保健医療科学

2020Vol.69 No.1 p.14－24

Topics: Recent topics in public health in Japan 2020

＜ Review ＞
National Health Promotion Measures in Japan:
Health Japan 21(the second term)
YOKOYAMA Tetsuji
Department of Health Promotion, National Institute of Public Health
Abstract
Japan has experienced a dramatic decrease in the age-adjusted mortality rate from cerebrovascular disease, which previously was exceptionally high in the world. Such a dramatic change is thought to be due tochanges in Japanese lifestyles, controlling of risk factors especially hypertension, and improvements in the
medical care quality. These favorable changes have been further promoted since a series of National Health
Promotion Measures began in 1978. Since then, the plan has been revised approximately every 10 years
according to PDCA cycles. The first National Health Promotion Measures focused on implementation ofhealth checkups, the establishment of municipal health centers, and the securing of manpower. The second
National Health Promotion Measures called “Active 80 Health Plan” aimed to ensure that the people at theage of 80 could take care of themselves and participate in social activities, and was focused on physical exercise. The third National Health Promotion Measures, called “Health Japan 21” and started in fiscal year
2000, set numerical targets for 70 items in 9 fields (later increased to 80 items, including duplicated items)
concerning lifestyle-related diseases and the improvement of lifestyles.
Based on the issues revealed in the evaluation of Health Japan 21 and subsequent discussion, the fourth
National Health Promotion Measures called “Health Japan 21 (the second term)” covered new areas including
the reduction of health disparities and improvement of the social environment. The midterm evaluation in2018 showed that the extension of healthy life expectancy and reduction of health disparities that were theoverall goals had improved significantly. However, there were several indicators that were unchanged or became worse. Issues to be prioritized in order to achieve the final evaluation target in 2022 were identified.
keywords: Health Japan 21, National Health Promotion Measures, health policy, policy evaluation, NCDs
(accepted for publication, January 14, 2020)

I. Introduction
After the end of World War II, the leading causes of deathin Japan shifted from tuberculosis and other infections to
non-communicable diseases (NCDs) including stroke, heartdiseases and malignant neoplasms (Figure 1)[1]. Particularly, stroke was the leading cause of death in Japan from the
1960s to the 1970s, and its age-adjusted mortality rate was
exceptionally high as compared with other developed countries (Figure 2)[2]. Although the age-adjusted mortality ratefrom stroke in Japan decreased rapidly thereafter, the rate

for men in recent years still ranked high among developed
countries. In contrast, the age-adjusted mortality rate fromischemic heart disease in Japan has been much lower thanthat in Scandinavian and North American countries, and isalso considerably lower even in comparison with France
and other Mediterranean countries (Figure 2). However, as
the pace of decrease has been low in recent years, the rate
is approaching that in France both for males and females.
Such dramatic changes in cause-specific mortality rate
are thought to be due to changes in Japanese lifestyles,
the controlling of risk factors, especially hypertension, andCorresponding author: YOKOYAMA Tetsuji
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
E-mail: yokoyama.t.aa@niph.go.jp

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J. Natl. Inst. Public Health, 69 (1) : 2020

National Health Promotion Measures in Japan: Health Japan 21(the second term)
100%

Others80%

Accidents and suicide
Pneumonia

Senility60%

Cerebrovascular diseases

40%

Heart diseases

Tuberculosis

20%

Malignant neoplasms

0%

1950

Figure 1

1960

1970

1980

1990

2000

2010 (Year)

Secular trends in the proportion of deaths from selected causes in Japan
Source: Vital Statistics, Ministry of Health, Labour and Welfare.

