Clinical Nutrition 39 (2020) 2238e2245

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original article

Association between improved adherence to the Japanese diet and

incident functional disability in older people: The Ohsaki Cohort 2006
Study
Sanae Matsuyama, Shu Zhang, Yasutake Tomata, Saho Abe, Fumiya Tanji, Yumi Sugawara,
Ichiro Tsuji*
Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine,
Sendai, Japan

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Although it has been reported that the Japanese dietary pattern is associated with a
Received 31 May 2019 lower risk of incident functional disability among older people, the potential benefits of improving
Accepted 7 October 2019 adherence to the Japanese diet remain unclear. The aim of the present study was to evaluate the asso-
ciation between 12-year change in adherence to the Japanese diet and the subsequent risk of incident
Keywords: functional disability in older people in Japan.
Improving diet
Methods: We analyzed 10-year follow-up data from a cohort study of 2923 Japanese older adults (age
Japanese diet

65 years) in 2006. We collected dietary information using a validated 39-item food frequency ques-
Functional disability
Prospective study
tionnaire at two time points (1994 and 2006). Adherence to the Japanese diet (high intake of rice, miso
soup, seaweeds, pickles, green and yellow vegetables, fish, green tea; low intake of beef and pork, and
coffee) was assessed using the Japanese Diet Index (JDI), which ranges from 0 to 9. Participants were
categorized into five groups according to changes in the JDI score at these two time points. Data on
incident functional disability from December 2006 to November 2016 were retrieved from the public
long-term care insurance database. The Cox proportional hazards model was used to estimate the hazard
ratios (HRs) and 95% confidence intervals (CIs) for incident functional disability.
Results: During 22,466 person-years of follow-up, 1093 cases of incident functional disability were
documented. Compared with participants in the group with the largest decrease in the JDI score (2),
the multivariate-adjusted HR (95% CI) of incident functional disability was 0.77 (0.61e0.98) for those in
the largest increase group (
þ2).
Conclusions: Improved adherence to the Japanese diet was associated with a significantly lower risk of
incident functional disability in older people in Japan.
© 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction partly attributable to the Japanese dietary pattern. In fact, it has

Japan has not only the longest life expectancy (81.1 years for
men and 87.1 years for women), but also the longest healthy life
expectancy (74.8 years for both sexes) in the world [1]. This may be
Abbreviations: JDI, Japanese Diet Index; LTCI, long-term care insurance; FFQ,
food frequency questionnaire; DR, dietary record; ADL, activities of daily living; HR,
hazard ratio; CI, confidence interval; BMI, body mass index; K6, Kessler 6-Item
Psychological Distress Scale; SD, standard deviation.
* Corresponding author. Division of Epidemiology, Department of Health Infor-
matics and Public Health, Tohoku University School of Public Health, Graduate
School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan.
Fax: þ81 22 717 8125.
E-mail address: tsuji1@med.tohoku.ac.jp (I. Tsuji).
been reported that the Japanese dietary pattern is associated with a
lower risk of incident functional disability [2], dementia [3], and
cerebrovascular disease [4]. However, these previous studies have
evaluated adherence to the Japanese diet at only a single time point.
Although improving adherence to healthy dietary patterns such
as Healthy Eating Index, Mediterranean Diet, and Dietary Approach
to Stop Hypertension (DASH) has been reported to be beneficial to
the health among middle-aged and older individuals [5,6], the
potential benefits of improving adherence to the Japanese diet
remain unclear.
Therefore, the aim of the present study, which utilized a pro-
spective cohort with repeated measurements of diet, lifestyle, and
other chronic diseases collected between 1994 and 2006, was to

