[Attempts for salt reduction in workers through specific food service facility guidance by public health center: A case study at a worksite in Kawagoe City, Saitama Prefecture].

Objective　The Kawagoe City Public Health Center implemented a project to reduce salt intake through specific food service facility guidance in workplace cafeterias. Here, we report the study results.Methods　The target worksite was company A, with approximately 270 employees, located in Kawagoe City, Saitama Prefecture. There were 214 participants (approximately 80%). The project was conducted from November 2019 to November 2021. The long-term goal was to decrease the number of hypertensive cases in the city. Project outcomes included decreased salt intake, urinary sodium/potassium ratio, and average blood pressure. The project aimed to improve the cafeteria menu, focusing on salt reduction by offering Smart Meals® and reducing the salt equivalents in all menus. The project output indicators included reduced amount of salt in cafeteria menu items, increased frequency of cafeteria use, increased positive evaluations of the cafeteria, and increased daily awareness of the need for salt reduction. Spot urine samples, blood pressure measurements, and self-administered questionnaire data were collected during annual physical examinations. The amount of salt in the cafeteria menu was evaluated by receiving monthly data from the food service company to which company A outsourced its cafeteria operations.Results　The analysis included 102 individuals with complete data from to 2019-2021. Estimated salt intake (g/day) from spot urine decreased from 10.3±2.1 in 2019 to 9.8±2.4 in 2020 and 9.5±2.0 in 2021 (P=0.003). Systolic blood pressure (mmHg) decreased from 114.7±12.5 in 2019 to 111.7±12.1 in 2020 and 110.6±12.0 in 2021 (P=0.010). Compared to 2019, changes in dietary salt equivalents in cafeteria menus in 2020 and 2021decreased for set meals A and B, curries, and noodles (P<0.001).Conclusion　We offered Smart Meals® and reduced salt equivalents in all workplace cafeteria menus. After 1-2 years, employees' salt intake and blood pressure levels were lower. These results provide implications for the implementation of food environment improvements in public health centers and other local government agencies to promote the Health Japan 21 (third term) strategy.

[Development of a new method for assessing the availability of low-sodium foods in Japan].

Objectives　Food environment improvement involving salt reduction requires improving access to and labeling low-sodium foods. Assessing the implementation status of these measures is also necessary. However, to date, no established methods exist for assessing the availability of low-sodium foods in communities. In this study, we aimed to devise a survey on the availability of low-sodium foods as a community food environment assessment method in order to establish common assessment methods, criteria, and practical measures, as well as standardization nationwide.Methods　A preliminary survey on the availability of low-sodium foods was conducted in Kitakyushu City in four stores with nationwide representation. Consent for providing information on handled product lists was obtained. The on-site lists collected through direct investigation by surveyors were compared with the handled product lists provided by the stores and analyzed to identify survey challenges and examine feasibility and the potential for accuracy. The definition of low-sodium foods, which emerged as a challenge in the preliminary survey, was confirmed. Preliminary survey data were carefully reviewed to establish classification criteria for low-sodium foods and create a low-sodium food list to serve as a reference for on-site surveys. Forms for recording the results of on-site surveys and a survey manual were developed. Registered dietitians conducted on-site surveys using the manual to confirm its applicability.Results　The preliminary survey results revealed that the on-site lists had fewer omissions and greater feasibility than store-provided lists. After clearly defining low-sodium foods, we established classification criteria (three major categories, seven subcategories, and 37 minor categories) considering the ease of on-site investigations and purchases. Three forms for recording survey results were developed, including a standard input form allowing detailed documentation of the availability of individual low-sodium foods, an aggregation form for a quantitative assessment of low-sodium foods availability, and a display form visualizing the availability of low-sodium foods by store. Furthermore, a survey manual was developed explaining the purpose and approach of the low-sodium foods availability survey, definition and classification criteria for low-sodium foods, and the three forms for recording survey results. Findings indicated that all registered dietitians could conduct on-site surveys using the manual and successfully collect and organize data.Conclusion　On-site surveys using the manual and documentation forms enabled easy and accurate assessments of low-sodium foods availability. Thus, this standardized method to assess the availability of low-sodium foods could be a food environment assessment method for regional salt reduction initiatives.

