Journal of Psychosomatic Research 67 (2009) 67 75

Associations of ikigai as a positive psychological factor with all-cause

mortality and cause-specific mortality among middle-aged and elderly
Japanese people: Findings from the Japan Collaborative Cohort Study
Kozo Tanno a,, Kiyomi Sakata a , Masaki Ohsawa a , Toshiyuki Onoda a , Kazuyoshi Itai a ,
Yumi Yaegashi a , Akiko Tamakoshi b
for JACC Study Group
a
Department of Hygiene and Preventive Medicine, Iwate Medical University School of Medicine, Iwate, Japan
b
Department of Public Health, Aichi Medical University School of Medicine, Aichi, Japan

Received 4 January 2008; received in revised form 19 September 2008; accepted 29 October 2008

Abstract

Objective: To determine whether presence of ikigai as a positive
psychological factor is associated with decreased risks for all-cause
and cause-specific mortality among middle-aged and elderly
Japanese men and women. Methods: From 1988 to 1990, a total
of 30,155 men and 43,117 women aged 40 to 79 years completed a
lifestyle questionnaire including a question about ikigai. Mortality
follow-up was available for a mean of 12.5 years and was classified
as having occurred in the first 5 years or the subsequent follow-up
period. Associations between ikigai and all-cause and cause-
specific mortality were assessed using a Cox's regression model.
Multivariate hazard ratios (HRs) were adjusted for age, body mass
index, drinking and smoking status, physical activity, sleep
duration, education, occupation, marital status, perceived mental
Keywords: Cohort study; Ikigai; Japan; Mortality; Positive psychological factors
stress, and medical history. Results: During the follow-up period,
10,021 deaths were recorded. Men and women with ikigai had
decreased risks of mortality from all causes in the long-term follow-
up period; multivariate HRs (95% confidence intervals, CIs) were
0.85 (0.800.90) for men and 0.93 (0.861.00) for women. The risk
of cardiovascular mortality was reduced in men with ikigai; the
multivariate HR (95% CI) was 0.86 (0.760.97). Furthermore, men
and women with ikigai had a decreased risk for mortality from
external causes; multivariate HRs (95% CIs) were 0.74 (0.590.93)
for men and 0.67 (0.510.88) for women. Conclusion: The
findings suggest that a positive psychological factor such as ikigai
is associated with longevity among Japanese people.
2009 Elsevier Inc. All rights reserved.

Introduction cal distress, are associated with increased risks of coronary

Negative psychological factors, such as depression,
anxiety, hopelessness, psychological stress, and psychologi-
The JACC Study has been supported by Grant-in-Aid for Scientific
Research from the Ministry of Education, Science, Sports and Culture of
Japan (nos. 61010076, 62010074, 63010074, 1010068, 2151065, 3151064,
4151063, 5151069, 6279102, 11181101, 17015022, 18014011).
Corresponding author. Department of Hygiene and Preventive
Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru,
Morioka, Iwate 020-8505, Japan. Tel.: +81 19 651 5111; fax: +81 19 623 8870.
E-mail address: ktanno@iwate-med.ac.jp (K. Tanno).
heart disease [15] and cerebrovascular disease [68].
Recently, there is growing evidence that positive psycholo-
gical factors are associated with greater longevity, reduced
risk of cardiovascular disease, and reduced risk of physical
disability [919].
In this study, we focused on ikigai as a psychological
factor that might be associated with all-cause mortality and
cause-specific mortality. Ikigai is a Japanese word that is
believed to be an important factor for achieving better
health and a fulfilling life [20]. Ikigai is defined in
Japanese dictionaries as something to live for, the joy and
goal of living, a life worth living, and the happiness and

0022-3999/08/$ see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2008.10.018
68 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775
benefit of being alive. It is also understood to be a com-
prehensive concept including not only pleasure and
happiness but also the meaning of one's life and self-
realization. Although there is no term fully comparable to
ikigai in English [21], we considered that the concept of
ikigai is similar to both hedonic and eudaimonic views
of well-being; a hedonic view defines well-being in terms
of pleasure attainment and pain avoidance, and a
eudaimonic view defines well-being in terms of degree to
which a person is fully functioning [22]. Therefore, ikigai
may play an important role in health-related outcomes as
well as other positive psychological factors.