https://doi.org/10.1016/j.clnu.2019.10.008
0261-5614/© 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245
clarify the impact of improved adherence to the Japanese diet in
older people by evaluating the association between 12-year change
in adherence to the Japanese diet and the subsequent risk of inci-
dent functional disability. The results could be expected to identify
possible ways to help prevent incident functional disability in older
people in Japan.
2. Materials and methods
2.1. Study cohort
Similar to our previous studies [7e9], we used merged data
from the Ohsaki Cohort 1994 Study and the Ohsaki Cohort 2006
Study, the details of which have been described elsewhere [10,11].
The Ohsaki Cohort 1994 Study was a population-based cohort
study involving seven municipalities (Furukawa City, Matsuyama
Town, Sanbongi Town, Kashimadai Town, Iwadeyama Town, Nar-
uko Town, and Tajiri Town) within the catchment zone of the
Ohsaki Public Health Center, Miyagi Prefecture, Japan, as of August
31, 1994 (these seven municipalities were merged into Ohsaki City
in 2006). The survey was conducted between October and
December 1994. Among the 32,978 adults aged 40e79 years, we
were able to distribute questionnaires to 32,126, among whom,
30,552 provided valid responses and formed the study cohort.
In the Ohsaki Cohort 2006 Study, which was conducted between
December 1e15, 2006 in Ohsaki City, the participants were all cit-
izens aged
65 years, and they were followed until November 30,
2016.
Figure 1 shows a flowchart of study participants. In the Ohsaki
Cohort 2006 Study, 23,091 individuals who provided valid re-
sponses comprised the study cohort. We excluded 6333 individuals
who did not provide written consent for review of their long-term
care insurance (LTCI) information, 1979 persons who had already
been certified as having a disability by LTCI at the time of the
baseline survey, and five persons who had died or moved during
the period of the baseline survey. About half of the 14,774 eligible
adults, also participated in the 1994 survey. Thus, by combining the
two data sets, we obtained information on changes in the Japanese
Diet Index (JDI) score between 1994 and 2006 for 8006 individuals.
Among these individuals, 3416 and 1667 with incomplete JDI score
components in the 2006 and 1994 surveys, respectively, were
excluded. Therefore, 2923 responses were finally analyzed for the
purposes of this study. All participants were free of disability in
both survey years.
During the 10-year period covered by this study, only 31 in-
dividuals who had not developed any functional disability were lost
to follow-up because they had moved away from the study area;
thus, the follow-up rate was 98.9%. From the resulting 22,466
person-years, incident functional disability was determined in 1093
persons, and the number of all-cause deaths without incident
functional disability was 305.
These surveys included questions about the recent average
frequency of consumption of 39 food items, as well as questions on
disease history, smoking status, alcohol drinking, body weight,
height, time spent walking per day, and education level. Addi-
tionally, the Ohsaki Cohort 2006 Study included the Kessler 6-Item
Psychological Distress Scale (K6) score [12,13]. The questionnaires
were distributed by the heads of individual administrative districts
and collected by postal mail.
2.2. Dietary assessment
We asked the participants about the average frequency of
consumption of each food item using a 39-item food frequency
questionnaire (FFQ), for which a validation study had previously
2239
been conducted in the same region (the precinct of Ohsaki
Public Health Center, Miyagi Prefecture) [14]. In brief, 113 par-
ticipants (55 men and 58 women) provided four 3-day dietary
records (DRs) within a 1-year period and subsequently respon-
ded to the FFQ. These data were used to develop a method for
calculating food and nutrient intake from the FFQ. The age- and
total energy-adjusted Spearman correlation coefficients between
the amounts of the 39 food items consumed according to both
the FFQ and the DRs were computed. The medians (ranges) of
the correlation coefficients were 0.35 (0.30 to 0.72) for men
and 0.34 (0.06 to 0.75) for women [14].
We calculated the consumption volume of each individual food
item by converting the selected frequency category for each item to
a daily intake, using portion sizes based on the median values
observed in the DRs. Missing values for the daily consumption
volume of food items that did not apply to the JDI were replaced by
0. From this, we determined energy intake using a food composi-
tion table that corresponded to the items listed in the question-
naire; the food composition table was developed based on the
Standard Tables of Food Composition published by the Science and
Technology Agency of Japan [14].
2.3. Exposure
We used the JDI that had been established in our previous
study to assess the degree of adherence to the Japanese diet
[2,15]. The JDI consists of nine components: rice, miso soup,
seaweeds, pickles, green and yellow vegetables (green vegeta-
bles, carrot, pumpkin, and tomato), fish (raw fish, fish boiled
with soy, roast fish, boiled fish paste, and dried fish), green tea,
beef and pork (beef, pork, ham, and sausage), and coffee. For
each of the seven adhering components (rice, miso soup, sea-
weeds, pickles, green and yellow vegetables, fish, and green tea),
participants received 1 point if their intake was more than or
equal to the sex-specific median. For each of the two non-
adhering components (beef and pork, and coffee), participants
received 1 point if their intake was less than the sex-specific
median. Thus, the JDI score ranged from 0 to 9, with higher
scores indicating greater dietary conformity. Supplemental
Table 1 shows the correlation coefficients of the dietary prod-
ucts included in the JDI.
We calculated the difference in JDI score by subtracting that in
1994 from that in 2006, and then categorized the participants into
five groups as follows: G1 (reference): the largest decrease (change
in the JDI score by 2 points); G2: moderate decrease (change in
the JDI score by 1 point); G3: relatively no change (no change in
the JDI score); G4: moderate increase (change in the JDI score by þ1
point); and G5: the largest increase (change in the JDI score by
þ2
points).
2.4. Follow-up (incident functional disability)
The end point of this study was incident functional disability,
which was defined as LTCI certification. The primary outcome was
LTCI certification (Support Level 1 or higher); deaths without LTCI
certification were treated as censored.
Based on an agreement about the secondary use of data, we
obtained a data set from the Ohsaki City government that
included information on the data regarding LTCI certification,
death, or emigration. With regard to LTCI certification, informa-
tion on care level was also provided. Under an agreement related
to epidemiologic research and privacy protection, all data are
transferred from the Ohsaki City government in December every
year.
2240 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245