Male

Female300↓ JapanFinland
UK

250

250

USA
Sweden200200↓ JapanCanada150

Australia

150

Italy

100

Spain

100

Portugal

50

France
Japan

0

1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015

0

50

1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015

age-adjusted mortality rate (per 100,000)

300

Cerebrovascular diseases

Male

450

Ischemic heart diseases
450

Female

400

UK

400

350

USA

350

300

Sweden300

Canada250

250

Australia

200

200
Italy

150

150

Spain

100

Portugal

100

50France50↑ Japan
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015

0

Figure 2Japan0↑ Japan
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015

age-adjusted mortality rate (per 100,000)

FinlandI nternational comparison of secular trends in age-adjusted mortality rates from cerebrovascular diseases and ischemic heart diseases

Source: Calculated using WHO Mortality Database (raw data files), updated as of May 2019, and the
population data from World Standard Population. Values are 3-year moving averages.

J. Natl. Inst. Public Health, 69 (1) : 202015

YOKOYAMA Tetsuji
improvements in medical care quality. To better understandthese changes, it will be helpful to divide the postwar history of Japan into five eras (Figure 3).
During the so-called age of postwar poverty, the priority
issues in public health were food measures and controlling
infections such as tuberculosis. In this period, the dietary
pattern of Japanese people was characterized by high salt,high carbohydrate, low fat, and low animal protein. Much
salt and extremely low meat consumption caused hypertension and extremely low levels of serum total cholesterol.
This presumably contributed to the large increase in therisks of developing cerebral hemorrhage and perforator in-

farction[3].
As the economy grew dramatically during the age of higheconomic growth from around 1960 to 1975, the lifestyles ofJapanese people were gradually modernized. The consumption of fat and animal protein increased year by year, andthe total energy intake peaked in 1971[4]. The age-adjusted
mortality rate from stroke started to decline. In this era,new priority issues in public health arose such as so-called
adult diseases (NCDs that frequently occur in middle-aged
to elderly people), mental health, and air pollution. Several
epidemiological studies to identify major risk factors ofNCDs, especially stroke, started in Japan. The adult diseas-

Socio-economic status
Defeat in WW II

1945

Treaty of
San Francisco

1950

Income-doubling 1960
plan
Oil shockPublic Health Issues

Post-warpoverty• Infectious diseases

Reconstruction• Food supply

High economic
growth• Universal insurance• NCDs• Environmental pollution

1975

1st Health promotion measures(health examination systems,
infrastructure development)

Low economic
growthCollapse of the
bubble economy

2nd Health promotion measures(physical exercise, diet,and to get enough rest)

1990
Post-bubble

3rd Health promotion measures“Health Japan 21”(primary prevention of NCDs
and improvement of QOL)

2000
2013

4th Health promotion measures“Health Japan 21 (the second term)”

Year

Figure 3 hanges in public health issues in post-war Japan, from theClecture material by Heizo Tanaka (partially altered)1978 - 1st National Health promotion measures (introduction of screening,
infrastructure development)

1988 - 2nd National Health promotion measures(health promotion, in particular promotion of exercise)2000 - 3rd National Health promotion
measures: “Health Japan 21”(primary prevention of NCDs, improvement of
QOL, extension of healthy life expectancy)
P
D
MidtermCevaluation A(2005)
PD
FinalC
evaluation A(2012)

Traditional Health Examination(for the prevention of stroke and IHD
through hypertension management)
Increasing Diabetes and Obesity
2008 - Specific Health
Examination and Guidance(focused on metabolic syndrome)P

Midterm
Evaluation A(2012)
Final
evaluation A(2017)

2013 - 4th Plan for Health promotion:“Health Japan 21 (2nd term)”
P

Midterm
evaluation A(2018)

C

Latter period

D

16

P
C

D

D

the third term2013 - Data-Health Plan (by health insurers)
P

EvaluationA(2017)

Figure 4

CCD

the second termOverview of Health Promotion Measures following the PDCA
cycle in Japan