[Relationship between the dietary behavior targets of Health Japan 21 (second term) and perceived food environment and health literacy].

Objective　The interim evaluation of Health Japan 21(second term), a national health promotion plan, suggested that improvements in the food environment did not lead to improvements in individual dietary habits. The present study aimed to evaluate the relationship between the dietary behavior targets of Health Japan 21 (second term) and perceived food environment and health literacy.Method　We conducted an online cross-sectional survey in March 2019 among adults aged 20-64 years. From the 9,667 registered monitors of the research firm, we collected 2,851 responses (29.5% response rate). The perceived food environment (how people perceive the local food environment) was estimated using the following six questions, namely, availability: easy access to nutritionally balanced meals, accessibility: no inconvenience in daily shopping, affordability: access to nutritionally balanced meals at reasonable prices, accommodation: easy access to food services within business hours, acceptability: satisfaction with the quality of food ingredients, and another form of acceptability: adequate food safety. Health literacy was evaluated using five questions related to information gathering, information selection, information transfer, information judgment, and self-determination. Last, we asked the respondents about two dietary behaviors, namely, the frequency of a balanced diet (defined as comprising the staple food, a main dish, and a side dish) and the quantity of vegetable intake, along with sociodemographic information. The analysis included 2,111 respondents, excluding those whose socioeconomic status was unknown. Multiple logistic regression analyses were performed to determine the relationship between perceived food environment and health literacy on dietary behaviors, while adjusting for sociodemographic factors.Result　A balanced diet was associated with the following perceptions of the food environment: "access to nutritionally balanced meals at reasonable prices" (adjusted odds ratio [95% confidence interval] = 1.37 [1.02, 1.82]; women), and "adequate food safety" (1.54 [1.19, 1.98]; men), and health literacy: "information gathering" (0.84 [0.73,0.97]; men) and "self-determination" (1.28 [1.10,1.50], 1.37 [1.14,1.63]; men, women). The quantity of vegetable intake was associated with the following perceptions of the food environment: "easy access to nutritionally balanced meals" (1.54 [1.15,2.06]; men), and "no inconvenience in daily shopping" (1.55 [1.12,2.15]; women), and health literacy: "information transfer" (1.30 [1.10,1.54]; men), and "self-determination" (1.67 [1.38,2.02]; women)).Conclusion　To achieve a balanced diet and increased vegetable intake in a population, it is necessary to promote both the acquisition of a higher level of "self-determination" (rather than "information gathering") in health literacy and the creation of a heathy food environment.

[Changes in dietary behaviors and food-related accessibility issues and information needs during the COVID-19 pandemic: comparison based on household economic status].