31,694 All citizens (65 years or older at the 2006 survey)

Response rate = 72.9%

23,091 Valid response

Participants who agreed to a review of

16,758 their Long-term Care Insurance information.

Participants who had not been certified as

14,779 having disability at the 2006 survey.

Participants who had not died or moved out

14,774 before follow-up.

Participants who had participated the 1994 survey.

8,006

Participants who had not been left blank on compornents of

4,590 the Japanese diet index at the 2006 survey.

Participants who had not been left blank on compornents of

2,923 the Japanese diet index at the 1994 survey.

Result of 10 years' follow-up

1,093 (37.4%) Incident functional disability

31 (1.1%) Lost to follow up (Emigration without incident functional disability)
305 (10.4%) Death without incident functional disability

Fig. 1. Flowchart of study participants.

2.5. LTCI system in Japan LTCI is a mandatory form of social insurance that assists the daily
activities of frail older individuals [16]. Everyone aged
40 years
In the present study, we defined incident functional disability as pays premiums, and everyone aged
65 years is eligible for formal
LTCI certification, which employs a nationally uniform standard. caregiving services. To receive caregiving services through the LTCI
 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245
system, an individual must be certified according to the nationally
uniform standard. The procedure for disability certification consists
of two parts: 1) assessment of the degree of functional disability
using a questionnaire developed by the Ministry of Health, Labour
and Welfare, and 2) reference to the doctor's opinion paper pre-
pared by the attending physician. If a person is judged eligible, the
Municipal Certification Committee decides on one of seven levels of
support, ranging from Support Level 1 to Support Level 2, and from
Care Level 1 to Care Level 5. In brief, LTCI certification levels are
defined as follows: from Support Level 1: “limited in instrumental
activities of daily living (ADL), but independent in basic ADL”, to
Care Level 5: “requiring care in all ADL tasks”. A community-based
study has shown that LTCI certification levels are well correlated
with the ability to perform ADL and Mini-Mental State Examination
scores [17]. LTCI certification has been used in a number of studies
as a measure of incident functional disability in older individuals
[18e20].
2.6. Covariate
In both the 1994 and 2006 surveys, body mass index (BMI) was
calculated as the self-reported body weight in kilograms divided by
the square of the self-reported height in meters.
In the 2006 survey, the K6 was used as an indicator of psycho-
logical distress [12,13]. Using six questions, respondents were asked
about their mental status over the last month. The total score
ranges from 0 to 24 points. As the optimal cutoff point for mental
illness in the validation study, we classified individuals with scores
of
13 as having psychological distress [13].
In addition, in the 2006 survey, self-rated health was assessed
using a single question that asked respondents to report whether
their health was excellent, good, fair, poor, or bad. We classified
those who reported that their self-rated health was poor or bad as
having poor self-rated health.
2.7. Ethical issues
We considered the return of a completed questionnaire to imply
consent to participate in the study involving the baseline survey
data and subsequent follow-up. We also confirmed information
regarding LTCI certification status after obtaining written consent.
The Ethics Committee of Tohoku University Graduate School of
Medicine (Sendai, Japan) reviewed and approved these study pro-
tocols (Ohsaki Cohort 1994 Study approval code: 2014-1-839;
Ohsaki Cohort 2006 Study: 2006-206).
2.8. Statistical analysis
We counted the person-years of follow-up for each participant
from December 16, 2006 until the date of incident functional
disability, date of emigration from Ohsaki City, date of death, or the
end of the study period (November 30, 2016), whichever occurred
first.
The multivariate-adjusted Cox proportional hazards model was
used to calculate the hazard ratios (HRs) and 95% confidence in-
tervals (CIs) for incident functional disability according to changes
in the JDI score. Changes in the JDI score were categorized into five
groups, from the largest decrease (G1) to the largest increase (G5).
Dummy variables were created for these groups, and the group
with the largest decrease was defined as the reference category.
Multivariate-adjusted models were adjusted for the following
variables. Model 1 was adjusted for age (65e69, 70e74, 75e79,
80e84, or
85 years) and sex. To examine whether the association
between changes in the JDI score and incident functional disability
was attributable to a physical health status or other lifestyle factors
2241
in 1994, Model 2 was further adjusted for BMI (<18.5, 18.5e25,

