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The secret of Japanese longevity
Article
The secret of Japanese longevity Keywords Japanese Longevity Health care Diet Testosterone
Shigeo Horie Abstract Currently, Japanese have achieved excellent longevity in the world. The contributing factors to this longevity would be the introduction of universal coverage of health insurance, high prevalence of regular health check-up in the working place and community, and the ubiquitous availability of medical resources. However, there have emerged many problems in Japanese public health recently that endanger the sustainability of Japanese longevity. Firstly, expenditures on health are likely to grow drastically as the society gets gray. Currently, there are about three workers to every pensioner in Japan; however, the number is expected to be halved by 2050. Consequently, the increased financial demand would jeopardize the universal health insurance system. Secondly, life-style diseases, such as metabolic syndrome, ischemic heart disease and prostate cancer, are getting more common even in younger generation because of the westernized preference of diets to traditional one and less opportunity for the physical exercise. Finally, a persistent longevity gap still exists between men and women. Under such circumstances, assessment of individual testosterone level might contribute to the promotion of men’s health in Japan. © 2011 WPMH GmbH. Published by Elsevier Ireland Ltd. All rights reserved.
Introduction Japan, the most graying country in the world Japan has been known for decades as getting older (Tables 1–3). Its growing life expectancy, the longest in the world, for women is 86 and for men 80. It is the fastest-ageing society on earth and the first big country in history to have started shrinking rapidly Table 1 The life expectancy in the world (2004) WHO world health report (2006) Age
81
Table 2 The aging rate in the world Rank
Country
1
Japan
21.0
2
Italy
20.0
Japan
3
Germany
18.8
Country
Top ten countries with the longest life expectancy 82
from natural causes. Its median age (44) and life expectancy (83) are among the highest which surpassed only by Monaco, a Mediterranean retreat for wealthy pensioners. Japan’s shrinking birth rate, i.e., 1.4 per woman, is the second-lowest in the developed countries, after South Korea’s. The census 2005 showed that the number of deaths
Rate aged 65 and over
Monaco
4
Greece
18.2
San Marino
5
Belgium
17.6
Australia
···
France
16.6
Iceland
···
America
12.3
Italy
World Population Prospects, 2004 Revision. United Nations.
Sweden Switzerland 80
France Canada & 6 other nations
Bottom ten countries with the shortest life expectancy Zimbabwe
Attainment year of aging population
37
Swaziland
7% (year)
14% (year)
39
Sierra Leone
Japan
1970
1994
40
Zambia
France
1865
1979
114
Botswana
Sweden
1890
1972
82
Angola
Germany
1930
1972
42
Niger
Great Britain
1930
1976
46
Malawi
Italy
1935
1990
55
Lesotho
USA
1945
2014
69
36
Shigeo Horie, MD Department of Urology, Teikyo University, 2-11-1 Kaga, Tokyo 173-8605, Japan. Tel.: +81 3 3964 2492; fax: +81 3 3964 8934. E-mail address: [email protected] (S. Horie).
Table 3 International comparison of aging speed
41
Central Africa
S4 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
Country
Necessary years
24
Japan Foundation for Aging and Health. © 2011 WPMH GmbH. Published by Elsevier Ireland Ltd.
Article
Figure 1. Statistic of Japanese population.
Figure 2. OECD Health statistics.
exceeded that of births for the first time (Figure 1). In the next 40 years, its population, currently 127 millions, is expected to fall by 38 millions, while by 2050 four out of ten Japanese will be over 65. This will make Japan a test case of how big countries across the world should handle ageing and population decline. Increasing health care expenditure Japan enjoys the lowest infant mortality rate and the longest life expectancy in the world. It is generally understood that life expectancy in Japan has gone up mainly because of improvements in the standard of living. The availability of health insurance and improvements in its coverage have also helped to raise the quality of people’s lives, and equity and stability in society. Universal health care coverage through a public health insurance scheme with fee-for-service payments is the basic definition of the Japanese system, which
has contributed to the equitable distribution of health services and relieved family from old-age support. One salient aspect of the Japanese health system is its establishment of low health expenditure through regulated fees. The country’s public health expenditure is less than 10 percent of its GDP (Figure 2); thus, Japan’s health care system might be regarded as quite efficient. Actually, there is very large number of beds in Japan; nevertheless, the health care system operates at a relatively low cost when judged against international statistics, largely because of the low prices of the resources used. In many local hospitals, most physician works as an employee with the fixed stipends; however, this approach faces serious limitations in the 1990s. Despite vigorous price control measures in the 1980s and 1990s, health expenditures increased by 1 trillion yens annually in recent years (Figure 3). Furthermore, due to the severe burden of medical demands and low salary, jmh Vol. 8, Suppl. 1, S4–S8, April 2011 S5
Article
Figure 3. Health expenditure of Japan.
