Objective: The latest evaluation of Health Japan 21 (the second term) reveals a worsening obesity trend among men, signaling the need for intensified efforts. This report provides specific measures and action plans guided by logic models and the ladder of interventions to reduce the proportion of obese adults and promote healthy weight maintenance, which aligns with Health Japan 21’s goals (the third term).

Methods: The report cites individual measures such as “Standard Health Examination and Health Guidance Program” and the “Extending Healthy Life Expectancy! Award” by the Ministry of Health, Labour, and Welfare, and “Examples of Corporate Nutrition Education Promotion for Healthy Employees” supported by the Ministry of Agriculture, Forestry and Fisheries.

Results: The logic model included measures to improve eating habits, attitudes, and knowledge/skills to reduce energy intake, which are intermediate outcomes of lowering obesity rates. Measures included serving appropriately portioned meals (level 6 intervention) and a practical action plan tailored for working-age men. This plan focused on health management, providing balanced meals in the company cafeteria with incentives, and implementing team-based weight-loss programs.

Conclusions: A logic model and individual measures were organized to reduce obesity rates. A practical action plan suggested a team-based weight loss program utilizing the company cafeteria and focusing on health management.

Objective: Childhood obesity has been rapidly increasing worldwide since the 1970s, and in Japan, its reduction was targeted in Health Japan 21 (2000). According to the School Health Examination Surveys, the proportion of children with obesity tendencies showed a decreasing trend or remained stable from around 2006 to 2018. However, in the final evaluation of Health Japan 21 (the second term) in 2022, the target item “reduction in the proportion of children with obesity tendencies” was judged as “deteriorating.” This report reviews literature focusing on internationally emphasized life-course and social environmental approaches, and presents new perspectives for possible measures, including in Health Japan 21 (the third term).

Methods: A narrative review of domestic and international literature on measures in countries and regions aimed at preventing childhood obesity was conducted. Searches were conducted using literature databases such as the Cochrane Library and PubMed.

Results: As indicated in the Cochrane Review (2019), the effectiveness of interventions focusing on individual behavior is limited. It was considered important to combine social environmental approaches based on the concept of an “obesogenic environment” and life-course approaches including nutritional care from prenatal stages.

Conclusion: In addition to conventional efforts in maternal and child health, childcare facilities, and schools, it is necessary to intervene more comprehensively in the social environment. This is an essential element in “the establishment of an environment to spontaneously promote health,” as highlighted in Health Japan 21 (the third term).

Objective: This study aimed to organize the strategies within a logic model and a ladder of interventions to achieve the goal of Health Japan 21 (the third term); particularly, the reduction of underweight young women, and present an action plan.

Methods: Intermediate outcomes were identified in the logic model, including other nutritional and dietary goals of Health Japan 21 and goals related to the reduced proportion of underweight young women, presented with a comprehensive action plan.

Results: Intermediate outcomes included adopting a balanced diet, increasing the number of steps walked, increasing the proportion of individuals who exercised regularly, reducing the number of smokers, decreasing the proportion of individuals skipping breakfast, increasing daylight exposure, and improving body image. Through enhancing appetite, increasing energy intake, and increasing muscle and bone mass, the proportion of underweight young women can be reduced. Measures, such as education and awareness, health screening and counseling, maintaining balanced diets for appropriate energy intake, regulating guidelines within the industry, creating indicators to evaluate body image improvement, and promoting women’s health as part of health management, have been proposed in various sectors, including national and local governments, insurers, related organizations and businesses, workplaces, and educational institutions, such as nurseries and schools.

Conclusion: Along with education and awareness efforts regarding nutrition, exercise promotion, and smoking cessation, the government should lead in creating guidelines that include the regulation of excessively thin models involving various related organizations and businesses.

Objective: Health Japan 21 (the second term) aims to decrease the proportion of older individuals with low nutritional tendencies (body mass index [BMI] ≤20 kg/m²) to less than 22% among those aged ≥65 years, and restrict the growing number of undernourished in this cohort. Despite the success of this program, further measures are needed to prevent increasing this number. The study aimed to present examples of individual measures and action plans based on a logic model and a ladder of interventions to reduce the proportion of undernourished older adults, as outlined in Health Japan 21 (the third term).