25 kg/m2, or missing), smoking status (current, former, never, or
missing), alcohol drinking (current, former, never, or missing), time
spent walking (
1, 0.5e1, <0.5 h/d, or missing), energy intake (in
kcal/d; sex-specific quintile categories, or missing), history of dis-
ease (hypertension, diabetes, myocardial infarction, or stroke [yes
or no for each term]), and the JDI score (<4, 4, 5, 6, or
7 points). In
addition to these adjustments, Model 3 was adjusted for the
following variables in 2006: BMI (<18.5, 18.5e25,
25 kg/m2, or
missing), smoking status (current, former, never, or missing),
alcohol drinking (current, former, never, or missing), time spent
walking (
1, 0.5e1, <0.5 h/d, or missing), energy intake (in kcal/d;
sex-specific quintile categories, or missing), history of disease
(hypertension, diabetes, myocardial infarction, or stroke [yes or no
for each term]), education level (15, 16e18,
19 years, or missing),
and psychological distress (<13,
13, or missing).
We also conducted several sensitivity analyses to test the
robustness of our findings. First, we applied multiple imputations
for missing consumption data for the JDI components because only
2923 out of 8006 eligible individuals answered the FFQ for all JDI
components in both the 1994 and 2006 surveys (Fig. 1). Based on
age, sex, and other observed values for the confounding factors,
missing values for the JDI components were substituted with the
most likely value using the multiple imputation procedure, and five
output data sets were created. Then, the multivariate-adjusted Cox
model was applied to the imputed data to calculate the pooled HRs
and 95% CIs for incident functional disability. Second, we conducted
analyses stratified by age in 1994 (<60 years and
60 years), BMI in
1994 (<25.0 kg/m2 and
25.0 kg/m2), and the JDI score in 1994 (low
score: 0e4 points; medium score: 5 points; and high score: 6e9
points) to assess whether the effects of the change in JDI score on
incident functional disability would vary according to age, BMI or
the JDI score in 1994. In addition, we investigated the relationship
between the JDI score in 1994 and incident functional disability by
changing the exposure from groups of change in the JDI score to
quintiles of the JDI score in 1994. Third, considering possible
reverse causality, we conducted an analysis by excluding partici-
pants who experienced incident functional disability within the
first 2 years of follow-up. For the same reason, we performed an
analysis by excluding participants whose self-rated health was poor
in the 2006 survey.
All data were analyzed using SAS version 9.4 (SAS Inc., Cary, NC).
All statistical tests described here were two-sided, and differences
at P < 0.05 were considered significant.
3. Results
Among the 2923 participants, the proportion of men was 46.7%,
the mean age (standard deviation [SD]) was 74.1 (5.5) years, and the
mean (SD) BMI was 23.4 (3.2) kg/m2. The mean (SD) follow-up time
was 7.7 (3.0) years.
Table 1 shows the characteristics of the study participants ac-
cording to changes in the JDI score. Participants with the largest
increase in the JDI score had a lower JDI score and less energy
intake in 1994, and a higher JDI score and greater energy intake in
2006. By contrast, participants with the largest decrease in the JDI
score had a higher JDI score and greater energy intake in 1994, and
a lower JDI score and less energy intake in 2006. Participants with
the largest decrease in the JDI score were older, had a lower edu-
cation level, and tended to suffer from psychological distress.
Table 2 shows the association between changes in the JDI score
and incident functional disability. As the JDI score increased, we
observed a significant inverse association with the incident risk of
functional disability; the multivariate-adjusted HRs (95% CIs) were
0.80 (0.65e0.98) for G3, 0.76 (0.61e0.95) for G4, and 0.77
2242 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245

Table 1
Characteristics of participants by changes in the JDI score (n ¼ 2923).

