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Takase M, Yamada M, Nakamura T, Nakaya N, Kogure M, Hatanaka R, Nakaya K, Kanno I, Nochioka K, Tsuchiya N, Hirata T, Hamanaka Y, Sugawara J, Kobayashi T, Fuse N, Uruno A, Kodama EN, Kuriyama S, Tsuji I, Hozawa A. The Association of Lung Function and Carotid Intima-Media Thickness in a Japanese Population: The Tohoku Medical Megabank Community-Based Cohort Study. J Atheroscler Thromb 2023; 30:1022-1044. [PMID: 36328568 PMCID: PMC10406635 DOI: 10.5551/jat.63826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/21/2022] [Indexed: 08/04/2023] Open
Abstract
AIM Impaired lung function is associated with atherosclerotic vascular events. Carotid intima-media thickness (cIMT) is a marker for subclinical atherosclerosis. However, few studies have examined the association between lung function and cIMT among never smokers or individuals stratified by age. We investigated the association between lung function and cIMT in the Japanese population. METHODS We conducted a cross-sectional study of 3,716 men and 8,765 women aged 20 years or older living in Miyagi Prefecture, Japan. Lung function was evaluated using forced expiratory volume at 1 s (FEV1) and forced vital capacity (FVC) was measured using spirometry. The maximum common carotid artery was measured using high-resolution B-mode ultrasound. An analysis of covariance was used to assess associations between lung function and cIMT and adjusted for potential confounders. A linear trend test was conducted by scoring the categories from 1 (lowest) to 4 (highest) and entering the score as a continuous term in the regression model. RESULTS After adjusting for potential confounders including passive smoking, lower FEV1 and FVC were associated with higher cIMT in both men and women (P<0.001 for linear trend). This association was confirmed even when we restricted our study to never smokers. Furthermore, even when we stratified by age, an inverse association between lung function and cIMT was confirmed in middle-aged (40-64 years) and elderly participants (65-74 years). CONCLUSIONS Lower lung function was associated with higher cIMT in the Japanese population independent of age and smoking. Assessment of atherosclerosis or lung function may be required for individuals with lower lung function or atherosclerosis.
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Affiliation(s)
- Masato Takase
- Graduate School of Medicine, Tohoku University, Sendai, Japan
| | | | - Tomohiro Nakamura
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Naoki Nakaya
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Mana Kogure
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Rieko Hatanaka
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Kumi Nakaya
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Ikumi Kanno
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Kotaro Nochioka
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Tohoku University Hospital, Tohoku University, Sendai, Japan
| | - Naho Tsuchiya
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takumi Hirata
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Institute for Clinical and Translational Science, Nara Medical University, Nara, Japan
| | - Yohei Hamanaka
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Junichi Sugawara
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Tohoku University Hospital, Tohoku University, Sendai, Japan
| | - Tomoko Kobayashi
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Tohoku University Hospital, Tohoku University, Sendai, Japan
| | - Nobuo Fuse
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Akira Uruno
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Eiichi N Kodama
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Shinichi Kuriyama
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Ichiro Tsuji
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Atsushi Hozawa
- Graduate School of Medicine, Tohoku University, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
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Maitusong B, Laguzzi F, Strawbridge RJ, Baldassarre D, Veglia F, Humphries SE, Savonen K, Kurl S, Pirro M, Smit AJ, Giral P, Silveira A, Tremoli E, Hamsten A, de Faire U, Gigante B, Leander K. Cross-Sectional Gene-Smoking Interaction Analysis in Relation to Subclinical Atherosclerosis-Results From the IMPROVE Study. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2023; 16:236-247. [PMID: 37021583 PMCID: PMC10284137 DOI: 10.1161/circgen.122.003710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/29/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Smoking is associated with carotid intima-media thickness (C-IMT). However, knowledge about how genetics may influence this association is limited. We aimed to perform nonhypothesis driven gene-smoking interaction analyses to identify potential genetic variants, among those included in immune and metabolic platforms, that may modify the effect of smoking on carotid intima-media thickness. METHODS We used baseline data from 1551 men and 1700 women, aged 55 to 79, included in a European multi-center study. Carotid intima-media thickness maximum, the maximum of values measured at different locations of the carotid tree, was dichotomized with cut point values ≥75, respectively. Genetic data were retrieved through use of the Illumina Cardio-Metabo- and Immuno- Chips. Gene-smoking interactions were evaluated through calculations of Synergy index (S). After adjustments for multiple testing, P values of <2.4×10-7 for S were considered significant. The models were adjusted for age, sex, education, physical activity, type of diet, and population stratification. RESULTS Our screening of 207 586 SNPs available for analysis, resulted in the identification of 47 significant gene-smoking synergistic interactions in relation to carotid intima-media thickness maximum. Among the significant SNPs, 28 were in protein coding genes, 2 in noncoding RNA and the remaining 17 in intergenic regions. CONCLUSIONS Through nonhypothesis-driven analyses of gene-smoking interactions, several significant results were observed. These may stimulate further research on the role of specific genes in the process that determines the effect of smoking habits on the development of carotid atherosclerosis.