J. Natl. Inst. Public Health, 69 (1) : 2020

National Health Promotion Measures in Japan: Health Japan 21(the second term)es or NCDs would later be called lifestyle-related diseases
because the epidemiological evidence revealed that theonset and progression of these diseases could be prevented
through lifestyle modification[5].
When the age of low economic growth started after theoil shock in the 1970s, the crude mortality rates from heartdiseases and malignant neoplasms were increasing due tothe aging population and further rapid aging was projected
for Japan. Furthermore, a mass health screening for theprevention of NCDs has not yet been introduced. Thus, thepreventive measures of NCDs by a population approach andhigh-risk approach became increasingly important.
In 1978, the Japanese government introduced the firstcomprehensive national health promotion measures to prevent NCDs. Since then, the plan has been revised approximately every 10 years according to PDCA (plan, do, check,and act) cycles (Figure 4). The current 4th revision so-called
Health Japan 21 (the second term) has been implemented
since 2013.
This article provides an overview of the history of national health promotion measures in Japan and the recent
midterm evaluation of Health Japan 21 (the second term).

II. History of First to Third Health Promotion Measures in Japan
1. First National Health Promotion Measures
In fiscal year 1978, Japan’s Ministry of Health and Welfare started to implement the First National Health Promotion Measures aiming to spread the concept that each of theJapanese people should protect their own health.
These measures were planned to spread a national campaign focusing on three pillars: 1) the implementation ofhealth checkups, 2) the establishment of municipal healthcenters, etc., and 3) the securing of manpower, including
public health nurses, dietitians, etc[5,6]. Because creationof an enabling environment was a primary prerequisite forthe long-term advancement of national health promotion
for the future, efforts were made for infrastructure development including municipal health centers and the securingof manpower including public health nurses and dietitians.
In particular, a high priority was given to establish healthcheckup and health guidance systems emphasizing theprevention of stroke and other cardiovascular diseases.
As mentioned above, the age-adjusted mortality rate from
cerebrovascular disease in Japan started to decrease rapidly
at about this time, and this may be attributed to the introduction of health checkups, widespread of blood pressure
management, lifestyle improvements, etc.

2. Second National Health Promotion Measures (Active 80 Health Plan)
The life expectancy of Japanese people continued toextend steadily, exceeding 80 years for women in 1984
(80.18 years for women and 74.54 years for men)[7]. The
Second National Health Promotion Measures called “Active
80 Health Plan” was started in fiscal year 1988, aiming toensure that the people at the age of 80 could take care ofthemselves and participate in social activities. In addition
to the traditional measures for disease prevention, a newgoal was set. It was to drive health promotion projects with
an emphasis on physical exercise, which had been making
relatively little progress. Facility development and humanresource development for health promotion were strengthened with the active use of private-sector resources, as wellas promotion of the training of health exercise instructors,
health exercise practice leaders, and exercise promotion
volunteers. In addition, exercise guidelines and other materials were formulated and revised.
3. Third National Health Promotion Measures (HealthJapan 21)
While the First and Second National Health Promotion
Measures achieved a certain degree of effectiveness, therapid aging of society and the diversification of lifestyles
contributed to a continued increase in the proportion oflifestyle-related diseases among all diseases and also to anincrease in the social burden. Accordingly, the Third National Health Promotion Measures (Health Japan 21) startingin fiscal year 2000 set concrete numerical targets for 70
items in 9 fields (later increased to 80 items, including duplicated items) concerning lifestyle-related diseases and theimprovements of lifestyles causing them. A new health promotion campaign was driven not only by the efforts of thenational and local governments but also the active participation and cooperation of various relevant organizations[8].
In addition, as a legal basis for further active advancementof national health promotion and disease prevention pivoted
on Health Japan 21, the Health Promotion Act was enacted.
Prefectures also formulated prefectural health promotion
plans as local plans under Health Japan 21, based on theprovisions of the Health Promotion Act and taking into consideration the basic policy of the national plan.
The important feature of Health Japan 21 was the definition of numerical targets. In the field of cardiovasculardiseases, a quantitative evaluation was performed regarding how much the improvement of lifestyle and risk factors could contribute to an improvement of morbidity andmortality from cardiovascular diseases, a decline in ADL(activities of daily living), and other health indicators basedon scientific evidence mainly derived from epidemiological