Recently, some prospective studies in Japan have shown
that the absence of ikigai was associated with an increased
risk for all-cause mortality [2326]. However, age-, sex-,
and/or cause-specific mortality risks were not estimated in
most of those studies because of a relatively small study
population in a certain area and a short follow-up period. The
purpose of this study was to determine whether presence of
ikigai is associated with decreased risks for all-cause and
cause-specific mortality among middle-aged and elderly
Japanese men and women, using data from the Japan
Collaborative Cohort (JACC) Study, which has a larger
study population and a longer follow-up period than those in
previous studies.
Materials and methods
Data used for this study were obtained from the Japan
Collaborative Cohort Study for Evaluation of Cancer Risk
(JACC study), a nationwide multicenter collaborative study
sponsored by the Ministry of Education, Culture, Sports,
Science, and Technology of Japan (Monbukagakusho). The
methods used in the JACC study have been described in
detail elsewhere [27,28]. Briefly, a baseline survey was
conducted between 1988 and 1990, enrolling 127,477
apparently healthy subjects living in 45 areas throughout
Japan. We followed 110,792 subjects (46,465 men and
64,327 women) aged 40 to 79 years at the time of the
baseline survey. In 22 of the 45 areas, all residents living in a
given target area were regarded as the study subjects and the
response rate was 83%. In 23 areas, persons who had
undertaken general health checkups periodically provided by
the municipalities were invited to participate in the study.
The subjects completed a self-administered questionnaire on
demographic characteristics, lifestyle habits, medical history,
and psychological attitudes toward life. Written informed
consent for participation was obtained individually from all
subjects with the exception of those in a few study areas in
which informed consent was provided at the group level after
the aim of the study and confidentiality of the data had been
explained to community leaders.
We excluded data for 27,105 persons from analyses
because the questionnaire did not include the question about
ikigai, and we excluded data for 4688 persons who reported
a previous history of cancer, stroke, or myocardial infarction
in the baseline survey. In addition, data for 5727 persons who
did not answer the specific question about ikigai were
excluded from analyses. Data for a total of 73,272 subjects
(30,155 men and 43,117 women) were therefore included in
the final analyses.
Follow-up
The follow-up study was conducted until the end of 2003.
The date and cause of death were annually or biannually
confirmed by using death certificates with permission of the
Director-General of the Prime Minister's Office (Ministry of
Public Management, Home Affairs, Post and Telecommuni-
cations). Data on moving out from the study area were also
annually verified by the investigator in each area reviewing
population-register sheets of the cohort members. The
deceased were treated as uncensored cases when the event
occurred. Those who were known to be alive at the end of
2003 and those who had moved away were treated as
censored cases. The cause of death was classified according
to the International Classification of Diseases, 10th Revision
(ICD-10) as follows: cancer, C00-C97; cardiovascular
disease, I01-99; coronary heart disease, I20-I25; cerebro-
vascular disease, I60-I69; and injuries, poisoning, and other
lesions from external causes, S00-T98. The study was
approved by the Ethical Board of Nagoya University School
of Medicine, where the central secretariat of the JACC study
was located.
Evaluation of ikigai
Status of ikigai was assessed by the single question, Do
you have ikigai in your life? Four possible answers were
provided: definitely yes, yes, not particular, and no
[29]. For the analysis, these responses were categorized into
two groups as follows: subjects who answered definitely
yes or yes were defined as those with ikigai, and subjects
who answered not particular or no were defined as those
without ikigai.
Statistical analysis
Subjects were classified into two or three categories by
self-reported responses to questions about health-related
behaviors such as alcohol drinking status, smoking status,
physical activity, and sleep duration. Alcohol drinking status
was classified into three categories: current drinker, past
drinker, and nondrinker. Smoking status was classified into
three categories: current smoker, past smoker, and non-
smoker. Physical activity was classified into two categories:
exercise 1 h/week and rarely. Sleep duration was classified
into three categories: b7, 78.9 h, and 9 h. Psychosocial
factors such as education level, job status, marital status, and
level of perceived mental stress were also assessed by a self-
administered questionnaire. Educational level was classified
 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775 69

into three categories: up to junior high, high school, and
college or higher. Job status was classified into two
categories: full-time workers and others (part-time workers
or unemployed). Marital status was classified into two
categories: living with a spouse and others (single, divorced,
or widowed). Level of perceived mental stress was assessed
by the single question, What is the level of stress in your
daily life? Four possible answers were provided: low,
moderate, high, and extremely high. For the analysis,
these responses were categorized into three groups as
follows: subjects who answered low were defined as
having a low stress level, subjects who answered moderate
were defined as having a middle stress level, and subjects
who answered high or extremely high were defined as
having a high stress level. Subjects who reported having
hypertension or diabetes diagnosed by physicians were
defined as those having a medical history. Body mass index
(BMI) calculated as weight (kilograms) divided by the
square of body height (meters) was used as a continuous
variable in the comparison between the groups of ikigai and
used as a three-category variable in the Cox's proportional
hazards model: b18.5, 18.524.9, and 25.0 kg/m2.