Characteristic Groups of change in the JDI score P valuea

G1 G2 G3 G4 G5

Largest decrease Moderate decrease Relatively no change Moderate increase Largest increase

2 1 0 þ1
þ2

(n ¼ 462) (n ¼ 513) (n ¼ 648) (n ¼ 642) (n ¼ 658)

In 1994 survey
The JDI score, mean (SD) 6.5 (1.3) 6.0 (1.3) 5.5 (1.4) 4.9 (1.4) 4.0 (1.4) <0.001
Body mass index (kg/m2), mean (SD) 23.5 (2.9) 23.5 (2.8) 23.6 (2.8) 23.3 (2.7) 23.7 (2.8) 0.332
History of disease (%)
Hypertension 31.2 34.3 27.3 26.3 28.9 0.026
Diabetes 5.0 6.6 4.0 4.5 4.1 0.239
Myocardial infarction 2.0 2.3 1.4 2.7 2.4 0.565
Stroke 1.3 1.6 1.2 1.7 1.1 0.868
Current smoker (%) 22.0 22.5 19.7 24.0 21.2 0.758
Current drinker (%) 46.9 48.4 48.3 46.6 48.9 0.477
Time spent walking
1 h/d (%) 44.3 45.6 45.1 43.9 42.3 0.623
Energy (kcal/d), mean (SD)b 1628 (404) 1626 (485) 1588 (478) 1574 (499) 1427 (477) <0.001
In 2006 survey
Change in the JDI score, median (%) 2 (60.6) 1 (100.0) 0 (100.0) þ1 (100.0) þ2 (58.7) <0.001
The JDI score, mean (SD) 3.9 (1.3) 5.0 (1.3) 5.5 (1.4) 5.9 (1.4) 6.5 (1.3) <0.001
Age (years), mean (SD) 74.3 (5.8) 74.1 (5.4) 74.1 (5.4) 73.8 (5.4) 74.1 (5.4) 0.660
Male (%) 45.2 45.8 44.4 48.1 49.1 0.417
Body mass index (kg/m2), mean (SD) 23.4 (3.6) 23.4 (3.1) 23.4 (3.2) 23.2 (3.0) 23.6 (3.2) 0.141
History of disease (%)
Hypertension 43.9 48.7 44.3 43.0 43.9 0.349
Diabetes 13.0 11.1 9.7 7.9 9.4 0.073
Myocardial infarction 5.2 5.3 3.6 4.4 5.5 0.470
Stroke 2.6 3.3 3.6 3.4 2.7 0.848
Current smoker (%) 12.3 13.4 11.6 13.9 10.1 0.442
Current drinker (%) 36.6 38.0 37.9 38.2 38.8 0.997
Time spent walking
1 h/d (%) 26.5 26.4 32.2 30.7 28.0 0.091
Energy (kcal/d), mean (SD)b 1325 (362) 1440 (367) 1532 (404) 1558 (387) 1601 (377) <0.001
Education level
19 years (%)c 27.2 27.6 30.6 29.9 30.3 0.404
Psychological distress score (%)d 5.4 4.6 3.1 4.5 4.5 0.494
a
Obtained by using c2 test for variables of proportion and one-factor ANOVA for continuous variables (missing value exclude).
b
Except energy intake from alcohol drinking.
c
Age at last school graduation
19 years.
d
Kessler 6-item psychological distress scale
13.

Table 2
Association between changes in the JDI score and incident functional disability (n ¼ 2923).a

Groups of change in the JDI score P-trend

G1 G2 G3 G4 G5

Largest decrease Moderate decrease Relatively no change Moderate increase Largest increase

2 1 0 þ1
þ2

(n ¼ 462) (n ¼ 513) (n ¼ 648) (n ¼ 642) (n ¼ 658)

No. of incident functional disability 191 191 238 228 245

Person-years 3321 3810 5102 5055 5178
Event/1000 person-years 57.5 50.1 46.7 45.1 47.3
Model 1b 1.00 (reference) 0.82 (0.67e1.00) 0.75 (0.62e0.91) 0.75 (0.62e0.90) 0.76 (0.63e0.91) 0.006
Model 2c 1.00 (reference) 0.78 (0.64e0.96) 0.74 (0.61e0.90) 0.69 (0.56e0.85) 0.69 (0.55e0.86) 0.001
Model 3d 1.00 (reference) 0.82 (0.66e1.01) 0.80 (0.65e0.98) 0.76 (0.61e0.95) 0.77 (0.61e0.98) 0.045
a
Analysis by Cox proportional hazards model.
b
Model 1 was adjusted for age (65e69, 70e74, 75e79, 80e84, or
85 years) and sex.
c
Model 2 was adjusted as for model 1 plus covariates in 1994, that is, BMI (<18.5, 18.5e25,
25 kg/m2, or missing), smoking status (current, former, never, or missing),
alcohol drinking (current, former, never, or missing), time spent walking (
1, 0.5e1, <0.5 h/d, or missing), energy intake (in kcal/d; sex-specific quintile categories, or missing),
history of disease (hypertension, diabetes, myocardial infarction, or stroke [yes, no; for each term]),the JDI score (<4, 4, 5, 6, or
7 points).
d
Model 3 was adjusted as for model 2 plus covariates in 2006, that is, BMI (<18.5, 18.5e25,
25 kg/m2, or missing), smoking status (current, former, never, or missing),
alcohol drinking (current, former, never, or missing), time spent walking (
1, 0.5e1, <0.5 h/d, or missing), energy intake (in kcal/d; sex-specific quintile categories, or missing),
history of disease (hypertension, diabetes, myocardial infarction, or stroke [yes, no; for each term]), education level (15, 16e18,
19 years, or missing), psychological distress
(<13,
13, or missing).