Objective　This study aimed to assess the household income changes during COVID-19 pandemic among Japanese adults, and to evaluate how this was related to changes in dietary behaviors and food-related accessibility issues and information needs during the emergency period.Method　We conducted an online cross-sectional survey in July, 2020 among residents (aged 20-69 years) of the 13 prefectures under special confinement during the COVID-19 pandemic. Participants were asked about their dietary behaviors before the pandemic (before February 2020) and during the confinement period (April-May 2020), as well as about their food-related accessibility issues and information needs during the confinement period. Data from 2,225 residents were analyzed. Participants were divided into three groups (decreased, unchanged, and increased) based on the household income changes due to COVID-19. Demographics, dietary behaviors, and food-related accessibility issues and information needs were then compared among these three groups. Multiple logistic regression analyses were performed to examine the effect of household income changes on dietary behavior changes, food-related accessibility issues, and food-related information needs, while adjusting for sociodemographic factors. Furthermore, the effect of household income changes and subjective economic status were also analyzed using multiple logistic regression analyses.Result　The participant distribution in each group were as follows: decreased (34.6%), unchanged (63.9%), and increased (1.6%). Higher proportion of those who were employed part-time, self-employed, or unemployed during the confinement period were found among the decreased group. The odds ratios (OR) of the decreased group were significantly higher than the unchanged group for lower frequency of eating out, and for higher frequency of home-cooking, consuming ready-to-eat convenience meals, and eating with children during the confinement period. Furthermore, regardless of the subjective economic status, the decreased group experienced difficulties in accessing required foods because of shortages and congestion in grocery stores, as well as increased prices. Additionally, food-related information needs regarding reduction of food expenses were also high among the decreased group.Conclusion　Participants with a decreased household income were more likely to experience difficulties with food accessibility and desire information about lowering food-related expenses. Furthermore, they reported lower frequency of eating out, and higher frequency of home-cooking and consuming ready-to-eat convenience meals during the confinement period than before the pandemic. Future studies should evaluate the direction (positive or negative) of these changed food consumption patterns.

Effect of workplace dietary intervention on salt intake and sodium-to-potassium ratio of Japanese employees: A quasi-experimental study.

OBJECTIVES: Excess salt intake is a major risk factor for hypertension and cardiovascular disease. Modifying workplace environments has been recognized to be important for reducing salt intake. However, studies examining the effects of improving the workplace environment regarding salt reduction are limited. This study aimed to evaluate the effects of workplace dietary intervention on employees' salt intake and sodium-to-potassium (Na/K) ratio. METHODS: A quasi-experimental study was conducted. Two small business establishments in Saitama Prefecture, Japan, were allocated as the intervention (n = 69) and comparison (n = 68) workplaces, respectively. The 1-year intervention involving healthy lunch and nutrition education was implemented in the intervention workplace. Spot urine samples, physical assessments, and self-administered questionnaire data were collected at baseline, 6 months, and 1 year after the start of the intervention. Analysis of covariance was conducted to investigate differences in the salt intake or Na/K ratio between the study workplaces at year 1. Educational status and rotating work schedules were included as covariates. RESULTS: Salt intake in the intervention workplace decreased significantly from 10.7 to 9.3 g (-1.4 g change; 95% confidence interval [CI]: "-2.4, -0.5"). The adjusted difference in changes in salt intake between workplaces was statistically significant (-3.7 g change; 95% CI: "-5.2, -2.3"). Although no significant change was observed in the Na/K ratio in the intervention workplace (3.37-3.08; -0.29 change; 95% CI: "-0.59, 0.01"), the adjusted difference in changes between the workplaces was statistically significant (-0.60 change; 95% CI: "-1.03, -0.17"). CONCLUSIONS: Providing healthy lunch and nutrition education may be effective approaches to reduce employees' salt intake and Na/K ratio.

[Consumption of ultra-processed foods and relationship between nutrient intake and obesity among participants undergoing specific health checkups provided by National Health Insurance].

