National policies and action plans in the health and sports sectors to promote physical activity in Japan
– Written by Yukio Oida, Japan
There is substantial evidence about the importance of physical activity in the prevention of non-communicable diseases and the promotion of health and well-being. However, many people are not performing an adequate amount of physical activity. In fact, the percentage of Japanese adults that exercises regularly is approximately 30% (an ‘exercise habit’ is defined as three times or more per week). Effective measures for solving this problem include government decision-making and the implementation of national and local policies and actions. Research on policies to promote physical activity has been conducted in recent years and information about how the national policy was decided upon and how the action plan was implemented is being collected1-3. The purpose of this paper is to outline national policies and action plans to promote physical activity in Japan.
JAPANESE POLITICAL SYSTEM
The Japanese government has 17 ministries. The government agencies that have primary responsibility for policies concerning physical activity promotion at the national level are the Ministry of Health, Labour and Welfare (MHLW) and the Ministry of Education, Culture, Sports, Science and Technology (MEXT). One of the missions of the MHLW is to increase the physical activity of the nation as a preventive measure against non-communicable diseases. The mission of the MEXT is to implement physical education and recreational sports programmes.
The Constitution of Japan has defined local autonomy. There are two types of local governments. The first type, prefectures, was formed by dividing the entire country into 47 areas. They are broad-based, self-governing bodies. The second type consists of 1747 cities, towns and villages, located within the prefectures. The national government decides issues of national importance and local governments implement those policies in each region. In other words, the Japanese political system is a centralised one.
LEGISLATION AND NATIONAL POLICY
In the health sector, the formulation of health promotion policies4 by the MHLW began in 1978 and processes related to past policies are presented in Table 1. The purposes of the first and second policies, including their strategies for managing high-risk populations and the target areas are almost the same. A point of difference is that the second policy focused on the implementation of physical activity. The third policy (Healthy Japan 21, 1st phase; HJ21–1st) was introduced in 2000 and continued until 2012. It was very different from previous policies. The population strategy was added to the conventional high-risk strategy. Under HJ21–1st, two laws were developed to support its implementation. The first was the Health Promotion law, which required all local governments to develop and implement an action plan according to the existing conditions of each region. Each prefecture was required to strengthen its cooperation with organisations concerned with the health sectors of cities within the prefecture. The organisations included those concerned with medical insurance, school hygiene and occupational health. The other legislation was the Specific Health Checkup and Health Guidance laws, which obligated medical insurers of unions of all local governments and companies to help prevent arteriosclerosis in all members (aged 40 to 74 years) of public medical insurance organisations. The people judged to be at high-risk of arteriosclerosis based on the health check-up had to receive instruction and counselling on physical activity and nutrition to improve their health status. The diagnostic criteria for high-risk arteriosclerosis included visceral fat obesity (abdominal circumference of 85 cm and above in males; 90 cm and above in females), plus two or more of the following health issues: dyslipidaemia, hypertension and hyperglycaemia. In 2013, the MHLW formulated its fourth policy (Healthy Japan 21, 2nd phase; HJ21–2nd) based on the Health Promotion legislation5. The policies of the first and second phases were almost the same. The purpose of the policy was to promote public health and prevent disease; it covered nine specific areas relating to non-communicable diseases and the lifestyle issues that can cause them. Among the issues were diet and nutrition, physical activity and exercise, leisure and mental health, smoking, alcohol, dental health, diabetes, cardiovascular disease and cancer. Different measures were outlined for each area with the incorporation of physical activity into a broad public health policy.
In the sports sector, the MEXT formula-ted the Basic Plan for the Promotion of Sports based on the Basic Act on Sports6. The goal is to develop the infrastructure required to promote sports, such as nurturing coaches, improving sports facilities, enriching physical education in schools and promoting international exchanges and contributions. It also creates environments to secure sports opportunities (e.g. sports promotion in the local community and organisation and encouragement of sports events) and enhances competition standards. The policy attempts to promote sport-related measures in a comprehensive and strategic manner.
In the health sector, the target behaviour of HJ21–2nd is an increase of approximately 1500 in the number of steps walked by each person per day on average from 2013 to 2022. For males aged 20 to 64 years, the target behaviour is an increase in the number of steps per day from 7841 to 9000 and, for females, from 6883 to 8500. For males over 65 years of age, the goal is to increase the number of steps per day from 5628 to 7000 and, for females, from 4584 to 6000. Other goals are to increase the number of adults with regular exercise habits by 10% in 10 years. The term ‘exercise habit’ was defined as at least 30 minutes, twice a week, for 1 year. For individuals aged 20 to 64 years, the goal is to increase the percentage of males partaking in regular exercise from 26.3 to 36.0% and, in females, from 22.9 to 33.0%. The percentage of males over 65 years of age that exercises regularly has increased from 47.6 to 58.0% and the percentage of females, from 37.6 to 48.0%. Further, the goal for the municipality is to improve the environment through better city planning to facilitate physical activity and exercise.
In the sports sector, one measure outlined in the Basic Plan for the Promotion of Sports was to increase the rate of sports participation among adults. However, quantitative goals to measure the attainment of this target have not been developed.