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Affiliation(s)
- Buamina Maitusong
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China (B.M.)
| | - Federica Laguzzi
- Unit of Cardiovascular & Nutritional Epidemiology, Institute of Environmental Medicine (F.L., U.d.F., K.L.), Karolinska Institutet, Stockholm, Sweden
| | - Rona J. Strawbridge
- Cardiovascular Medicine Unit, Department of Medicine Solna (R.J.S., B.G.), Karolinska Institutet, Stockholm, Sweden
- Mental Health & Wellbeing, Institute of Mental Health & Wellbeing, University of Glasgow (R.J.S.)
- Health Data Research, United Kingdom (R.J.S.)
| | - Damiano Baldassarre
- Department of Medical Biotechnology & Translational Medicine, Università degli Studi di Milano (D.B.)
- Centro Cardiologico Monzino, IRCCS, Milan, Italy (D.B., F.V., E.T.)
| | - Fabrizio Veglia
- Centro Cardiologico Monzino, IRCCS, Milan, Italy (D.B., F.V., E.T.)
| | - Steve E. Humphries
- Cardiovascular Genetics, Institute Cardiovascular Science, University College London, United Kingdom (S.E.H.)
| | - Kai Savonen
- Foundation for Research in Health Exercise & Nutrition, Kuopio & Research Institute of Exercise Medicine, Kuopio, Finland (K.S.)
- Department of Clinical Physiology & Nuclear Medicine, Kuopio University Hospital (K.S.)
| | - Sudhir Kurl
- Institute of Public Health & Clinical Nutrition, University of Eastern Finland, Kuopio (S.K.)
| | - Matteo Pirro
- Unit of Internal Medicine, Angiology & Arteriosclerosis Diseases, Department of Medicine, University of Perugia, Italy (M.P.)
| | - Andries J. Smit
- Department of Medicine, University Medical Center Groningen, the Netherlands (A.J.S.)
| | - Philippe Giral
- Unités de Prévention Cardiovasculaire, Assistance Publique-Hôpitaux de Paris, Service Endocrinologie-Métabolisme, Groupe Hospitalier Pitié-Salpétrière, France (P.G.)
| | - Angela Silveira
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet & Karolinska Hospital, Stockholm, Sweden (A.S., A.H.)
| | - Elena Tremoli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy (D.B., F.V., E.T.)
| | - Anders Hamsten
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet & Karolinska Hospital, Stockholm, Sweden (A.S., A.H.)
| | - Ulf de Faire
- Unit of Cardiovascular & Nutritional Epidemiology, Institute of Environmental Medicine (F.L., U.d.F., K.L.), Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Cardiovascular Medicine Unit, Department of Medicine Solna (R.J.S., B.G.), Karolinska Institutet, Stockholm, Sweden
| | - Karin Leander
- Unit of Cardiovascular & Nutritional Epidemiology, Institute of Environmental Medicine (F.L., U.d.F., K.L.), Karolinska Institutet, Stockholm, Sweden
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Sugiura T, Dohi Y, Takagi Y, Yokochi T, Yoshikane N, Suzuki K, Tomiishi T, Nagami T, Iwase M, Takase H, Ohte N, Seo Y. Increased Impact of Serum Uric Acid on Arterial Stiffness and Atherosclerosis in Females. J Atheroscler Thromb 2022; 29:1672-1691. [PMID: 35110425 DOI: 10.5551/jat.63368] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS Serum uric acid increases with metabolic disorders; however, whether the effects of uric acid on atherosclerosis are different in females and males has not been sufficiently evaluated. Therefore, this study compared the impact of uric acid on arterial stiffness and atherosclerosis between females and males. METHODS We enrolled 10196 untreated middle-aged subjects (46±8 years, 3021 females and 7175 males) who underwent periodic health check-ups. Serum uric acid levels were measured and arterial stiffness and atherosclerosis were assessed by the cardio-ankle vascular index (CAVI), carotid intima-media thickness (IMT), and plaque, using ultrasound imaging. RESULTS Females with increased arterial stiffness (CAVI ≥ 8.0) or carotid plaques had higher uric acid than those without (P<0.0001), but males did not. In multivariable regression analyses including overall participants, uric acid was significantly associated with the CAVI, where sex interacted with uric acid. In sex-specific analyses, uric acid was significantly associated with the CAVI, but not with carotid IMT, in both sexes. However, logistic regression analyses revealed that serum uric acid was independently associated with the presence of carotid plaques in females. The exclusion of subjects with abdominal obesity or metabolic syndrome from the analysis did not alter the results in females. CONCLUSIONS Serum uric acid was significantly associated with the CAVI in both sexes, but the interaction of sex was confirmed and associated with a carotid plaque only in females. These findings support the increased impact of serum uric acid on arterial stiffness and atherosclerosis in females.