J. Natl. Inst. Public Health, 69 (1) : 202017

YOKOYAMA Tetsuji
studies in Japan. According to the epidemiological evidence,
the risk factors for the development of stroke in Japan were1) hypertension, 2) smoking, 3) impaired glucose tolerance,and 4) heavy drinking. Those for ischemic heart disease
were 1) hypertension, 2) smoking, and 3) hyperlipidemia.
Therefore, cardiovascular disease prevention measures
were developed principally targeting at 1) hypertension, 2)
smoking, 3) impaired glucose tolerance, 4) heavy drinking,and 5) hyperlipemia. Since the prevention of obesity, salt
reduction, intake of potassium, exercise, and other factors
are important for the prevention of hypertension, the effectiveness of the improvement of these lifestyle factors in
reducing blood pressure of Japanese population as a whole
was also evaluated based on clinical epidemiological studies
and other evidence[8].
Health measures such as Health Japan 21 have been
evaluated and revised according to the concept of PDCA cycles (Figure 4), including an interim evaluation in 2005 anda final evaluation and revision in 2012[9,10]. The final evaluation identified the following issues in the field of cardiovascular disease, and these were considered in the review
for the development of the next (fourth) National Health
Promotion Measures. 1) Although improvements were seenin the mean levels of blood pressure and the prevalence ofhypertension, the prevalences were still high mainly among
elderly people. Nationwide strengthening of prevention
measures of hypertension was needed. Measures against
obesity were considered to be important, since there wasconcern about the future increase in blood pressure due tothe increase in obesity. 2) To reduce the prevalence of hy-

perlipidemia, there was a need for population strategy, suchas education and dissemination activities concerning the reduction of the intake of saturated fatty acid and the nutrient
labeling.
3) Potassium intake was showing a decreasing trend.
Because of the concern that this might contribute to theincrease in blood pressure, measures were needed such asincreases in the intake of vegetables and fruits. 4) Efforts
to improve health checkups rate should be made, mainly focusing on women and young adults. Although the cardiovascular mortality rate was showing a decreasing trend, there
was a need for incidence rate monitoring by construction ofa disease registration system, etc.

III. Health Japan 21 (the second term) (Fourth
National Health Promotion Measures)
1. Basic direction
Based on the issues revealed in the evaluation of HealthJapan 21 and subsequent discussion, Health Japan 21 (thesecond term) defined the desirable state of affairs 10 years
into the future as “Realization of a society with vitality inwhich every people supports each other and can lead ahealthy and blissful life.” As for the basic directions, thesemeasures addressed the five areas: 1) extension of healthy
life expectancy and reduction of health disparities, 2) primary and secondary prevention of lifestyle-related diseases, 3)maintenance and improvement of functions needed for living in society, 4) improvement of social environment to support and protect health, and 5) improvement of lifestyle andRealization of a society with vitality in which every people
supports each other and can lead a healthy and blissful life
Extension of healthy life expectancy andreduction of health disparities

Improvement of quality of life
Cancer, CVD,
Diabetes, COPD
Primary andsecondary preventionof lifestyle-relateddiseases

Improvement of qualityof social environment

Mental health,Children's health,
Health of elderly

Maintenance Increase intheandimprovement opportunities
of social life for social
participation
function

Lifestyle improvement(reduction of risk factors)

Improvement ofaccess toresources forhealth andensuring fairness

Improvement of social environment

Nutrition and healthy diet, Physical activity and exercise, Proper rest,
Alcohol drinking, Tobacco smoking, Oral health

Concrete actions in Health Japan 21 (the second term)

Figure 5

The whole picture of Health Japan 21 (the second term)

Source: Reference material of Health Japan 21 (the second term) (partially altered).