(0.61e0.98) for G5 (P-trend ¼ 0.045 in Model 3). This inverse as- To minimize the potential bias attributed to the complete case
sociation did not differ between the sexes (P-interaction ¼ 0.373 for analysis, we used the data for the JDI components after multiple
sex; data not shown). imputations. However, the inverse association trend across all
 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245 2243

groups did not change substantially (P-trend ¼ 0.031 in Model 3;
Supplemental Table 2).
In a stratified analysis by age in 1994 (<60 years and
60 years),
we observed that the largest increase (
þ2 points) in the JDI score
was associated with a lower risk of incident functional disability,
regardless of age; the corresponding multivariate-adjusted HRs
(95% CIs) were 0.67 (0.36e1.25) for <60 years and 0.80 (0.62e1.04)
for
60 years (Table 3).
In a stratified analysis by BMI in 1994 (<25.0 kg/m2 and

25.0 kg/m2), we observed that the largest increase (
þ2 points)
in the JDI score was associated with a lower risk of incident func-
tional disability, regardless of BMI; the corresponding multivariate-
adjusted HRs (95% CIs) were 0.88 (0.66e1.18) for <25.0 kg/m2 and
0.52 (0.33e0.82) for
25.0 kg/m2 (Table 3).
In a stratified analysis by the JDI score in 1994 (low, medium,
and high), we observed that the largest increase (
þ2 points) in the
JDI score was associated with a lower risk of incident functional
disability, regardless of the JDI score in 1994; the corresponding
multivariate-adjusted HRs (95% CIs) were 0.66 (0.33e1.33) for low
score, 0.63 (0.38e1.05) for medium score, and 0.82 (0.55e1.22) for
high score (Table 3).
In our analysis using the JDI score in 1994 as an exposure vari-
able, we did not observe an association with incident functional
disability (Supplemental Table 3).
To examine possible reverse causality, we excluded 160 partic-
ipants who experienced incident functional disability in the first 2
years of follow-up; the results tended to be similar. The
multivariate-adjusted HRs (95% CIs) (Model 3) were 1.00

Table 3
Association between changes in the JDI score and incident functional disability stratified by age, BMI, and the JDI score in 1994.d

Groups of change in the JDI score P-trend P-interaction

G1 G2 G3 G4 G5

Largest decrease Moderate decrease Relatively no change Moderate increase Largest increase

2 1 0 þ1
þ2

Age in 1994
<60 years
No. of participants 163 168 218 241 221
No. of incident functional disability 28 39 39 40 32
Modele 1.00 (reference) 1.25 (0.75e2.10) 0.94 (0.55e1.62) 0.83 (0.48e1.44) 0.67 (0.36e1.25) 0.080 0.332a

60 years
No. of participants 299 345 430 401 437
No. of incident functional disability 163 152 199 188 213
Modele 1.00 (reference) 0.74 (0.59e0.94) 0.76 (0.61e0.96) 0.75 (0.59e0.96) 0.80 (0.62e1.04) 0.208
BMI in 1994
<25.0 kg/m2
No. of participants 320 355 448 470 458
No. of incident functional disability 126 135 171 155 171
Modelf 1.00 (reference) 0.93 (0.72e1.20) 0.87 (0.68e1.12) 0.74 (0.57e0.97) 0.88 (0.66e1.18) 0.146 0.967b

