Professional Documents
Culture Documents
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 causespecific 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
Introduction
Negative psychological factors, such as depression,
anxiety, hopelessness, psychological stress, and psychologi-
68
benefit of being alive. It is also understood to be a comprehensive concept including not only pleasure and
happiness but also the meaning of one's life and selfrealization. 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.
69
Table 1
Selected baseline characteristics of the subjects according to ikigai by sex
Men
No. of subjects
Age (years),* mean (S.D.)
BMI (kg/m2),* mean (S.D.)
Smoking (%)
Current
Past
Never
Missing data
Drinking (%)
Current
Past
Never
Missing data
Physical activity (%)
Exercise N1 h/week
Rarely
Missing data
Sleep duration (%)
b7 h
78.9 h
9 h
Missing data
Education (%)
Primary or junior high school
High school
College or higher education
Missing data
Job status (%)
Full-time
Part-time or unemployed
Missing data
Marital status (%)
Living with a spouse
Single, divorced, or widowed
Missing data
Perceived mental stress level (%)
High
Middle
Low
Missing data
Medical history (%)
Hypertension
Diabetes
Women
With ikigai
Without ikigai
15,390
56.8 (10.2)
22.8 (2.8)
14,765
57.3 (10.2)
22.5 (2.8)
50.9
24.2
21.0
3.9
52.3
24.2
19.0
4.5
74.7
5.0
16.6
3.8
71.1
6.4
18.3
4.2
35.9
60.2
4.0
24.9
70.1
4.9
16.7
70.6
9.9
2.7
16.0
68.4
12.0
3.7
27.0
43.1
19.5
10.4
35.9
40.3
13.4
10.4
73.0
19.1
7.9
65.5
27.2
7.3
89.0
4.3
6.7
83.7
7.3
9.0
23.0
55.2
20.5
1.2
22.1
64.1
12.2
1.6
17.9
6.0
19.3
6.1
P values
b.001
b.001
b.001
With ikigai
Without ikigai
18,353
56.8 (9.8)
23.1 (3.1)
24,764
57.8 (10.1)
22.9 (3.2)
4.6
1.2
83.6
10.6
4.7
1.3
81.8
12.2
24.7
1.6
67.4
6.3
20.1
1.6
70.5
7.7
27.7
66.5
5.8
18.2
74.9
6.9
27.8
62.9
5.3
4.0
26.4
62.0
6.8
4.7
27.1
49.8
11.6
11.6
37.4
44.4
7.7
10.4
32.8
57.5
9.7
27.3
65.0
7.7
78.9
14.1
7.0
74.0
15.7
10.3
18.0
56.9
24.0
1.1
20.9
65.2
11.8
2.1
19.2
3.2
21.1
3.8
b.001
b.001
b.001
b.001
b.001
b.001
b.001
b.001
b.001
b.001
.001
.534
b.001
b.001
.295
b.001
b.001
b.001
P values
b.001
P values were estimated (*) by the t test and () by the chi-squared test, with the exception of missing data.