18

J. Natl. Inst. Public Health, 69 (1) : 2020

National Health Promotion Measures in Japan: Health Japan 21(the second term)social environment in terms of nutrition and healthy diet,physical activity and exercise, proper rest, alcohol drinking,smoking, and dental and oral health[11].
The relationship among these desirable state of society and basic directions can be summarized as in Figure
5. Efforts are made to prevent the onset and progressionof lifestyle-related diseases through improvements of thelifestyles of individuals and improvements of social environment surrounding individuals, to improve the quality oflife through the reduction of a loss of social life functions, toimprove the access to the resources for health and ensure
fairness, and to improve the quality of the social environment through the increase in the opportunities for social
participation, ultimately realizing an extension of healthy
life expectancy and reducing health disparities.
Because Health Japan 21 was developed by mainly focusing on the lifestyles of individuals, it generally lacked aperspective of social environment. However, the health ofindividuals and the development of a social environmentare both indispensable like a pair of wheels. Health Japan
21 (2nd edition), therefore, considers it necessary to clarify
the issues related to social environment, and placed muchemphasis on the development of social environment, where
the society as a whole protects health through mutual support, aiming at a reduction of health disparity (differencesin health status among groups arising from differences inlocation or socioeconomic conditions).
With respect to the prevention of cardiovascular diseases,
the main focus is on the management of risk factors, as was
the case with Health Japan 21. Four established risk factors
were identified: hypertension, dyslipidemia, smoking, anddiabetes. Smoking, which was not included in Health Japan21, was added as an indicator. Of these factors, hypertension
shows a very high population attributable risk percentage

for the onset of cardiovascular diseases, and it is the mostimportant risk factor in Japan. When the targets were set,the causal relationships among these indicators were organized into the three stages of “prevention of cardiovasculardiseases,” “improvement of risk factors,” and “improvementof lifestyles” (Figure 6), and the relationships among theindicators were quantified mainly based on epidemiologicalevidence.
2. Midterm-evaluation
The midterm-evaluation was performed in fiscal year2018 for the purpose of confirming whether the current
status of indicators and related efforts were progressing
smoothly toward the final targets that should be achieved in
2022. According to the midterm-evaluation, the issues thatshould be prioritized to achieve the targets were clarified.
The indicators have been monitored by available statistical
data including lifetables, vital statistics, the Comprehensive
Survey of Living Conditions, the National Health and Nutrition Survey, etc. The annual change in the indicator was
visualized using a chart.
By comparing the baseline and latest values, the indicators were evaluated in the following four categories: a)
improved, b) unchanged, c) became worse, and d) cannot
evaluate (lack of data, etc.). The improved indicators in
category a) were also assessed to establish whether or notthey were likely to achieve the final goals.
Table 1 summarizes the results of the evaluation of thebasic directions in five areas. Of these, the overall goals
were the extension of healthy life expectancy and reductionof health disparities. The healthy life expectancy (average
period of time spent without limitation in daily activities),
calculated based on lifetables and the Comprehensive
Survey of Living Conditions, was 70.42 years in males andPrevention of cardiovascular diseases
To reduce age-adjusted death
rate from stroke by 16% in men
and 8% in women

To reduce age-adjusted death rate fromischemic heart diseases by 14% in men
and 10% in women

Improvement of risk factors

If the 4 goals will be achieved…

Hypertension
Lower SBP by 4 mmHg
as a population mean

Hyperlipidemia
Decrease by 25%

Lower SBP by 2.3 mmHg

1.5 mmHg

Nutrition and Diet

Salt intake ↓Vegs and fruit intake ↑Obesity ↓Physical activity

Foot steps ↑Habitual exercise ↑Smoking
All smokers whowant to quit smoking
do quitDiabetes
Stop the increasing
trend

0.12 mmHg (men only)