Methods: Immediate outcomes within the logic model were identified using indicators from long-term care and frailty prevention programs. Examples of output indicators that could evaluate individual measures were established. Individual measures were collected from the national and local governments, as well as relevant organizations.

Results: Intermediate outcomes included knowledge and skills, behavior, appetite, oral health, and nutrient and food intake. Individual measures corresponding to each level of the ladder of interventions are presented. An example of an action plan was presented, where “dining together” was incorporated into a frailty prevention activity. This action plan also promotes enjoying meals with a variety of foods, while considering the nutritional requirements of the elderly.

Conclusion: The action plans presented in this study are expected to help older adults in healthcare and weight management by creating a food environment that ensures adequate dietary intake to prevent undernutrition.

Objectives: To organize measures and suggest an action plan to achieve the goal of “increasing the percentage of individuals who eat balanced diets” using a logic model and a ladder of interventions.

Methods: Intervention studies and cross-sectional studies that utilized the frequency of balanced diets intake as an outcome for healthy Japanese adults were investigated. A logic model was created with reference to behavioral science theories and models. Next, individual measures for each implementing organization were organized using a ladder of interventions. Additionally, local governments' efforts were discussed as part of an action plan for promoting balanced diets.

Results: Five eating behaviors have been identified as intermediate outcomes to achieve the outcome of “increasing the percentage of individuals who eat balanced diets with staple food, main dish, and side dish more than twice a day” in the logic model: increase in the percentage of individuals who “cook,” “eat three meals a day,” “consume rice as their staple food,” “consume vegetables,” and “choose balanced diets.” Multiple measures (levels 4 to 6) that utilize nudges and incentives were proposed in the ladder of interventions organized by implementing organizations. The implementation of the Smart Meal initiative in the region was introduced as part of the action plan.

Conclusion: There were fewer intervention studies promoting the intake of balanced diets compared to studies focusing on foods such as vegetables and salt. Further research on diet-level interventions is needed to promote effective approaches for achieving balanced diets.

Objective: In Health Japan 21 (the second term), the goal was to increase vegetable intake to 350 g/day and reduce the proportion of individuals consuming less than 100 g of fruits; however, these targets were not met. Considering the anticipated benefits such as intake of dietary fiber, potassium, and reduction in lifestyle-related diseases, Health Japan 21 (the third term) set average intake goals for vegetables and fruits at 350 g/day and 200 g/day respectively. This paper outlines examples of a logic model, individual strategies, and an action plan aimed at increasing vegetable and fruit consumption.

Methods: Health promotion and nutrition education initiatives by the government, local governments, and organizations were collected online. Additionally, initiatives published in academic journals and reports were manually searched.

Results: The intermediate outcomes consisted of 6 items for vegetables, 5 items for fruits, 2 items for eating attitudes, and 1 item for knowledge and skills related to eating behaviors. Examples of individual measures are depicted by organization on the ladder of interventions. In one example of an action plan, local governments acted as intermediaries to distribute donated foods from farmers and food manufacturers in collaboration with agricultural cooperatives to child cafeterias and needy households. By collaborating with JA and other organizations to hygienically store and distribute donated food, local governments aim to accomplish increased donations and improved product lineup balance.

Conclusion: These action plans are expected to promote healthy and sustainable dietary habits by extending healthy life expectancy, reducing health disparities among the impoverished, and addressing environmental issues through food loss reduction.

Objective: To create a logic model and organize measures using a ladder of intervention aimed at reducing salt intake among other nutrition and dietary goals, and to present an example action plan.

Methods: The logic model was set up using the PRECEDE-PROCEED model with intermediate outcome factors. Measures for which there were existing cases and papers were organized using a ladder of interventions. Action plans were developed based on measures for which evidence had been reported in Japan.