We calculated the means and proportions of selected
variables in the groups of ikigai by sex. Continuous variables

Table 1
Selected baseline characteristics of the subjects according to ikigai by sex
Men Women
With ikigai Without ikigai P values With ikigai Without ikigai P values
No. of subjects 15,390 14,765 18,353 24,764
Age (years),* mean (S.D.) 56.8 (10.2) 57.3 (10.2) b.001 56.8 (9.8) 57.8 (10.1) b.001
BMI (kg/m2),* mean (S.D.) 22.8 (2.8) 22.5 (2.8) b.001 23.1 (3.1) 22.9 (3.2) b.001
Smoking (%) b.001 .295
Current 50.9 52.3 4.6 4.7
Past 24.2 24.2 1.2 1.3
Never 21.0 19.0 83.6 81.8
Missing data 3.9 4.5 10.6 12.2
Drinking (%) b.001 b.001
Current 74.7 71.1 24.7 20.1
Past 5.0 6.4 1.6 1.6
Never 16.6 18.3 67.4 70.5
Missing data 3.8 4.2 6.3 7.7
Physical activity (%) b.001 b.001
Exercise N1 h/week 35.9 24.9 27.7 18.2
Rarely 60.2 70.1 66.5 74.9
Missing data 4.0 4.9 5.8 6.9
Sleep duration (%) b.001 b.001
b7 h 16.7 16.0 27.8 26.4
78.9 h 70.6 68.4 62.9 62.0
9 h 9.9 12.0 5.3 6.8
Missing data 2.7 3.7 4.0 4.7
Education (%) b.001 b.001
Primary or junior high school 27.0 35.9 27.1 37.4
High school 43.1 40.3 49.8 44.4
College or higher education 19.5 13.4 11.6 7.7
Missing data 10.4 10.4 11.6 10.4
Job status (%)
Full-time 73.0 65.5 b.001 32.8 27.3 b.001
Part-time or unemployed 19.1 27.2 57.5 65.0
Missing data 7.9 7.3 9.7 7.7
Marital status (%) b.001 b.001
Living with a spouse 89.0 83.7 78.9 74.0
Single, divorced, or widowed 4.3 7.3 14.1 15.7
Missing data 6.7 9.0 7.0 10.3
Perceived mental stress level (%) b.001 b.001
High 23.0 22.1 18.0 20.9
Middle 55.2 64.1 56.9 65.2
Low 20.5 12.2 24.0 11.8
Missing data 1.2 1.6 1.1 2.1
Medical history (%)
Hypertension 17.9 19.3 .001 19.2 21.1 b.001
Diabetes 6.0 6.1 .534 3.2 3.8 b.001
P values were estimated (*) by the t test and () by the chi-squared test, with the exception of missing data.
70 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775

were compared using the t test, and categorical variables were
compared using the chi-squared test between the groups of
ikigai by sex, with the exception of missing values.
Age- and multivariate-adjusted hazard ratios (HRs) and
their 95% confidence intervals (CIs) for all-cause and cause-
specific mortality according to ikigai were calculated using
Cox's proportional hazards model separately by sex. In
multivariate analysis, we adjusted several factors known to be
associated with mortality: age, BMI, alcohol drinking status,
smoking status, physical activity, sleep duration, education,
job status, marital status, level of perceived mental stress,
and medical histories of hypertension and diabetes at entry.
The assumption of proportional hazard was tested using
an interaction term between time and ikigai in models. This
assumption was not satisfied over the entire follow-up
period, but it was satisfied when the follow-up period was
more than 5 years. Therefore, we conducted subsequent
analyses separately for the short-term (within 5 years) and
long-term (more than 5 years) follow-up. We also conducted
stratified analyses by age group (40 to 64 years and 65 to 79
years) in the long-term follow-up to assess the effect of
modification, and the presence of interaction was tested by
using cross-product terms of sex and age group with ikigai
variables in the proportional hazard models.