0.17 mmHg

Alcohol drinking

Medications

Heavy drinkers ↓(40+g ethanol/day)Increase 10% in
people who need
medications

Improvement of lifestyles

Figure 6

The whole picture of Cardiovascular diseases

J. Natl. Inst. Public Health, 69 (1) : 2020

19

YOKOYAMA Tetsuji
Table 1 Results of the midterm-evaluation of Health Japan 21 (the second term)
1. Extension of healthy life expectancy and reduction of health disparities (overall goals)a) Improved•Extension of healthy life expectancy (average period oftime spent without limitation in daily activities)•Reduction of health disparities (gap among prefectures inaverage period of time spent without limitation in daily activities)
2. Prevention of onset and progression of life-style related diseases (prevention of NCDs)a) Improved•Reduction in age-adjusted mortality rate of cancer underage 75•Increase in participation rate of cancer screenings•Reduction in age-adjusted mortality rate of cerebrovasculardisease (CVD) and ischemic heart disease (IHD)•Improvement of hypertension (reduction in average systolic blood pressure)•Increase in participation rates of specified health checkups
and specified health guidance (focused on metabolic syndrome)•Decrease in percentage of individuals with elevated blood
glucose levelsb) Unchanged•Reduction in percentage of adults with dyslipidemia•Reduction in number of definite and at-risk people withmetabolic syndrome•Reduction in diabetic complications (number of patients
newly introduced to dialysis due to diabetic nephropathy)•Increase in percentage of patients who continue treatment•Prevention of increase in number of diabetic persons•Increase in recognition of COPD
3. Maintenance and improvement of functions necessary for engaging in social lifea) Improved•Reduction in suicide rate
•Increase in percentage of occupational settings where interventions for mental health are available•Increase in number of pediatricians and child psychiatrists
per 100,000 children•Increase in percentage of children who maintain healthy
lifestyle (nutrition, dietary habits, physical activity)•Increase in percentage of individuals who know about locomotive syndrome•Restraint of the increase in undernourished elderly (BMI
under 20)
•Decrease in the number of elderly with back or foot pain(per 1,000)b) Unchanged•Decrease in percentage of individuals who suffer frommood disorders or anxiety disorders•Increase in percentage of children with ideal body weight•Restraint of the increase in Long-Term Care Insurance
service users•Promotion of social participation (employed or engaged incommunity activities)d) Cannot evaluate•Increase in identification rate of high-risk elderly with low
cognitive function
4. Establishment of a social environment where the health of individuals is protected and supporteda) Improved•Strengthening of community ties
•Increase in number of corporations that deal with healthpromotion and educational activities•Increase in number of civilian organizations that offer
accessible opportunities for health promotion support orcounseling20•Increase in number of local governments that make efforts
to solve health disparity issuesb) Unchanged•Increase in percentage of individuals who are involved inhealth promotion activities
5. Improvement of social environment and lifestyle, such as nutrition and dietary habits, physical activity and exercise, rest,
alcohol drinking, tobacco smoking, and oral health(1) Nutrition and dietary habitsa) Improved•Increase in number of corporations in food industry that
supply food product low in salt and fat•Increase in percentage of specific food service facilities
that plan, cook, and evaluate and improve nutritional
content of menu based on the needs of clientsb) Unchanged•Increase in percentage of individuals maintaining ideal
body weight•Increase in percentage of individuals who consume appropriate quality and quantity of food
•Increase in dining with family regularly(2) Physical activity and exercisea) Improved•Increase in number of local governments that offer community development and environment to promote physical activityb) Unchanged•Increase in daily number of steps•Increase in percentage of individuals who regularly exercise(3) Resta) Improved•Reduction in percentage of employees who work 60
hours or more per weekb) Unchanged•Reduction in percentage of individuals who do not takerest through sufficient sleep(4) Alcohol drinkinga) Improved•Eradication of underage drinking•Eradication of alcohol consumption among pregnant
womenb) Unchanged•Reduction in percentage of individuals who consume
alcohol over recommended limits (males>40 g, females>20 g per day)(5) Tobacco smokinga) Improved•Reduction in percentage of adult smoking rate (quiting
smoking among smokers who want to quit)•Eradication of underage smoking•Eradication of smoking during pregnancy•Reduction in percentage of individuals who are exposed
to passive smoking(6) Dental and Oral healtha) Improved•Prevention of tooth loss
•Increase in number of children without dental caries•Increase in percentage of individuals who participated indental check-up during the past yearb) Unchanged•Maintenance and improvement of oral functionc) Became worse•Decrease in percentage of individuals with periodontal
diseaseJ. Natl. Inst. Public Health, 69 (1) : 2020