many physicians in rural areas now fled to big cities to engage in private practices. The huge loss of physicians from local hospitals has caused local medical delivery in jeopardy, which demands the remodeling of medical delivery systems. The Japanese Government has attempted to promote home cares for frail elderly and avoid long-term hospitalization with the introduction of Long-term Care Insurance that took place in 2000. It separates long-term care from medical care insurance and establishes a system as a first step towards revising the structure of social security [2].
Changes in Japanese diet For the last 60 years, Japanese’s diet has changed drastically; instead of grains, Japanese now take more calories and more fat (Figure 4). Interestingly, after 1990 when the bubble economy in Japan has terminated, total calorie intake has been decreasing, although the incidence of diabetes is increasing as fat intake soars (Figures 4,5). Recently, obesity is becoming a serious health care issue in Japan. The rate of obesity among women has been decreasing for the last 20 years, although among
Figure 4.
S6 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
Figure 5. National survey on nutrition (1990). http://metabolic-syndrome.net/2007/01/ 000617.php.
men its rate is increasing over 40 years old. The incidence of population with hyperglycemia is more than 30% over 60 years old (Table 4). Importantly, one specific feature in Japanese men’s health is the “tsunami” of prostate cancer which is also one of the leading cancers among men in the world and researchers have explored a number of possible dietary factors contributing to prostate cancer risk. Westernization of Japanese diet is considered to contribute to the drastic increase in the incidence of prostate cancer [3]. Estimated prevalence in 2020 compared with 1995 will increase close to 6 times (Figure 6), and predictive mortality rate of prostate cancer in Japan will increase almost 3 folds from 2000 to 2020 (Figure 7). However, the exposure of early detection by prostate-specific antigen screening is still low and the proportion of advanced-stage prostate cancers remains high [3]. The incidence of prostate cancer has been lower in Asian countries than in western countries. One reason for this may be the high intake of soy products which
Article Table 4 National survey on nutrition 1999 Male Age (year)
20~29
30~39
40~49
50~59
60~69
70~
Frequency of hyperglycemia (%)
4.2
7
12.2
19.2
30.1
36.6
Age (year)
20~29
30~39
40~49
50~59
60~69
70~
Frequency of hyperglycemia (%)
5.1
7.4
11.2
18.6
30.2
42.4
Female
Figure 6. Predictive mortality rate of prostate cancer in Japan.
Figure 7. Asian countries have tended to have less prostate cancer patients than western contries. However the number of prostate cancer is now soaring in Japan. It is the most increasing cancer in Japan.
help reduce heart disease and high blood pressure, and are a great source of protein. Soybeans provide adequate protein without the saturated fat and cholesterol of meats and high-fat dairy. Evidence suggests that intake of soy derivatives may decrease the risk of prostate cancer [4,5].
Japanese men’s health Even though Japan enjoys the longevity, men’s life expectancy has been shorter than that of women for 7–8 years, which is the mediocre level among nations (Figure 8). High suicide rate is another major concern
Figure 8. Indeed Japan enjoys the longest longevity in the world. However, the difference of longevity between male and female is quite significant. Produced from United Nations data: http://unstats.un.org/unsd/ demographic /products / indwm /ww2005/ tab3a.htm (courtesy Leeds Metropolitan University).
among Japanese male. According to the World Health Organization (WHO), Japan’s male suicide rate is about 36 per 100,000 people, where men committing suicide more than twice at the rate of women, which is twice the rate in the United States (18 per 100,000), but less than some Eastern European countries such as Lithuania (70 per 100,000) (Figure 9). The economic turmoil in Japan for the last 2 decades might be a major reason for this high suicide rate and, at the same time, depression is a grave health issue in Japanese men’s health. Late onset hypogonadism (LOH) is now appreciated to precipitate depression [6]. According to our survey of Japanese healthy volunteers, jmh Vol. 8, Suppl. 1, S4–S8, April 2011 S7
Article populations of 40–50 years old has lower salivary testosterone level than over 60 [7]. Specific measures to detect and enhance testosterone level might contribute to the prevention of depression and suicide of Japanese male (Figure 10).