For each covariate, missing values were treated as an
additional category in the variables and were included in the
models. In all analyses, two-sided P values b.05 were
considered to be statistically significant. All analyses were
performed using SPSS software (version 11.0J, SPSS Japan,
Inc., Tokyo, Japan).
Results
During the follow-up period (average, 12.5 years; total of
918,644 person-years), a total of 10,021 deaths (5855 men
and 4166 women) were recorded. The causes of death
included cancer in 2376 cases, cardiovascular disease in
1599 cases (coronary heart disease in 356 cases, cerebro-
vascular diseases in 724 cases), and external causes in 430
cases in men. The corresponding numbers of deaths in
women were 1421, 1405 (273, 648), and 331, respectively.
Table 1 shows selected baseline characteristics of the
subjects according to presence of ikigai by sex. The
proportions of men and women with ikigai were 51.3%
and 42.6%, respectively. Significant differences were
observed in all variables between persons with and those
without ikigai among both men and women, with the

Table 2
Age- and multivariate-adjusted HRs and their 95% CIs according to ikigai by sex
Men Women
Follow-up interval 5 years Follow-up interval N5 years Follow-up interval 5 years Follow-up interval N5 years
Without With Without With Without With Without With
ikigai ikigai ikigai ikigai ikigai ikigai ikigai ikigai
No. of subjects 14,765 15,390 13,683 14,486 24,764 18,353 23,669 17,758
No. of person-years 71,307 74,903 176,929 190,490 121,331 90,355 308,196 233,114
All causes
No. of cases 851 616 2355 2033 623 303 2021 1219
Age-adjusted HR 1.0 0.71 (0.640.79) 1.0 0.79 (0.740.84) 1.0 0.73 (0.630.83) 1.0 0.87 (0.810.94)
Multivariate HR 1.0 0.80 (0.720.89) 1.0 0.85 (0.800.90) 1.0 0.80 (0.690.92) 1.0 0.93 (0.861.00)
Cancer
No. of cases 337 279 870 890 238 124 595 464
Age-adjusted HR 1.0 0.81 (0.690.95) 1.0 0.94 (0.851.03) 1.0 0.76 (0.610.94) 1.0 1.09 (0.971.23)
Multivariate HR 1.0 0.88 (0.741.03) 1.0 0.99 (0.901.09) 1.0 0.77 (0.620.97) 1.0 1.11 (0.981.26)
Cardiovascular disease
No. of cases 232 164 641 562 206 105 696 398
Age-adjusted HR 1.0 0.70 (0.570.85) 1.0 0.80 (0.710.89) 1.0 0.78 (0.620.99) 1.0 0.85 (0.750.96)
Multivariate HR 1.0 0.78 (0.640.96) 1.0 0.86 (0.760.97) 1.0 0.92 (0.721.17) 1.0 0.94 (0.831.07)
Coronary heart disease
No. of cases 47 31 144 134 33 17 148 75
Age-adjusted HR 1.0 0.65 (0.411.03) 1.0 0.85 (0.671.07) 1.0 0.81 (0.451.45) 1.0 0.76 (0.581.01)
Multivariate HR 1.0 0.68 (0.421.08) 1.0 0.94 (0.741.20) 1.0 1.02 (0.561.88) 1.0 0.83 (0.621.11)
Cerebrovascular disease
No. of cases 91 59 303 271 99 47 321 181
Age-adjusted HR 1.0 0.64 (0.460.88) 1.0 0.81 (0.690.96) 1.0 0.72 (0.511.02) 1.0 0.84 (0.701.00)
Multivariate HR 1.0 0.72 (0.511.01) 1.0 0.87 (0.731.03) 1.0 0.91 (0.641.31) 1.0 0.90 (0.741.08)
External causes
No. of cases 66 47 185 132 48 24 180 79
Age-adjusted HR 1.0 0.69 (0.471.00) 1.0 0.66 (0.530.82) 1.0 0.71 (0.431.16) 1.0 0.61 (0.470.80)
Multivariate HR 1.0 0.79 (0.541.16) 1.0 0.74 (0.590.93) 1.0 0.80 (0.481.33) 1.0 0.67 (0.510.88)
Multivariate HR was adjusted for age, body mass index, smoking status, drinking status, physical activity, sleep duration, education, job status, marital status,
perceived mental stress, and medical history of hypertension and diabetes.