National Health Promotion Measures in Japan: Health Japan 21(the second term)
Table 2 The extension of healthy life expectancy from 2010
to 2016
Year
2010

The extension of healthy life expectancy was longer thanthat of average life expectancies during the same period.
Thus, the unhealthy period has shortened in both males andfemales (Table 2). The reduction of health disparities wasevaluated by comparing the longest and shortest healthy
life expectancies among the 46 prefectures in Japan (oneprefecture was not evaluated because the data was notavailable due to a big earthquake in 2016) (Figure 7). The
difference in the range of healthy life expectancy shortened
from 2.79 to 2.00 years in males and from 2.95 to 2.70 years
in females. Not only the range but also the variance of
healthy life expectancies among the 46 prefectures became
significantly smaller as graphically illustrated in Figure 8.

Extension

2016

Male
Healthy life expectancy

70.42

72.14

1.72

Life expectancy

79.55

80.98

1.43

Unhealthy period

9.13

8.84

-0.29

FemaleHealthy life expectancy

73.62

74.79

1.17

Life expectancy

86.30

87.14

0.84

Unhealthy period

12.68

12.35

-0.33

Values are in years.

73.62 years in females at the baseline in 2010 and extended
to 72.14 years in males and 74.79 years in females in 2016.

Male

76

72

75

2013 ●2016 (year)

73

71

Plotting on the upper sideof the diagonal line means
an extension of healthy life
expectancy.

70

69

68

69

70

71
2010 (year)

72

73

74

Plotting on the upper sideof the diagonal line means
an extension of healthy life
expectancy.

73

72

Values are estimated healthy
life expectancy±standard errorof each prefecture

68

Female77○○2013 ●2016 (year)

74

Values are estimated healthy
life expectancy±standard errorof each prefecture

71
74

71

72

73

74
2010 (year)

75

76

77

One prefecture was not shown because the data was not available due to a big earthquake in 2016.

Figure 7 Comparison of healthy life expectancy (average period of time spent without
limitation in daily activities) among 46 prefectures in Japan between 2010,2013, and 2016
P = 0.001 for reductionof health disparities
among prefectures

73
72
71
2016 (SD=0.37)
2013 (SD=0.47)
2010 (SD=0.58)

70
69
68

SD: standard deviation of healthy life
expectancies among the prefectures.
A larger SD means a larger disparities.

-3

-2

Lower

-1

P = 0.041 for reductionof health disparities
among prefectures

76

Healthy life expectancy (years)

Healthy life expectancy (years)

740Z-score

1

2

Upper

3

75
74
73
2016 (SD=0.53)
2013 (SD=0.61)
2010 (SD=0.65)

72
71
70

SD: standard deviation of healthy life
expectancies among the prefectures.
A larger SD means a larger disparities.

-3

-2

-1

0
Z-score

1

Lower

2

3

Upper

The values were corrected for the error variance.
One prefecture was not shown because the data was not available due to a big earthquake in 2016.