GUIDELINES ON PHYSICAL ACTIVITY FOR HEALTH PROMOTION
The MHLW guidelines7 were announced in 2013. They were based on the results of a systematic review and meta-analysis of domestic and foreign evidence of an association between physical activity/exercise and lifestyle-related diseases. Two sets of standards were formulated: one set targeted adults 18 to 64 years old and, the other, those aged 65 years and above. The guideline for adults 18 to 64 years old is 23 metabolic equivalents (METs) per hour per week, including 4 METs per hour per week of active exercise at an intensity of over 3 METs. This guideline specifies 60 minutes of walking or physical activity every day at an equal or greater intensity than walking. For adults 65 years or older, the recommendation is for 10 METs per hour per week. This guideline specifies 40 minutes every day of physical activity with an intensity of less than 3 METs. There was no standard for those under 18 years of age because the evidence was insufficient. The MHLW encouraged increasing individuals’ physical activity by 10 minutes. A current campaign with the slogan The Plus 10 aims to encourage this activity8.
In the sports sector, the MEXT announced that as part of the physical activity guidelines for children (kindergarten through elementary school), more than 60 minutes of physical activity should be provided daily.
Since 1947, the National Health and Nutrition Survey9 has been conducted annually by the MHLW. This survey, based on the Health Promotion law, attempts to determine the current state of health, food intake, nutritional intake and lifestyle of the Japanese people and to obtain basic data to implement effective measures for health. The questionnaire’s items include exercise habits – defined as 30 minutes of walking twice a week for 1 year, with the number of daily steps measured by a pedometer. There are 900,000 districts in the entire country; 5000 districts were chosen by cluster random sampling. Each district comprised one unit and one unit consisted of approximately 20 households. Three hundred units were sampled randomly from the 5000 districts. The participants of this survey consisted of approximately 6000 households (20,000 people). There was no age limit.
In the sports sector, the MEXT has been conducting an annual survey since 1964 to determine the current state of fitness or exercise capacity of Japanese people aged 6 to 79 years. In addition, the MEXT has been conducting surveys to determine the physical fitness levels of Japanese children in elementary (Grade 5) and junior high school (Grade 2), since 2008.
OUTCOMES OF THE INTERVENTIONS OF THE NATIONAL POLICY HJ21–1ST
The goals for physical activity in HJ21–1st were to increase walking steps and increase the percentage of adults engaged in regular exercise. However, the mean number of steps has decreased by approximately 1000 steps per day 10 years after baseline. The percentage of people in the working population between the ages of 20 and 60 years undertaking regular exercise has decreased, but for those older than 60 years of age, it has increased. These results suggest that the number of steps other than exercise has decreased. The action plan for physical activity promotion existed in all prefectures within several years after the national policy was enforced. Nevertheless, the amount of physical activity did not increase nationwide. It is speculated that there are problems in the process of developing a national policy and implementing action plans in each municipality. However, the reasons are not certain and further study is required.
APPRAISAL OF THE NATIONAL POLICY FOR THE PROMOTION OF PHYSICAL ACTIVITY
The working group on national approaches to physical activity promotion in HEPA (Health-enhancing Physical Activity) Europe developed a policy audit tool (PAT) for physical activity promotion10. The purpose of developing the PAT was to take a general view of the policies in each section on physical activity. The PAT consists of three sections and 27 items. The first section pertains to political structure and history, the second section covers the content and development process of the national physical activity policy and the third describes the experience of implementing the policy. The policies of seven countries in Europe have been compared using this tool11.
It is very important to audit national policy in order to develop future policies and implement action plans. We tried to assess the policy for physical activity in Japan using the PAT. However, we were not able to clarify the items concerning the implementation of the regional plan. In Japan, research concerning the development of the national policy on physical activity is a new field. Assessing the progress, capacity and challenges of policy implementation at the local level will provide valuable feedback to the national planning process for the promotion of physical activity in Japan. Further, it is necessary to include in the analysis the policies of other sectors such as education, transport, urban design and environment.
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Ministry of Health, Labour and Welfare. Measures for national health promotion. From http://www.mhlw.go.jp/english/wp/wp-hw2/part2/p3_0024.pdf Accessed October 2014.
Ministry of Health, Labour and Welfare. Healthy Japan 21, 2nd phase. From http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000047330.pdf Accessed October 2014.
Ministry of Education, Culture, Sports, Science and Technology. The Sport Basic Plan. From http://www.mext.go.jp/component/a_menu/sports/detail/__icsFiles/afieldfile/2012/08/08/1319359_5_2_1.pdf Accessed October 2014.
National Institute of Health and Nutrition. Exercise and Physical Activity Reference for Health Promotion (EPAR), 2013. From http://www0.nih.go.jp/eiken/english/research/program_exercise.html Accessed October 2014.
National Institute of Health and Nutrition. Active Guide 2013. From http://www0.nih.go.jp/eiken/english/research/pdf/active_guide2013.pdf Accessed October 2014.
National Institute of Health and Nutrition. National Health and Nutrition Survey. From http://www0.nih.go.jp/eiken/english/research/project_nhns.html Accessed October 2014.
Bull F, Milton K, Kahlmeier S. Health-enhancing physical activity (HEPA) policy audit tool. WHO Regional Office for Europe, Copenhagen 2011. From http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/publications/2011/health-enhancing-physical-activity-hepa-policy-audit-tool Accessed October 2014.
Bull F, Milton K, Kahlmeier S, Arlotti A, Jurican AB, Belander O et al. Turning the tide: national policy approaches to increasing physical activity in seven European countries. Br J Sport Med 2014 [Epub ahead of print].
Yukio Oida Ph.D.
School of Engineering
Image by Jeff Boyd