 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775 71

exceptions of smoking status in women and of history of
diabetes in men. Mean age was younger and mean body
mass index was lower among persons with ikigai than those
without ikigai. The proportion of current smokers was lower
in men with ikigai than in those without ikigai. The
proportion of current drinkers and the proportion of subjects
who exercised 1 h or more per week were higher in subjects
with ikigai, while the proportion of subjects who slept for 9 h
and longer was lower in subjects with ikigai. Persons with
ikigai were more likely than persons without ikigai to have
a high education level, work full-time, live with a spouse,
and have a low stress level. The proportion of subjects with
hypertension was lower among both men and women with
ikigai than those without ikigai, and the proportion of
subjects with diabetes was lower in women with ikigai.
Table 2 shows age- and multivariate-adjusted HRs and
95% CIs of all-cause and cause-specific mortality according
to ikigai by sex in each follow-up period. Compared with
men and women without ikigai, those with ikigai had a
significantly decreased risk for all-cause mortality after age
and multivariate adjustment in both periods; the multi-
variate-adjusted HRs (95% CIs) among men were 0.80
(0.720.89) in the short-term follow-up and 0.85 (0.80
0.90) in the long-term follow-up, and the multivariate-
adjusted HRs (95% CIs) among women were 0.80 (0.69
0.92) and 0.93 (0.861.00), respectively. In addition, a
preventive effect of ikigai on all-cause mortality in men was
stronger than that in women in the long-term follow-up
(P for interaction of ikigai with sex was .046).
Men with ikigai had a lower risk for cardiovascular
mortality than those without ikigai after age and multi-
variate adjustment in both periods; the multivariate-adjusted
HRs (95% CIs) were 0.78 (0.640.96) in the short-term
follow-up and 0.86 (0.760.97) in the long-term follow-up.
Among women, presence of ikigai was associated with a
decreased risk for cardiovascular mortality after age
adjustment in both periods; however, there was no
statistically significant association after multivariate adjust-
ment in both periods. For mortality from cerebrovascular
disease, men with ikigai had a significantly lower risk than
those without ikigai after age adjustment in both periods.
After multivariate adjustment, this significant association
disappeared, but risk for mortality from cerebrovascular
disease tended to be lower among men with ikigai than
those without ikigai in both periods. Women with ikigai
tended to have a lower risk for mortality from cerebrovas-
cular disease than those without ikigai, although there was
no significant association after age and multivariate
adjustment in both periods. Risk for mortality from
coronary heart disease tended to be lower among men and
women with ikigai than among those without ikigai,
although there was no statistically significant association.
Compared with men and women without ikigai, those
with ikigai also had a decreased risk for mortality from
external causes after age and multivariate adjustment in the
long-term follow-up; multivariate-adjusted HRs were 0.74
(0.590.93) for men and 0.67 (0.510.88) for women. For
cancer, significant associations were found among both

Table 3
Age group-specific multivariate-adjusted HRs and their 95% CIs according to ikigai by sex
Men Women
4064 years 6579 years 4064 years 6579 years
Without With Without With Without With Without With
ikigai ikigai ikigai ikigai ikigai ikigai ikigai ikigai
No. of subjects 10,564 11,240 3119 3246 17,524 13,715 6145 4043
No. of person-years 140,698 151,508 36,231 38,982 233,505 183,591 74,691 49,523
All causes
No. of cases 1092 957 1263 1076 701 509 1320 710
Multivariate HR 1.0 0.88 (0.810.97) 1.0 0.81 (0.750.89) 1.0 0.99 (0.881.12) 1.0 0.89 (0.810.98)
Cancer
No. of cases 504 504 366 386 312 256 283 208
Multivariate HR 1.0 0.99 (0.871.12) 1.0 1.00 (0.861.16) 1.0 1.06 (0.901.26) 1.0 1.18 (0.981.43)
Cardiovascular disease
No. of cases 247 219 394 343 172 119 524 279
Multivariate HR 1.0 0.91 (0.751.10) 1.0 0.83 (0.720.97) 1.0 1.03 (0.811.31) 1.0 0.91 (0.781.06)
Coronary heart disease
No. of cases 59 59 85 75 33 17 58 50
Multivariate HR 1.0 1.04 (0.721.51) 1.0 0.87 (0.631.21) 1.0 0.76 (0.421.39) 1.0 0.86 (0.621.19)
Cerebrovascular disease
No. of cases 118 99 185 172 78 57 243 124
Multivariate HR 1.0 0.84 (0.641.11) 1.0 0.89 (0.721.11) 1.0 1.02 (0.711.45) 1.0 0.86 (0.691.08)
External causes
No. of cases 117 86 68 46 88 55 92 24
Multivariate HR 1.0 0.77 (0.581.02) 1.0 0.70 (0.471.03) 1.0 0.92 (0.651.31) 1.0 0.42 (0.260.66)
Multivariate HR was adjusted for age, body mass index, smoking status, drinking status, physical activity, sleep duration, education, job status, marital status,
perceived mental stress, and medical history of hypertension and diabetes.