Conclusions
Figure 9. The rate of suicide is higher in Japan and in Korea compared to the Western countries. Especially males in Japan or Korea may suffer severe pressures.
Japanese now enjoy the longest life expectancy; however Japanese are now suffering from the rapid population aging, rapid loss of traditional life style, and rapid increase in life-style diseases including prostate cancer. Developing public programs for awareness building about testosterone level might be especially beneficial to promoting men’s health in Japan.
Conflict of interest statement The author has no conflict of interest to report.
Figure 10. We measured the testosterone level in men living in Tokyo, this slide shows the diurnal rhythm of testosteronelevel. Surprisingly testosterone of 40–50 years old are lower than that of over 60 years old.
References [1] Following resources were utilized for this manuscript without citation: Statistical Abstracts on Health and Welfare in Japan 2006, Health and Welfare Statistics Association, Japan, OECD Health Data 2010: Statistics and Indicators (http://stats.oecd.org/Index.aspx ?DataSetCode=HEALTH), WHO statistic (http://www.who.int/countries/jpn/en/). National Health and Nutrition Survey, Ministry of Health, Labour and Welfare of Japan. Cancer statistic, Ministry of Health, Labour and Welfare of Japan.
S8 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
[2] http://www.mhlw.go.jp/english/topics/ elderly/care/1.html. [3] Namiki M, Akaza H, Lee SE, et al. Prostate Cancer Working Group report. Jpn J Clin Oncol 2010 Sep;40(Suppl 1):i70–75. ¨ PJ, Lawrentschuk N, [4] Trottier G, Bostrom et al. Nutraceuticals and prostate cancer prevention: a current review. Nat Rev Urol 2010;7:21–30. [5] Ide H, Tokiwa S, Sakamaki K, et al. Combined inhibitory effects of soy isoflavones and curcumin on the production of prostate-specific antigen. Prostate 2010; 70:1127–33.
[6] Zitzmann M, Faber S, Nieschlag E. Association of specific symptoms and metabolic risks with serum testosterone in older men. J Clin Endocrinol Metab 2006;91:4335–43. [7] Yasuda M, Furuya K, Yoshii T, et al. Low testosterone level of middle-aged Japanese men: the association between low testosterone levels and qualityof-life. J Men’s Health and Gender 2007;4:149–155.
The secret of Japanese longevity Keywords Japanese Longevity Health care Diet Testosterone
Shigeo Horie Abstract Currently, Japanese have achieved excellent longevity in the world. The contributing factors to this longevity would be the introduction of universal coverage of health insurance, high prevalence of regular health check-up in the working place and community, and the ubiquitous availability of medical resources. However, there have emerged many problems in Japanese public health recently that endanger the sustainability of Japanese longevity. Firstly, expenditures on health are likely to grow drastically as the society gets gray. Currently, there are about three workers to every pensioner in Japan; however, the number is expected to be halved by 2050. Consequently, the increased financial demand would jeopardize the universal health insurance system. Secondly, life-style diseases, such as metabolic syndrome, ischemic heart disease and prostate cancer, are getting more common even in younger generation because of the westernized preference of diets to traditional one and less opportunity for the physical exercise. Finally, a persistent longevity gap still exists between men and women. Under such circumstances, assessment of individual testosterone level might contribute to the promotion of men’s health in Japan. © 2011 WPMH GmbH. Published by Elsevier Ireland Ltd. All rights reserved.
Introduction Japan, the most graying country in the world Japan has been known for decades as getting older (Tables 1–3). Its growing life expectancy, the longest in the world, for women is 86 and for men 80. It is the fastest-ageing society on earth and the first big country in history to have started shrinking rapidly Table 1 The life expectancy in the world (2004) WHO world health report (2006) Age
81
Table 2 The aging rate in the world Rank
Country
1
Japan
21.0
2
Italy
20.0
Japan
3
Germany
18.8
Country
Top ten countries with the longest life expectancy 82
from natural causes. Its median age (44) and life expectancy (83) are among the highest which surpassed only by Monaco, a Mediterranean retreat for wealthy pensioners. Japan’s shrinking birth rate, i.e., 1.4 per woman, is the second-lowest in the developed countries, after South Korea’s. The census 2005 showed that the number of deaths
Rate aged 65 and over
Monaco
4
Greece
18.2
San Marino
5
Belgium
17.6
Australia
···
France
16.6
Iceland
···
America
12.3
Italy
World Population Prospects, 2004 Revision. United Nations.