Objective　Obesity associated with an increased consumption of ultra-processed foods (UPF) has been reported by studies abroad using the NOVA food classification system, an international framework for classifying food according to the degree of processing. However, no such study has been conducted in Japan. In this study, we evaluated the association between UPF consumption, nutrient intake, and obesity using the NOVA system.Method　In September 2017, we conducted a survey using a questionnaire of patients who had attended routine health checkups in Manazuru Town, Kanagawa Prefecture and collected their three-day dietary records as well as medical examination results. The final analysis included 169 patients (66 men, 103 women). Food consumed by the respondents were classified into four groups of NOVA systems. The dietary share of UPF (UPF energy ratio) was compared to total energy intake (except alcoholic beverages and eating out). Nutrient intake and obesity risk were compared across the UPF energy ratio tertile (low, middle, and high intake). Covariance and logistic regression analysis were conducted and adjusted based on age, sex, household structure, education, income, and total energy intake (except energy-providing nutrients, macronutrients, and protein intake per body weight) to analyze the association between UPF consumption and nutrient intake. Finally, for obesity, we adjusted for physical activity and smoking status using a similar analysis of the relationship between UPF consumption and energy providing nutrients and macronutrients.Result　Approximately 75% of patients investigated were older than 65 years. The average (standard deviation) UPF energy ratio was 29.7% (15.0). There were no significant differences in socioeconomic status among groups according to the UPF energy ratio. The high-UPF group had a significantly greater total energy intake. However, the protein energy ratio, protein intake per body weight, dietary fiber, and vitamins A, E, K, B1, B6, C, niacin, folic acid, potassium, magnesium, and iron intake were significantly lower in the high-UPF group. Moreover, the high-UPF group had a significantly higher BMI. The odds ratio for obesity was higher (4.51[1.50-13.57]) in the high-UPF group than in the low-UPF group (1.00).Conclusion　Those who consumed more UPF had lower protein intake and suffered from multiple vitamin and mineral deficiencies. Furthermore, their energy intake was greater, and the odds ratio for obesity was significantly higher. It has been suggested that excessive UPF consumption warrants further attention.

[Status and challenges related to creating a healthy food environment: a questionnaire survey for public health dieticians].

Objectives　Creating a healthy food environment is crucial for healthful longevity in Japan. This study aimed to provide an overview of the status and challenges related to creating that environment through prefectural public health centers.Methods　Public health dieticians working at 489 prefectural public health centers in March 2015 individually completed an anonymous self-administered questionnaire. Berelson's content analysis was utilized for response analysis.Results　Data from 359 (response rate: 74.3%) prefectural public health centers, involving 599 public health dieticians, were included in the analysis. More than 80% of the prefectural public health centers implemented a registration system for dining facilities such as restaurants. Furthermore, greater than 80% of the public health dietitians thought that creating a healthy food environment was an important aspect of their work mission. On the other hand, more than 50% of these dieticians expressed dissatisfaction in their role. In terms of evaluation, the public health centers only monitored the number of registered facilities, with few other evaluations conducted. Approximately 80% of the participants requested national guidelines and/or some legal support from the Ministry of Health, Labor, and Welfare and/or the prefectural administration.Conclusion　This study demonstrated that there are challenges related to creating a healthy food environment through prefectural health centers. Improving the evaluation methods and government/administrative provision of national guidelines and/or legal supports were identified as courses of action.

Oseltamivir and early deterioration leading to death: a proportional mortality study for 2009A/H1N1 influenza.

OBJECTIVE: To examine the epidemiological association between sudden deterioration leading to death and Tamiflu use. DESIGN: Proportional mortality study. SETTING: Japan. PARTICIPANTS: 162 deaths without deterioration before the first consultation among all 198 deaths of mostly confirmed 2009A/H1N1 influenza. POPULATION AT RISK: Age-specific population of influenza patients prescribed Tamiflu and Relenza. MAIN OUTCOME MEASURE: Age-stratified pooled odds ratio (OR) for early (within 12 hours) deterioration and overall death of Tamiflu prescribed to Relenza prescribed patients. RESULTS: Of 119 deaths after Tamiflu was prescribed, 38 deteriorated within 12 hours (28 within 6 hours), while of 15 deaths after Relenza, none deteriorated within 12 hours. Pooled OR for early deterioration and overall death were 5.88 (95% CI: 1.30 to 26.6, p = 0.014) and 1.91 (p = 0.031) respectively. Baseline characteristics including risk factors did not contribute to early deterioration after Tamiflu use. CONCLUSIONS: These data suggest Tamiflu use could induce sudden deterioration leading to death especially within 12 hours of prescription. These findings are consistent with sudden deaths observed in a series of animal toxicity studies, several reported case series and the results of prospective cohort studies. From "the precautionary principle" the potential harm of Tamiflu should be taken into account and further detailed studies should be conducted.