72 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775
sexes in the short-term follow-up; however, these associa-
tions disappeared in the long-term follow-up. There was no
interaction effect between ikigai and sex for death from
cancer, cardiovascular disease, coronary heart disease,
cerebrovascular disease, and external causes (P for interac-
tion N.05).
Table 3 shows the multivariate-adjusted HRs and 95%
CIs of all-cause and cause-specific mortality according to
ikigai by sex, further stratifying by two age groups (40 to
64 and 65 to 79 years) in the long-term follow-up. Middle-
aged and elderly men and elderly women with ikigai had a
decreased risk for all-cause mortality compared with those
without ikigai: multivariate-adjusted HRs (95% CIs) were
0.88 (0.810.97) for middle-aged men, 0.81 (0.750.89) for
elderly men, and 0.89 (0.810.98) for elderly women. For
cardiovascular mortality, elderly men with ikigai had a lower
risk than those without ikigai: the multivariate-adjusted HR
(95% CI) was 0.83 (0.710.97). For mortality from external
causes, elderly women with ikigai had a significantly lower
risk than those without ikigai; the multivariate-adjusted HR
(95% CI) was 0.42 (0.260.66). Compared with middle-
aged and elderly men without ikigai, those with ikigai had a
marginally significantly decreased risk for mortality from
external causes: multivariate-adjusted HRs (95% CIs) were
0.77 (0.581.02, P=.066) and 0.70 (0.471.03, P=.071),
respectively. There was a significant interaction effect
between ikigai and age for external causes among women
(P=.017), although there was no significant interaction effect
between ikigai and age for other causes of death in both
sexes (PN.05).
Discussion
We demonstrated that the presence of ikigai contributed
to a reduction of risk for mortality from all causes among
middle-aged and elderly Japanese men and women. For
cardiovascular mortality, men with ikigai had a significantly
lower risk and women with ikigai tended to have a lower risk
than those without ikigai. We also showed that mortality
risks for cerebrovascular disease and coronary heart disease
tended to be lower among men and women with ikigai than
among those without ikigai. Furthermore, men and women
with ikigai had a significantly lower risk for mortality from
external causes.
There have been a few prospective epidemiologic studies
on the association between ikigai and mortality [2326]. A
7-year follow-up study of 1065 elderly people aged 60 to 74
years showed that presence of ikigai decreased the risk for
mortality from all causes after adjustment for sex, age, and
previous medical histories [23]. A 42-month follow-up study
of 1266 community-residing elderly people showed that
absence of ikigai was significantly associated with an
increased risk for all-cause mortality in univariate analysis
but not in multivariate analysis [24]. In the same cohort,
persons who lost ikigai during a 6-year follow-up period had
an increased risk of all-cause mortality [25]. Sakata et al. [26]
examined sex- and cause-specific mortality risks according
to ikigai using 10-year follow-up data for 2711 persons in
one local area of the JACC study. They showed that absence
of ikigai was associated with increased risks for mortality
from cardiovascular disease and stroke among men and
increased risk for mortality from heart disease among women
after adjustment for age, smoking and drinking status, and
prevalence of hypertension [26]. The strength of the present
study is in having a larger study population throughout Japan
and a longer follow-up period than those in previous studies.
Results of many previous studies on psychological factors
associated with all-cause mortality and cardiovascular
mortality and morbidity have been reported. Positive
psychological factors have been shown to be associated
with decreased risks for all-cause mortality [1014] and
cardiovascular mortality and morbidity [1417]. Further-
more, recent studies have shown that positive attitudes may
be related to low prevalence of hypertension and less
progression of subclinical atherosclerosis [3032]. Our
results are consistent with the results of previous studies.
Low risk for mortality from coronary heart disease was
observed among men and women with ikigai; however, there
was no statistically significant association. This finding may
be due to the small number of deaths from coronary heart
disease, which would have contributed to insufficient
statistical power in our cohort.