Sweden Switzerland 80
France Canada & 6 other nations
Bottom ten countries with the shortest life expectancy Zimbabwe
Attainment year of aging population
37
Swaziland
7% (year)
14% (year)
39
Sierra Leone
Japan
1970
1994
40
Zambia
France
1865
1979
114
Botswana
Sweden
1890
1972
82
Angola
Germany
1930
1972
42
Niger
Great Britain
1930
1976
46
Malawi
Italy
1935
1990
55
Lesotho
USA
1945
2014
69
36
Shigeo Horie, MD Department of Urology, Teikyo University, 2-11-1 Kaga, Tokyo 173-8605, Japan. Tel.: +81 3 3964 2492; fax: +81 3 3964 8934. E-mail address: [email protected] (S. Horie).
Table 3 International comparison of aging speed
41
Central Africa
S4 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
Country
Necessary years
24
Japan Foundation for Aging and Health. © 2011 WPMH GmbH. Published by Elsevier Ireland Ltd.
Article
Figure 1. Statistic of Japanese population.
Figure 2. OECD Health statistics.
exceeded that of births for the first time (Figure 1). In the next 40 years, its population, currently 127 millions, is expected to fall by 38 millions, while by 2050 four out of ten Japanese will be over 65. This will make Japan a test case of how big countries across the world should handle ageing and population decline. Increasing health care expenditure Japan enjoys the lowest infant mortality rate and the longest life expectancy in the world. It is generally understood that life expectancy in Japan has gone up mainly because of improvements in the standard of living. The availability of health insurance and improvements in its coverage have also helped to raise the quality of people’s lives, and equity and stability in society. Universal health care coverage through a public health insurance scheme with fee-for-service payments is the basic definition of the Japanese system, which
has contributed to the equitable distribution of health services and relieved family from old-age support. One salient aspect of the Japanese health system is its establishment of low health expenditure through regulated fees. The country’s public health expenditure is less than 10 percent of its GDP (Figure 2); thus, Japan’s health care system might be regarded as quite efficient. Actually, there is very large number of beds in Japan; nevertheless, the health care system operates at a relatively low cost when judged against international statistics, largely because of the low prices of the resources used. In many local hospitals, most physician works as an employee with the fixed stipends; however, this approach faces serious limitations in the 1990s. Despite vigorous price control measures in the 1980s and 1990s, health expenditures increased by 1 trillion yens annually in recent years (Figure 3). Furthermore, due to the severe burden of medical demands and low salary, jmh Vol. 8, Suppl. 1, S4–S8, April 2011 S5
Article
Figure 3. Health expenditure of Japan.
many physicians in rural areas now fled to big cities to engage in private practices. The huge loss of physicians from local hospitals has caused local medical delivery in jeopardy, which demands the remodeling of medical delivery systems. The Japanese Government has attempted to promote home cares for frail elderly and avoid long-term hospitalization with the introduction of Long-term Care Insurance that took place in 2000. It separates long-term care from medical care insurance and establishes a system as a first step towards revising the structure of social security [2].
Changes in Japanese diet For the last 60 years, Japanese’s diet has changed drastically; instead of grains, Japanese now take more calories and more fat (Figure 4). Interestingly, after 1990 when the bubble economy in Japan has terminated, total calorie intake has been decreasing, although the incidence of diabetes is increasing as fat intake soars (Figures 4,5). Recently, obesity is becoming a serious health care issue in Japan. The rate of obesity among women has been decreasing for the last 20 years, although among
Figure 4.
S6 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
Figure 5. National survey on nutrition (1990). http://metabolic-syndrome.net/2007/01/ 000617.php.
men its rate is increasing over 40 years old. The incidence of population with hyperglycemia is more than 30% over 60 years old (Table 4). Importantly, one specific feature in Japanese men’s health is the “tsunami” of prostate cancer which is also one of the leading cancers among men in the world and researchers have explored a number of possible dietary factors contributing to prostate cancer risk. Westernization of Japanese diet is considered to contribute to the drastic increase in the incidence of prostate cancer [3]. Estimated prevalence in 2020 compared with 1995 will increase close to 6 times (Figure 6), and predictive mortality rate of prostate cancer in Japan will increase almost 3 folds from 2000 to 2020 (Figure 7). However, the exposure of early detection by prostate-specific antigen screening is still low and the proportion of advanced-stage prostate cancers remains high [3]. The incidence of prostate cancer has been lower in Asian countries than in western countries. One reason for this may be the high intake of soy products which
Article Table 4 National survey on nutrition 1999 Male Age (year)
20~29
30~39
40~49
50~59
60~69
70~
Frequency of hyperglycemia (%)
4.2
7
12.2
19.2
30.1
36.6
Age (year)
20~29
30~39
40~49
50~59
60~69
70~
Frequency of hyperglycemia (%)
5.1
7.4
11.2
18.6
30.2
42.4
Female
Figure 6. Predictive mortality rate of prostate cancer in Japan.