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Affiliation(s)
- Tomonori Sugiura
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences.,Health Support Center WELPO, Toyota Motor Corporation
| | - Yasuaki Dohi
- Health Support Center WELPO, Toyota Motor Corporation.,Department of Internal Medicine, Faculty of Rehabilitation Sciences, Nagoya Gakuin University
| | - Yasuyuki Takagi
- Health Support Center WELPO, Toyota Motor Corporation.,Toyota Memorial Hospital
| | - Takashi Yokochi
- Health Support Center WELPO, Toyota Motor Corporation.,Midtown Clinic Meieki
| | | | - Kenji Suzuki
- Health Support Center WELPO, Toyota Motor Corporation
| | | | | | | | - Hiroyuki Takase
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences.,Department of Internal Medicine, Enshu Hospital
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
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4
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Sugiura T, Dohi Y, Takagi Y, Yokochi T, Yoshikane N, Suzuki K, Tomiishi T, Nagami T, Iwase M, Takase H, Seo Y, Ohte N. Examination of Large Artery Atherosclerosis could Reveal Small Artery Retinopathy in Untreated Middle-Aged Individuals. J Atheroscler Thromb 2022; 29:11-23. [PMID: 33239480 PMCID: PMC8737076 DOI: 10.5551/jat.59857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Small arteries can be visualized in the ocular fundus, and findings of retinopathy based on Scheie classification are often applied to evaluate the impact of hypertension and atherosclerosis. However, the relationship between damage in the large and small arteries has not been investigated sufficiently, especially in the early stages. The present study investigated possible associations between large artery atherosclerosis and small artery retinopathy in untreated middle-aged individuals. METHODS Untreated middle-aged workers undergoing periodic health check-ups (n=7,730, 45±8 years) were enrolled in this study. The absence or presence and extent of retinopathy were characterized by ophthalmologists as hypertensive (H0-4) and atherosclerotic grades (S0-4) based on Scheie classification. Large artery atherosclerosis was examined based on functional assessment of the cardio-ankle vascular index (CAVI) and morphological assessment of the carotid intima-media thickness (IMT) by ultrasound. RESULTS We found significant differences in CAVI and carotid IMT between individuals with and without hypertensive or atherosclerotic retinopathy. Multivariable regression analysis showed that the presence of hypertensive and atherosclerotic retinopathy was significantly associated with CAVI and carotid IMT. Logistic regression analysis with the endpoint of a hypertensive or atherosclerotic lesion revealed that CAVI and carotid IMT are independent determinants of retinopathy. CONCLUSIONS CAVI and carotid IMT were significantly associated with the presence of retinopathy based on Scheie classification in untreated middle-aged subjects, implying that atherosclerotic examination in large arteries could reveal early-stage small artery retinopathy.
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Affiliation(s)
- Tomonori Sugiura
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences.,Health Support Center WELPO, Toyota Motor Corporation
| | - Yasuaki Dohi
- Health Support Center WELPO, Toyota Motor Corporation.,Department of Internal Medicine, Faculty of Rehabilitation Sciences, Nagoya Gakuin University
| | - Yasuyuki Takagi
- Health Support Center WELPO, Toyota Motor Corporation.,Toyota Memorial Hospital
| | - Takashi Yokochi
- Health Support Center WELPO, Toyota Motor Corporation.,Midtown Clinic Meieki
| | | | - Kenji Suzuki
- Health Support Center WELPO, Toyota Motor Corporation
| | | | | | | | - Hiroyuki Takase
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences.,Department of Internal Medicine, Enshu Hospital
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
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5
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Wang TY, Chen HH, Su CH, Hsu SP, Ho CW, Hsieh MC, Lin CL, Kao CH. The Association Between Pleural Empyema and Peripheral Arterial Disease in Younger Patients: A Retrospective National Population-Based Cohort Study. Front Med (Lausanne) 2021; 8:621330. [PMID: 33869244 PMCID: PMC8044994 DOI: 10.3389/fmed.2021.621330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To investigate the relationship between pleural empyema (PE) and peripheral arterial disease (PAD). Methods: We conducted a retrospective cohort study using data from the National Health Institute Research Database. Univariable and multivariable Cox's proportional hazard regressions were performed to investigate the association between PE and the risk of PAD. Kaplan–Meier method and the differences were assessed using a log-rank test. Results: The overall incidence of PAD was higher in the PE cohort than in the non-PE cohort (2.76 vs. 1.72 per 1,000 person-years) with a crude hazard ratio (HR) of 1.61 [95% confidence interval (CI) = 1.41–1.83]. After adjustment for age, gender, and comorbidities, patients with PE were noted to be associated with an increased risk of PAD compared with those without PE [adjusted HR (aHR) = 1.18, 95% CI = 1.03–1.35]. Regarding the age-specific comparison between the PE and non-PE cohorts, PAD was noted to be significantly high in the ≤ 49 years age group (aHR = 5.34, 95% CI = 2.34–10.1). The incidence of PAD was higher in the first 2 years, with an aHR of 1.35 (95% CI = 1.09–1.68) for patients with PE compared with those without PE. Conclusion: The risk of PAD was higher if patients with PE were younger than 49 years and within the 2-year diagnosis of PE.