Results: The logic model was designed with a final outcome of reduced salt intake. Intermediate outcomes were reduced salt intake at home, for take-away/restaurant food, and for meal services; participation in nutrition education; and attitudes, knowledge, and skills such as interest and confidence in reducing salt intake. Existing measures were mostly level 6 to 8 on a ladder of interventions, while a few were level 5 or 4. The action plans included reducing salt in company cafeteria food and delivered lunches as well as providing nutrition education in the workplace. Measures in the workplace included regional/workplace cooperation projects implemented by local governments such as the health and productivity management, as well as guidance for meal service facilities, and there is evidence of their effectiveness. The key to implementation is to increase choice and promote the purchase of low-salt foods by introducing a system of collaboration between the health management department and the meal service department, and to provide incentives for a ladder of interventions.

Conclusion: When local governments create action plans, it is important to create a logic model based on an understanding of the actual situation, and to combine promotion campaigns and incentives to encourage the purchase of low-salt food products in addition to reducing the amount of salt in the food environment.

Objective: To present a logic model for increasing daily steps in the population and to categorize interventions using a ladder of interventions. Additionally, an example action plan is provided.

Methods: Relevant policies and studies were reviewed, and 23 experts were interviewed. The logic model, based on the SLOTH model (Sleep, Leisure, Occupation, Transportation, Household), categorized daily life domains and considered steps during work, transportation, and at home & in the community as intermediate outcomes. Individual interventions were categorized using a ladder of interventions. An example action plan introduced multi-strategic community-wide interventions with evidence of success in promoting physical activity at the community level.

Results: The logic model outlined individual interventions categorized by implementing entities (government, workplaces, health insurance associations, schools, related organizations). By envisioning domains of walking, specific measures emerged to increase step counts. The proposed individual interventions included not only information provision and health education but also interventions corresponding to levels 1-6 of the ladder of interventions. Multi-strategic community-wide intervention is an intervention that works on multiple levels of factors from individual to environment in a multifaceted manner, indicating the need for collaboration with various organizations and residents on a long-term basis from the perspective of the target population.

Conclusion: Efforts should be directed not only within the health and welfare sector but also across various sectors such as education, sports, urban planning, and urban transportation. Strategies tailored to specific domains of daily life and from the perspective of residents should be considered, and a long-term, systematic approach is needed.

Objective: Regarding the Health Japan 21 (the third term), this study aims to present a logic model and an example of action plan for increasing the proportion of regular exercisers in Japanese population.

Methods: A logic model was developed with setting the increase in the percentage of regular exercisers as the outcome. Individual policy in the logic model were designed to be consistent with the efforts of the Japanese Sports Agency and other relevant ministries and agencies. Furthermore, they were organized by level of intervention using a “ladder of interventions.” We picked “add-on” program to existing programs up as an example of action plan because that can effectively utilize existing programs and resources.

Results: Individual policies aimed at increasing the percentage of regular exercisers in population are shown separately for the health sector, the education and sports sector, and other sectors (e.g., urban planning sector) in the government. In addition, initiatives with the job sector, health insurers, schools, and related organizations/others as implementing entities were also presented. As a result of organizing by the ladder of interventions, it became clear that there were few individual measures corresponding to levels 1–3. Therefore, in addition to health education targeting individuals and small groups, which corresponds to level 7, it was considered important to improve the community environment, which corresponds to the higher levels, levels 4–6.

Conclusion: In order to achieve an increase in the percentage of regular exercisers in Japanese population, it is important to implement measures in the administrative and occupational health sectors, as well as in the education and sports sectors. It is expected that measures will focus not only on health education for individuals and small groups, but also on the development of an environment that encourages exercise.

Tobacco control continues to be an important issue in Health Japan 21 (the third term), which aims to extend healthy life expectancies and requires effective countermeasures. In Health Japan 21 (the third term), four targets and target values for smoking and secondhand smoke (SHS) exposure were set almost as in the second term, namely numerical targets for adults, underage, pregnant women, and SHS exposure. In the first and second term, targets were set, but no roadmap or measures to achieve them were presented.