In contrast, results for associations between psychological
factors and cancer risk are inconsistent [3335]. In this
study, we showed that there was no significant association
between ikigai and risk for cancer mortality in the long-term
follow-up. However, recent meta-analyses have shown that
depression and stress-related psychosocial factors are
associated with an increased risk of site-specific cancer
incidence [34,35]. Previous analysis on association of ikigai
with breast cancer incidence by using data obtained in the
JACC study has also shown that women with ikigai had a
significantly lower risk of breast cancer incidence [29].
Psychological factors might be associated with incidence of
cancer in a certain site.
Sex-specific analysis showed that risk reduction for all-
cause mortality according to ikigai was stronger in men than
in women after multivariate adjustment. For mortality from
cardiovascular disease and cerebrovascular disease, the
reduction of risk tended to be stronger among men than
among women; however, there was no significant interaction
effect between ikigai and sex. Previous studies have
demonstrated that the risk reductions by positive psycholo-
gical factors in all-cause mortality and stroke incidence were
stronger in men than in women [14,15]. Although the
reasons for these findings are not clear, this interaction of
ikigai with sex is probably due to different statistical
power between men and women; mortality rates were
always higher in men than in women. Further studies are
needed to determine whether there is sex difference in the
effect of ikigai on mortality.
 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775
Most previous studies have shown associations of
positive affects with mortality and morbidity among elderly
people [9]. In this study, we showed that ikigai had a
preventive effect on all-cause mortality not only in the
elderly group but also in the middle-aged group. This
effect was stronger in the elderly group than in the middle-
aged group. One of the reasons may be that mortality rates
are much lower in middle-aged persons than in elderly
persons with or without ikigai. In addition, the propor-
tions of subjects who had a smoking habit, immobility, low
education levels, no job, and high stress levels were higher
in the elderly group than in the middle-aged group in this
study (data not shown). Adverse health-related beha-
viors and poor psychosocial factors may have an influence
on increasing mortality rates among elderly persons
without ikigai.
This study also demonstrated that both men and women
with ikigai had a decreased risk for mortality from external
causes in the long-term follow-up. Koivumaa-Honkanen
et al. [11] showed that life dissatisfaction was associated with
about a twofold increased risk of death from injury. It has
also been shown that life dissatisfaction predicted both fatal
unintentional and intentional injury [36] and that life
dissatisfaction was associated with a higher risk of suicide
[37]. Higher mortality rate from external causes among men
and women without ikigai in this study may be attributable
to the inclusion of suicide in the category of death from
external causes.
The mechanisms underlying the preventive effects of
positive psychological factors such as ikigai on mortality
remain unclear, though there are several possible explana-
tions. First, ikigai may be associated with preferable health-
related behaviors. In this study, there was a lower proportion
of current smokers among men with ikigai. Proportions of
current drinkers, subjects who exercised 1 h or more per
week, and subjects who slept for 7 to 9 h were higher in men
and women with ikigai. We also found that persons with
ikigai were more likely to have good psychosocial factors
such as living with a spouse, working full-time, a high
educational level, and a low stress level. The effect of ikigai
on all-cause and cause-specific mortality slightly weakened
after adjustment for variables on health-related behaviors or
psychosocial factors (data not shown). It is thought that
preferable health-related behaviors and good psychosocial
factors may partially explain the association between ikigai
and mortality.
Second, absence of ikigai may be associated with
existence of a medical history. In this study, prevalence of
medical history such as hypertension and diabetes was
higher among persons without ikigai than among those with
ikigai. In addition, we showed that the risk reduction for all-
cause and cause-specific mortality according to ikigai was
stronger in the short-term follow-up (within 5 years) than in
the long-term follow-up (more than 5 years). This finding
may be related to the existence of undetected disease such as
cancer. A person who had undetected disease at entry may
73
have lost ikigai in the baseline survey and may have died
during the short-term follow-up. Therefore, the existence of
undetected diseases may increase mortality rates among
persons without ikigai in the short-term follow-up.
Third, positive psychological factors such as ikigai may
be directly associated with neuroendocrine, inflammatory,
and immune responses. A cross-sectional study showed that
positive affective states were inversely related to salivary
cortisol output and that plasma fibrinogen stress responses
were smaller in happier individuals [38]. Another cross-
sectional analysis of elderly women showed that higher
levels of eudaimonic well-being were associated with lower
levels of cortisol and pro-inflammatory cytokines [39].
Clearly, further studies are needed to elucidate the mechan-
isms underlying the preventive effects of positive psycho-
logical factors on mortality.
