMI values for children (7-11 years old) were calculated from Japanese National Nutrition Survey (NNS) data. Our TMI values for school children were compared with those from NNS data and evaluated to assess whether our values were appropriate for use in the calculation of theoretical maximum of daily intake (TMDI) of the pesticides.
Methods: The TMI values of pesticides for children were estimated using the intake amounts of agricultural products calculated from school lunch data in three elementary school districts (in Hyogo, Tokyo and Yamagata prefectures) and the survey of data from meals at home. Furthermore, TMI values for children (7-11 years old) were estimated from NNS data relating to agricultural products intake. Target pesticides for TMI calculations were chlorpyrifos, cyhalothrin, fenbutatin oxide, malathion, meltribuzin, oxamyl, permethrin and vamidothion.
Results: TMI of malathion from school lunch data corresponded to 58% of ADI and was too large for exposure from one meal in comparison to other pesticides (8-24%). Our estimations of TMI of chlorpyrifos, cyhalothrin, oxamyl and vamidothion in the school lunches were smaller than those from the NNS data. However TMI of malathion calculated from the school lunch data was larger than that from the NNS data. TMI of fenbutatin oxide, meltribuzin and permethrin from the school lunch data were similar to those from the NNS data.
Conclusions: The TMI values for children in three districts depended upon the agricultural products used in school lunches. Even though the survey methods differed between the NNS's and our data, the TMI values closely corresponded. We concluded that the school lunch data might compensate for the lack of NNS data in order to estimate more appropriate TMDI for children's ingestion of agricultural products.

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Objectives: Intense noise exposure having been observed in vicinal areas around the U. S. military airfields in Okinawa, Japan, suggests the possibility of adverse effects on fetal growth, as studies have reported such effects around other airfields. This study analyzes the birth records in Okinawa prefecture and investigates whether lower birth weights of infants and shorter gestation periods are observed around the airfields.
Methods: The records of 160, 460 births in 15 municipalities around the Kadena and Futenma airfields from 1974 to 1993 were subjected to analysis. Average WECPNL among residents in each municipality was calculated as a measure of noise exposure, since the birth records did not contain information on precise birth addresses but only the municipalities. The odds ratios of low birth weight, i. e. under 2, 500 grams, and preterm birth, i. e. less than 37 weeks, were obtained by multiple logistic regression analysis with adjustment for the primary factors that would be related to fetal growth. The factors included sex, maternal age, live birth order, occupation of householder, legitimacy of the infant, year of birth and interaction between maternal age and live birth order.
Results: The logistic regression analysis showed a significant dose-response relationship between low birth weight and noise exposure. The significance probability of trend test was less than 0.0001. The adjusted odds ratio was 1.3 in the highest noise exposure area, which was Kadena Town, located in the immediate vicinity of the Kadena airfield. Significantly higher rates of preterm births were also found across the noise exposed municipalities. Although the obtained results were not adjusted for some confounding factors like smoking habit, another survey conducted by the present authors did not show paticular differences in the female smoking rate between Kadena Town and the other municipalities around the Kadena airfield.
Conclusion: Aircraft noise exposure is most likely to cause adverse effects on fetal growth, raising the rates of low birth weight and preterm infants around the Kadena airfield.

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Objectives: To clarify the needs and to consider establishing a social support system for patients with Minamata disease (MD), or methylmercury poisoning, by investigating their health and socioeconomic conditions.
Methods: The total number of people certified as having MD in May 1999 by the Kumamoto and Kagoshima Prefecture Government Committees on MD was 2265. We sent two questionnaires to 917 individuals who were surviving at that time, which corresponded to 40.5% of the total number of MD patients. The first survey sought information on the individual's health-seeking behavior, and the second survey was about their socio-economic conditions and requirements for welfare and medical care in the future.
Results: The average age among male patients was 68.0±13.2yrs (n=477) and that among female patients was 71.2±13.0yrs (n=440). The response rates were 45.7% (n=416) for the first questionnaire and 38.6% (n=354) for the second questionnaire. Among the MD patients, 71.7% judged their health condition to be ‘bad’ or ‘very bad’, and 97.4% received medical treatments that included acupuncture or moxacautery and massage. Regarding the activity of daily living (ADL), which includes ‘communicating’, ‘walking’, ‘eating’, ‘use of toilet’, ‘dressing’ and ‘taking a bath’, the rates of ‘independent’ were relatively low among those under 49yrs and those over 75yrs compared with the other age groups. Many individuals emphasized that they had anxiety about their health and health care in the future.
Conclusion: We concluded that the quality of life (QOL) of MD patients was low. It is important to consider developing a social support system for MD patients.

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