Therefore, to promote tobacco control in the third plan, a logic model for achieving the four goals was developed, and various measures were categorized and organized according to the ladder of interventions and summarized by the implementing entity. In addition, among these measures, we examined recommended action plans (“best buy plans”) and proposed three plans that can be implemented through cooperation and collaboration among implementing entities based on the current state of tobacco control and that can be expected to be feasible and effective. The three best buy plans are 1) brief interventions for smoking cessation in health services such as routine medical care and health checkups, 2) promotion of tobacco control in the workplace, and 3) enactment of ordinances to prevent SHS exposure and reinforce compliance with laws and regulations.

Objective: This study aimed to present a logic model and example action plan to achieve the goals of “reducing the smoking rate (those who want to quit smoking)” and “eliminating smoking among pregnant women” set out in Health Japan 21 (the third term).

Methods: We reviewed previous studies and advanced cases in Japan and overseas on reducing smoking prevalence in the community. We examined a logic model for reducing smoking prevalence among adults and pregnant women, considered a laddar of interventions, and created an example action plan of a brief intervention for smoking cessation.

Results: The logic model provides examples of measures to reduce the smoking rate, set out by implementing entity. These include the national government, local governments, and other organizations. The example action plan includes brief interventions for smoking cessation delivered via health services such as routine medical care and health checkups. These individual measures are supported by scientific evidence of effectiveness and could be implemented across the country. It is important to establish a system to provide brief interventions for smoking cessation to all smokers via routine health services including dental checkups and health promotion projects.

Conclusion: We created a logic model that systematically shows effective measures to support smoking reduction, based on scientific evidence. We also provided an example action plan for the establishment of a brief intervention for smoking cessation among local governments. These methods could reduce the smoking rate, a key goal of Health Japan 21 (the third term).

Objective: Workplaces are valuable settings for continuously providing health-promotion program to diverse populations. This study aimed to organize the positioning of interventions in the logic model and a ladder of interventions for reducing smoking prevalence and protecting from exposure to second-hand smoke in the workplace, and to present an example of an action plan for workplace tobacco control.

Methods: Measures compromising a logic model and a ladder of interventions were selected based on the results of a scoping review of smoking cessation interventions in Japan and a literature search. The action plan included information on need, significance, evidence of effectiveness, organizations and roles involved, key points for implementation, and good practices.

Results: The most recommended measures to prevent second-hand smoke exposure in the workplace were smoke-free policies and smoking bans during work hours. Other major measures included smoking cessation promotion activities, the establishment of a support system for brief smoking cessation support during health check-ups in cooperation with health check-up centers, and the promotion and strengthening of laws and regulations at the national level, such as the Industrial Safety and Health Act and the revised Health Promotion Act. In addition, the key to implementing smoking cessation measures in the workplace was combining multi-level interventions and implementing them according to workplace characteristics, such as employee size and industry type.

Conclusion: This action plan example can further promote tobacco control measures in the workplace, by reducing smoking prevalence and preventing second-hand smoke exposure.

Objective: Health Japan 21 (the third term) states “reducing the number of people with unwanted secondhand smoke exposure” as part of improving the quality of the social environment. The purpose of this paper is to organize the logic model for the promotion of protection from secondhand smoke exposure and the positioning of each policy in the ladder of interventions, and to present an example action plan for enacting ordinances to prevent secondhand smoke exposure.

Methods: The following policies and measures were selected as components of the logic model and the ladder of interventions: strengthening laws and regulations on tobacco use in public places, promoting smoke-free environments, encouraging restaurants, workplaces, and households, and monitoring. The action plan includes information on the need and significance, evidence of effectiveness, organizations and roles, key implementation points, and good practices.

Results: The logic model and ladder of interventions indicate that the most important measures are legislative control of tobacco use in public places by national and local governments. Additionally, promoting clean air policies, educating restaurants, workplaces, etc. to become smoke-free based on legislative regulations, and monitoring each measure are also important. The action plan requires local governments to enact additional ordinances by establishing organizations and cooperating with related parties, ensuring compliance with laws and regulations, and encouraging restaurants, workplaces, and other entities.

Conclusion: The national government is required to strengthen the revised Health Promotion Act. This action plan, along with other measures such as support for smoking cessation, will be expected to contribute to the realization of a society free of secondhand smoke.