There are several limitations in this study. First, ikigai
was evaluated by a simple single question: Do you have
ikigai in your life? Ikigai is a complex concept including
positive emotions and positive attitudes toward one's life.
Therefore, the reliability and validity of the question about
ikigai in this study should be assessed by comparison with
other psychological measurements. Second, since we
assessed ikigai at one specific time point, change in ikigai
with time was not evaluated in this study. A study on
association between changes in ikigai during a period of 6
years and mortality showed that loss of ikigai during the
interval of two surveys resulted in an increased risk of
mortality [25]. Therefore, the effect of change in ikigai with
time would have been to attenuate our results. Third, it is
possible that our subjects did not include persons with illness
and disability, because we excluded persons who had a
previous history of cancer, stroke, or myocardial infarction in
the baseline survey. Therefore, we could not estimate the
effect of ikigai on mortality among persons with illness and
disability. Finally, there would be residual confounding on
the association of ikigai with risk of mortality, although we
adjusted for known risk factors.
In conclusion, this study suggests that the presence of
ikigai as a positive psychological factor reduces the risks
of mortality from all causes, cardiovascular disease, and
external causes among middle-aged and elderly Japanese
people. Our findings suggest that a positive psychological
factor is an important factor for achieving better health and a
fulfilling life not only among elderly people but also among
middle-aged people.
Acknowledgments
The authors express their appreciation to Dr. Kunio Aoki,
Professor Emeritus, Nagoya University School of Medicine
and the former chairman of the JACC study Group, and Dr.
Haruo Sugano, the former Director of the Cancer Institute of
the Japanese Foundation for Cancer Research, who greatly
contributed to initiating the study, and Dr. Yoshiyuki Ohno,
Professor Emeritus, Nagoya University School of Medicine,
74 K. Tanno et al. / Journal of Psychosomatic Research 67 (2009) 6775
who was the past chairman of the study. The authors also
wish to thank Dr. Akizumi Tsutsumi, University of
Occupational and Environmental Health and Dr. Fumiyoshi
Kasagi, Radiation Effects Research Foundation, for their
helpful comments.
The investigators involved, with the co-authorship of this
paper, in the JACC Study and their affiliations are as follows:
Dr. Akiko Tamakoshi (present chairman of the study group),
Aichi Medical University School of Medicine; Drs. Mitsuru
Mori and Fumio Sakauchi, Sapporo Medical University
School of Medicine; Dr. Yutaka Motohashi, Akita Univer-
sity School of Medicine; Dr. Ichiro Tsuji, Tohoku University
Graduate School of Medicine; Dr. Yosikazu Nakamura, Jichi
Medical School; Dr. Hiroyasu Iso, Osaka University
Graduate School of Medicine; Dr. Haruo Mikami, Chiba
Cancer Center; Michiko Kurosawa; Juntendo University
School of Medicine; Dr. Yoshiharu Hoshiyama, University
of Human Arts and Sciences; Dr. Hiroshi Suzuki; Niigata
University School of Medicine; Dr. Koji Tamakoshi, Nagoya
University School of Health Sciences; Dr. Kenji Wakai,
Nagoya University Graduate School of Medicine; Dr.
Shinkan Tokudome, Nagoya City University Graduate
School of Medical Sciences; Dr. Koji Suzuki, Fujita Health
University School of Health Sciences; Dr. Shuji Hashimoto,
Fujita Health University School of Medicine; Dr. Shogo
Kikuchi, Aichi Medical University School of Medicine; Dr.
Yasuhiko Wada, Kansai Rosai Hospital; Dr. Takashi
Kawamura, Kyoto University Center for Student Health;
Drs. Yoshiyuki Watanabe and Kotaro Ozasa, Kyoto
Prefectural University of Medicine Graduate School of
Medical Science; Dr. Tsuneharu Miki, Graduate School of
Medical Science, Kyoto Prefectural University of Medicine;
Dr. Chigusa Date, Faculty of Human Life and Environment,
Nara Women's University; Dr. Kiyomi Sakata, Iwate
Medical University School of Medicine; Dr. Yoichi Kur-
ozawa, Tottori University Faculty of Medicine; Dr. Takesumi
Yoshimura, Fukuoka Institute of Health and Environmental
Sciences; Dr. Yoshihisa Fujino, University of Occupational
and Environmental Health; Dr. Akira Shibata, Kurume
University School of Medicine; Dr. Naoyuki Okamoto,
Kanagawa Cancer Center; and Dr. Hideo Shio, Moriyama
Municipal Hospital.
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