25.0 kg/m2
No. of participants 134 151 188 158 184
No. of incident functional disability 62 53 63 65 64
Modelf 1.00 (reference) 0.67 (0.45e0.99) 0.62 (0.41e0.94) 0.71 (0.46e1.08) 0.52 (0.33e0.82) 0.024
The JDI score in 1994
Low (0, 1, 2, 3, and 4 points)
No. of participants 29 62 140 238 415
No. of incident functional disability 10 23 57 87 155
Modelg 1.00 (reference) 0.71 (0.32e1.57) 0.90 (0.44e1.85) 0.73 (0.36e1.48) 0.66 (0.33e1.33) 0.124 0.998c
Medium (5 points)
No. of participants 74 119 183 177 159
No. of incident functional disability 30 49 65 70 55
Modelg 1.00 (reference) 0.73 (0.44e1.21) 0.61 (0.37e0.99) 0.69 (0.43e1.12) 0.63 (0.38e1.05) 0.189
High (6, 7, 8, and 9 points)
No. of participants 359 332 325 227 84
No. of incident functional disability 151 119 116 71 35
Modelg 1.00 (reference) 0.83 (0.65e1.07) 0.80 (0.61e1.04) 0.73 (0.53e0.99) 0.82 (0.55e1.22) 0.067
a
P-interaction (age in 1994  change in the JDI score).
b
P-interaction (BMI in 1994  change in the JDI score).
c
P-interaction (the JDI score in 1994  change in the JDI score).
d
Analysis by Cox proportional hazards model.
e
Model was adjusted for age (65e69, 70e74, 75e79, 80e84, or
85 years) in 2006, sex, BMI (<18.5, 18.5e25,
25 kg/m2, or missing) in 1994 and 2006, smoking status
(current, former, never, or missing) in 1994 and 2006, alcohol drinking (current, former, never, or missing) in 1994 and 2006, time spent walking (
1, 0.5e1, <0.5 h/d, or
missing) in 1994 and 2006, energy intake (in kcal/d; sex-specific quintile categories, or missing) in 1994 and 2006, the JDI score (<4, 4, 5, 6, or
7 points) in 1994, history of
disease (hypertension, diabetes, myocardial infarction, or stroke [yes, no; for each term]) in 1994 and 2006, education level (15, 16e18,
19 years, or missing) in 2006,
psychological distress (<13,
13, or missing) in 2006.
f
Model was adjusted for age (65e69, 70e74, 75e79, 80e84, or
85 years) in 2006, sex, BMI (<18.5, 18.5e25,
25 kg/m2, or missing) in 2006, smoking status (current,
former, never, or missing) in 1994 and 2006, alcohol drinking (current, former, never, or missing) in 1994 and 2006, time spent walking (
1, 0.5e1, <0.5 h/d, or missing) in
1994 and 2006, energy intake (in kcal/d; sex-specific quintile categories, or missing) in 1994 and 2006, the JDI score (<4, 4, 5, 6, or
7 points) in 1994, history of disease
(hypertension, diabetes, myocardial infarction, or stroke [yes, no; for each term]) in 1994 and 2006, education level (15, 16e18,
19 years, or missing) in 2006, psychological
distress (<13,
13, or missing) in 2006.
g
Model was adjusted for age (65e69, 70e74, 75e79, 80e84, or
85 years) in 2006, sex, BMI (<18.5, 18.5e25,
25 kg/m2, or missing) in 1994 and 2006, smoking status
(current, former, never, or missing) in 1994 and 2006, alcohol drinking (current, former, never, or missing) in 1994 and 2006, time spent walking (
1, 0.5e1, <0.5 h/d, or
missing) in 1994 and 2006, energy intake (in kcal/d; sex-specific quintile categories, or missing) in 1994 and 2006, history of disease (hypertension, diabetes, myocardial
infarction, or stroke [yes, no; for each term]) in 1994 and 2006, education level (15, 16e18,
19 years, or missing) in 2006, psychological distress (<13,
13, or missing) in
2006.
2244 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245
(reference) for G1, 0.86 (0.68e1.09) for G2, 0.89 (0.71e1.11) for G3,
0.86 (0.68e1.10) for G4, and 0.89 (0.69e1.16) for G5 (P-
trend ¼ 0.502; data not shown). For the same reason (i.e., to
examine possible reverse causality), we also analyzed the associa-
tion after selecting 2438 participants whose self-rated health was
not poor (excellent, good, or fair) in 2006; however, the results did
not change substantially. The multivariate-adjusted HRs (95% CIs)
(Model 3) were 1.00 (reference) for G1, 0.80(0.63e1.02) for G2, 0.81
(0.64e1.02) for G3, 0.77 (0.60e0.99) for G4, and 0.74 (0.57e0.98)
for G5 (P-trend ¼ 0.059; data not shown).
4. Discussion
In this cohort study, we investigated the association between
changes in adherence to the Japanese diet and incident functional
disability. We observed that an improved JDI score over the 12-year
study period was significantly associated with a lower risk of
incident functional disability in older age in a dose-dependent
relationship. It is unlikely that the missing data for the JDI score
components would have been a potential source of bias because the
results did not change substantially when multiple imputation
analysis was conducted. In addition, even after excluding in-
dividuals whose self-rated health was poor at the 2006 survey, the
results were nearly the same.
The Japanese diet is characterized as involving high levels of
consumption of vegetables, fish, miso soup, seaweeds, and green
tea. These foods are known to be associated with a lower risk of
functional disability. For example, high levels of vegetable con-
sumption are associated with better functional health [21], and low
levels of fish consumption are associated with lower functional
mobility [22] and with a higher risk of Alzheimer's disease [23]. In
addition, miso soup [24] and seaweed [25] consumption have been
associated with a decreased risk of stroke and cerebrovascular
disease, and green tea intake with a lower risk of functional
disability and dementia [26,27]. Since higher adherence to the JDI
score means an increase in the consumption of these food items,
this change in the dietary pattern would lead to a decreased risk of
functional disability.
The Japanese dietary pattern has some characteristics in com-
mon with the Mediterranean diet, for instance, high levels of con-
sumption of vegetables, legumes, and fish, and reduced
consumption of meat. Therefore, the mechanism underlying the
association between improving adherence to the Japanese diet and
reducing the risk of incident functional disability might be similar
to that reported in previous studies of the Mediterranean diet
[5,6,28e32].
In the present study, we found that improved adherence to
the Japanese diet was associated with a lower risk of incident
functional disability regardless of age, BMI, or initial adherence
status.
In a stratified analysis by age in 1994, an inverse association with
incident functional disability was observed in both age groups. We
observed that the risk of disability decreased as the JDI score
improved among both groups (<60 years and
60 years). In the