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Affiliation(s)
- Tzu-Yuan Wang
- Department of Internal Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Division of Endocrinology and Metabolism, China Medical University Hospital, Taichung, Taiwan
| | - Hsin-Hung Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asia University Hospital, Taichung, Taiwan.,School of Medicine, Institute of Medicine and Public Health, Chung Shan Medical University, Taichung, Taiwan.,Chung Sheng Clinic, Nantou, Taiwan
| | - Chun-Hung Su
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Sheng-Pang Hsu
- Division of Endocrinology and Metabolism, Department of Medicine, Everan Hospital, Taichung, Taiwan
| | - Chun-Wei Ho
- Intelligent Diabetes Metabolism and Exercise Center, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Chia Hsieh
- Intelligent Diabetes Metabolism and Exercise Center, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrative Medicine, China Medical University, Taichung, Taiwan.,Division of Clinical Nutrition, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences Science, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan.,Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan.,Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
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6
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Watanabe K, Onoue A, Omori H, Kubota K, Yoshida M, Katoh T. Association Between Airflow Limitation and Carotid Intima-Media Thickness in the Japanese Population. Int J Chron Obstruct Pulmon Dis 2021; 16:715-726. [PMID: 33776430 PMCID: PMC7989542 DOI: 10.2147/copd.s291477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/22/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE This study aimed to reveal the association between airflow limitation (AL) and carotid intima-media thickness (IMT) according to smoking status in Japan. SUBJECTS AND METHODS This cross-sectional study was performed in 2809 subjects, who underwent a comprehensive health examination with pulmonary function tests and carotid ultrasonographic measurement. AL was defined as forced expiratory volume in 1 s/forced vital capacity of <0.7. The subjects were divided into the following four groups: never smokers without AL, never smokers with AL, former/current smokers without AL, and former/current smokers with AL. Mean IMT, the maximum measurable IMT value in the left and right common carotid arteries (IMT-C max), and mean IMT-C max were measured by carotid ultrasonography. The carotid wall thickness as defined as follows: IMT ≥ 1.1 mm (IMT1.1), IMT-C max ≥ 1.2 mm (IMTc1.2), and IMT-C max > 1.5 mm (IMTc1.5), based on each measured region. The association between AL and the carotid wall thickness according to smoking status was assessed by logistic regression analysis. RESULTS The mean carotid IMT and mean IMT-C max were significantly higher in never smokers with AL and former/current smokers with or without AL than in never smokers without AL. In logistic regression models adjusted for sex, age, body mass index, hypertension, dyslipidemia, hyperglycemia, physical activity, and alcohol consumption, the risk of carotid wall thickness (IMT1.1 [odds ratio {OR}: 1.55; 95% confidence interval {CI}: 1.07-2.24]; IMTc1.2 [OR: 1.52; 95% CI: 1.03-2.24]; IMTc1.5 [OR: 1.99; 95% CI: 1.15-3.46]) were significantly higher in former/current smokers with AL than in never smokers without AL. CONCLUSION The present results suggest that greater IMT and risk of carotid wall thickness were associated with AL and smoking experience.
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Affiliation(s)
- Kazuhiko Watanabe
- Department of Public Health, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Ayumi Onoue
- Department of Biomedical Laboratory Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisamitsu Omori
- Department of Biomedical Laboratory Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Kubota
- Japanese Red Cross Kumamoto Health Care Center, Kumamoto, Japan
| | - Minoru Yoshida
- Japanese Red Cross Kumamoto Health Care Center, Kumamoto, Japan
| | - Takahiko Katoh
- Department of Public Health, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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