2

Figure 8 Comparison of healthy life expectancy (average period of time spent without limitation in daily activities) corrected for error variance among 46
prefectures in Japan between 2010, 2013, and 2016

J. Natl. Inst. Public Health, 69 (1) : 202021

YOKOYAMA Tetsuji

IV. Conclusion
During the period of post-war economic growth, Japan
experienced a dramatic decrease in the age-adjusted mortality rate from cerebrovascular disease, which previously
was exceptionally high in the world. Such a dramatic change
is thought to be due to changes in Japanese lifestyles, thecontrolling of risk factors especially hypertension, and improvements in medical care quality.
These favorable changes have been further promoted
since a series of National Health Promotion Measures began in 1978. However, new health issues have appearedsuch as the increasing trend of obesity and diabetes. Accordingly, a new health examination system called Specific Health Examination and Health Guidance have been
introduced since 2008 focusing on metabolic syndrome.
The Health Promotion Measures have been evaluated andrevised approximately every 10 years according to the
PDCA cycle, and are expected to continuously contributeto improving the health of the Japanese population and theextending of healthy life expectancy.
This article is an overview of the National Health Promotion Measures and its history. For more information about
features, basic ideas, outline of measures, and related guidelines concerning the National Health Promotion Measures,
readers are advised to see other English literatures[12-14].

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statistics (Volume 1, Death, Table 5.12).] (in Japanese)
厚生労働省．平成28年度人口動態統計（ 1 巻，死亡，表5,12）．
[2] World Health Organization. WHO Mortality Database(raw data files), Updated as of May 2019. https://www.
who.int/healthinfo/mortality_data/en/ (accessed 202001-11)[3] Japan Epidemiological Association, edited. [Epidemiology handbook: Epidemiology and prevention of important diseases.] Tokyo: Nankodo; 1998. p.82-83, 183-202.
(in Japanese)
日本疫学会，編．疫学ハンドブック・重要疾患の疫学と予防．東京：南江堂；1998．p.82-83, 183-202.
[4] Ministry of Health, Labour and Welfare. [National nutrition survey / National health and nutrition survey.
1945-2010.] https://www.mhlw.go.jp/bunya/kenkou/
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J. Natl. Inst. Public Health, 69 (1) : 202023

YOKOYAMA Tetsuji

国民健康づくり対策―健康日本 21（第二次）―

横山徹爾
国立保健医療科学院生涯健康研究部

抄録
かつて世界でも際だって高かったわが国の脳血管疾患の年齢調整死亡率は，食習慣をはじめとする
生活習慣の改善や，循環器健診の導入，医療の進歩等によって劇的に改善してきた．これらの望ましい変化は，1978年に国民健康づくり対策が始まって以来，さらに推進されてきている．国民健康づく
り対策は，PDCAサイクルに従ってほぼ10年ごとに改訂されており，第 1 次健康づくり対策では生涯を通じての健康づくり推進のための予防・健診の体制整備，健康づくりの基盤整備として市町村保健センター等の設置と保健師・栄養士等のマンパワーの確保の推進，健康づくりの啓発普及から始まり，第 2 次健康づくり対策（アクティブ80ヘルスプラン）では特に運動の推進に力を入れ，第 3 次に相当する健康日本21では，健康増進と生活習慣病の一次予防によって，QOLの向上と健康寿命の延伸を目指すようになり，9 分野約70項目の数値目標を設定して取り組みが進められ，評価・見直しが行われるようになった．現在の第 4 次国民健康づくり対策である健康日本21（第二次）では，健康日
本21の評価結果を踏まえて，新たに健康格差の縮小や社会環境の整備にも力が入れられるようになった．2018年の中間評価では，平均寿命の延びを上回る健康寿命の延びと，健康寿命の都道府県格差の縮小が順調に達成されていることが確認されたが，変化が見られないあるいは悪化した目標項目もあり，2022年の最終評価での目標達成に向けて，今後重点的に取り組むべき課題が明らかにされた．
キーワード：健康日本21，国民健康づくり対策，健康政策，政策評価，生活習慣病

24

J. Natl. Inst. Public Health, 69 (1) : 2020