60 years group, we observed a constant risk decline. These results
suggest that it is never too late to improve adherence to the Japa-
nese diet for healthy aging.
In a stratified analysis by BMI in 1994, an inverse association
with incident functional disability was observed in both BMI
groups, which suggests that improving adherence to the Japanese
diet is associated with a reduced risk of incident functional
disability, regardless of BMI status.
In a stratified analysis by the JDI score in 1994, the beneficial
effect of increasing adherence to the Japanese diet was verified in
all three groups. This finding suggests that regardless of the initial
score, improving adherence to the Japanese diet can have a bene-
ficial effect.
Additionally, in our analysis using the JDI score in 1994 as an
exposure variable, we did not observe an association with incident
functional disability; this result suggests the importance of
considering changes in dietary habits in regard to the association
between dietary habits and health outcomes.
To our knowledge, this is the first study to examine the associ-
ation between improved adherence to the Japanese diet and inci-
dent functional disability. Our study had a number of strengths.
First, we used a relatively large population-based cohort with 2923
older participants. Second, the follow-up rate was very high
(98.9%). Third, many confounding factors were taken into account
because lifestyle information was available at both time points.
However, this study also had several limitations. First, we did
not investigate the causes of functional disability in participants
who received LTCI certification. Therefore, the mechanism
responsible for the reduction of functional disability by
improving adherence to the Japanese diet remains unclear.
Second, because not all candidates applied for LTCI certification,
this study may not have been completely free from detection
bias. Third, although we adjusted for energy intake, which was
measured using a 39-item FFQ in both the 1994 and 2006 sur-
veys, it is difficult to measure energy intake using a short FFQ,
and our adjustments may therefore be insufficient. Fourth,
although we were able to adjust for many potential con-
founders, residual and unmeasured confounders such as income
[33e35] could not be completely ruled out.
In conclusion, the results of the present study indicate that
improved adherence to the Japanese diet is associated with a lower
risk of incident functional disability in older people in Japan. These
findings suggest that improving adherence to the Japanese diet
may have a preventive effect against functional disability in older
age, and that it is never too late to improve adherence to the Jap-
anese diet for healthy aging.
Funding
The present study was supported by the Project of the NARO
Bio-oriented Technology Research Advancement Institution
(advanced integration research for agriculture and interdisciplinary
fields) [grant number 17943029].
Statement of authorship
Sanae Matsuyama: Conceptualization, Formal analysis, Writing
e original draft.
Shu Zhang: Conceptualization, Formal analysis, Writing e re-
view & editing.
Yasutake Tomata: Conceptualization, Investigation, Writing e
review & editing.
Saho Abe: Writing e review & editing.
Fumiya Tanji: Writing e review & editing.
Yumi Sugawara: Writing e review & editing.
Ichiro Tsuji: Conceptualization, Funding acquisition, Investiga-
tion, Resources, Supervision, Writing e review & editing.
Conflicts of interest
None of the authors has any conflicts of interest to declare.
Acknowledgments
The authors would like to thank Yoshiko Nakata for her tech-
nical assistance.
 S. Matsuyama et al. / Clinical Nutrition 39 (2020) 2238e2245
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnu.2019.10.008.
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