b.001
b.001
70
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, cerebrovascular 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
No. of subjects
No. of person-years
All causes
No. of cases
Age-adjusted HR
Multivariate HR
Cancer
No. of cases
Age-adjusted HR
Multivariate HR
Cardiovascular disease
No. of cases
Age-adjusted HR
Multivariate HR
Coronary heart disease
No. of cases
Age-adjusted HR
Multivariate HR
Cerebrovascular disease
No. of cases
Age-adjusted HR
Multivariate HR
External causes
No. of cases
Age-adjusted HR
Multivariate HR
Women
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
14,765
71,307
15,390
74,903
13,683
176,929
14,486
190,490
24,764
121,331
18,353
90,355
23,669
308,196
17,758
233,114
851
1.0
1.0
616
2355
0.71 (0.640.79) 1.0
0.80 (0.720.89) 1.0
2033
623
0.79 (0.740.84) 1.0
0.85 (0.800.90) 1.0
303
2021
0.73 (0.630.83) 1.0
0.80 (0.690.92) 1.0
1219
0.87 (0.810.94)
0.93 (0.861.00)
337
1.0
1.0
279
870
0.81 (0.690.95) 1.0
0.88 (0.741.03) 1.0
890
238
0.94 (0.851.03) 1.0
0.99 (0.901.09) 1.0
124
595
0.76 (0.610.94) 1.0
0.77 (0.620.97) 1.0
464
1.09 (0.971.23)
1.11 (0.981.26)
232
1.0
1.0
164
641
0.70 (0.570.85) 1.0
0.78 (0.640.96) 1.0
562
206
0.80 (0.710.89) 1.0
0.86 (0.760.97) 1.0
105
696
0.78 (0.620.99) 1.0
0.92 (0.721.17) 1.0
398
0.85 (0.750.96)
0.94 (0.831.07)
47
1.0
1.0
31
144
0.65 (0.411.03) 1.0
0.68 (0.421.08) 1.0
134
33
0.85 (0.671.07) 1.0
0.94 (0.741.20) 1.0
17
148
0.81 (0.451.45) 1.0
1.02 (0.561.88) 1.0
75
0.76 (0.581.01)
0.83 (0.621.11)
91
1.0
1.0
59
303
0.64 (0.460.88) 1.0
0.72 (0.511.01) 1.0
271
99
0.81 (0.690.96) 1.0
0.87 (0.731.03) 1.0
47
321
0.72 (0.511.02) 1.0
0.91 (0.641.31) 1.0
181
0.84 (0.701.00)
0.90 (0.741.08)
66
1.0
1.0
47
185
0.69 (0.471.00) 1.0
0.79 (0.541.16) 1.0
132
48
0.66 (0.530.82) 1.0
0.74 (0.590.93) 1.0
24
180
0.71 (0.431.16) 1.0
0.80 (0.481.33) 1.0
79
0.61 (0.470.80)
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.
71
Table 3
Age group-specific multivariate-adjusted HRs and their 95% CIs according to ikigai by sex
Men
Women
4064 years
No. of subjects
No. of person-years
All causes
No. of cases
Multivariate HR
Cancer
No. of cases
Multivariate HR
Cardiovascular disease
No. of cases
Multivariate HR
Coronary heart disease
No. of cases
Multivariate HR
Cerebrovascular disease
No. of cases
Multivariate HR
External causes
No. of cases
Multivariate HR
6579 years
4064 years
6579 years
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
Without
ikigai
With
ikigai
10,564
140,698
11,240
151,508
3119
36,231
3246
38,982
17,524
233,505
13,715
183,591
6145
74,691
4043
49,523
1092
1.0
957
1263
0.88 (0.810.97) 1.0
1076
701
0.81 (0.750.89) 1.0
509
1320
0.99 (0.881.12) 1.0
710
0.89 (0.810.98)
504
1.0
504
366
0.99 (0.871.12) 1.0
386
312
1.00 (0.861.16) 1.0
256
283
1.06 (0.901.26) 1.0
208
1.18 (0.981.43)
247
1.0
219
394
0.91 (0.751.10) 1.0
343
172
0.83 (0.720.97) 1.0
119
524
1.03 (0.811.31) 1.0
279
0.91 (0.781.06)
59
1.0
59
85
1.04 (0.721.51) 1.0
75
33
0.87 (0.631.21) 1.0
17
58
0.76 (0.421.39) 1.0
50
0.86 (0.621.19)
118
1.0
99
185
0.84 (0.641.11) 1.0
172
78
0.89 (0.721.11) 1.0
57
243
1.02 (0.711.45) 1.0
124
0.86 (0.691.08)
117
1.0
86
68
0.77 (0.581.02) 1.0
46
88
0.70 (0.471.03) 1.0
55
92
0.92 (0.651.31) 1.0
24
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
sexes in the short-term follow-up; however, these associations 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 interaction 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. Middleaged 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 middleaged 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
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 crosssectional 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 mechanisms underlying the preventive effects of positive psychological 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
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 University 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 Kurozawa, 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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