Figure 7. Asian countries have tended to have less prostate cancer patients than western contries. However the number of prostate cancer is now soaring in Japan. It is the most increasing cancer in Japan.
help reduce heart disease and high blood pressure, and are a great source of protein. Soybeans provide adequate protein without the saturated fat and cholesterol of meats and high-fat dairy. Evidence suggests that intake of soy derivatives may decrease the risk of prostate cancer [4,5].
Japanese men’s health Even though Japan enjoys the longevity, men’s life expectancy has been shorter than that of women for 7–8 years, which is the mediocre level among nations (Figure 8). High suicide rate is another major concern
Figure 8. Indeed Japan enjoys the longest longevity in the world. However, the difference of longevity between male and female is quite significant. Produced from United Nations data: http://unstats.un.org/unsd/ demographic /products / indwm /ww2005/ tab3a.htm (courtesy Leeds Metropolitan University).
among Japanese male. According to the World Health Organization (WHO), Japan’s male suicide rate is about 36 per 100,000 people, where men committing suicide more than twice at the rate of women, which is twice the rate in the United States (18 per 100,000), but less than some Eastern European countries such as Lithuania (70 per 100,000) (Figure 9). The economic turmoil in Japan for the last 2 decades might be a major reason for this high suicide rate and, at the same time, depression is a grave health issue in Japanese men’s health. Late onset hypogonadism (LOH) is now appreciated to precipitate depression [6]. According to our survey of Japanese healthy volunteers, jmh Vol. 8, Suppl. 1, S4–S8, April 2011 S7
Article populations of 40–50 years old has lower salivary testosterone level than over 60 [7]. Specific measures to detect and enhance testosterone level might contribute to the prevention of depression and suicide of Japanese male (Figure 10).
Conclusions
Figure 9. The rate of suicide is higher in Japan and in Korea compared to the Western countries. Especially males in Japan or Korea may suffer severe pressures.
Japanese now enjoy the longest life expectancy; however Japanese are now suffering from the rapid population aging, rapid loss of traditional life style, and rapid increase in life-style diseases including prostate cancer. Developing public programs for awareness building about testosterone level might be especially beneficial to promoting men’s health in Japan.
Conflict of interest statement The author has no conflict of interest to report.
Figure 10. We measured the testosterone level in men living in Tokyo, this slide shows the diurnal rhythm of testosteronelevel. Surprisingly testosterone of 40–50 years old are lower than that of over 60 years old.
References [1] Following resources were utilized for this manuscript without citation: Statistical Abstracts on Health and Welfare in Japan 2006, Health and Welfare Statistics Association, Japan, OECD Health Data 2010: Statistics and Indicators (http://stats.oecd.org/Index.aspx ?DataSetCode=HEALTH), WHO statistic (http://www.who.int/countries/jpn/en/). National Health and Nutrition Survey, Ministry of Health, Labour and Welfare of Japan. Cancer statistic, Ministry of Health, Labour and Welfare of Japan.
S8 jmh Vol. 8, Suppl. 1, S4–S8, April 2011
[2] http://www.mhlw.go.jp/english/topics/ elderly/care/1.html. [3] Namiki M, Akaza H, Lee SE, et al. Prostate Cancer Working Group report. Jpn J Clin Oncol 2010 Sep;40(Suppl 1):i70–75. ¨ PJ, Lawrentschuk N, [4] Trottier G, Bostrom et al. Nutraceuticals and prostate cancer prevention: a current review. Nat Rev Urol 2010;7:21–30. [5] Ide H, Tokiwa S, Sakamaki K, et al. Combined inhibitory effects of soy isoflavones and curcumin on the production of prostate-specific antigen. Prostate 2010; 70:1127–33.
[6] Zitzmann M, Faber S, Nieschlag E. Association of specific symptoms and metabolic risks with serum testosterone in older men. J Clin Endocrinol Metab 2006;91:4335–43. [7] Yasuda M, Furuya K, Yoshii T, et al. Low testosterone level of middle-aged Japanese men: the association between low testosterone levels and qualityof-life. J Men’s Health and Gender 2007;4:149–155.