Скачать презентацию How Has The National Policy To Prevent The Скачать презентацию How Has The National Policy To Prevent The

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How Has The National Policy To Prevent The Metabolic Syndrome Been Developed In The How Has The National Policy To Prevent The Metabolic Syndrome Been Developed In The Japanese Ministry Of Health? -To Facilitate The Healthier Longevity Society. At ECOSAC Regional Ministerial Meeting on Financing Strategies for Health Care 16 -18 March 2009 Colombo, Sri Lanka Kiyotaka SEGAMI, M. D. , Ph. D. Executive Board-Director Welfare and Medical Service Agency The former Minister’s counsel in health [email protected] ac. jp segami [email protected] go. jp

r he ns Ot cer n Co ns Co Oth n ce er r r he ns Ot cer n Co ns Co Oth n ce er r O t n he ce r rn s o er s th ern O c n Co Financial Concerns -Containment of -- Social Concerns -Better QOL Medical Concerns –Better Health Business Concerns -Finding Chances C Aging Population Issues Sustainability in Policy Feeling Not Unhappy, Not in Poverty among Citizen 28 Sept 06/ Segami, K

Depiction of Medical Expenditure Growth Increase of medical Expenditure A n a ly s Depiction of Medical Expenditure Growth Increase of medical Expenditure A n a ly s is o f fa c t o r s Increase of Medical Expenditure of the elderly is a Major Factor Aging of the population Per Capita Medical Expenditure of the Elderly 1. 5 ratio of elderly to non-elderly Large Variation of Per Capita Medical Expenditure for the elderly (Average 750, 000, Highest:900, 000, Lowest:600, 000) Increase of Inpatient Medical Expenditure per Patient Increase of Outpatient Medical Expenditure per Patient Large number of Beds (Long Average LOS) Prevalence of Lifestyle-related Disease in Outpatient Low Home Care Rate Increase of Patients with Life Style-Related Disease due to Visceral Obesity / Adipose Tissue

Japanese Trial in Various Methods of Controlling Medical Expenditure <Chronic> + Promotion of Home Japanese Trial in Various Methods of Controlling Medical Expenditure <Chronic> + Promotion of Home Care Improvement of Residence Other than Home Referral System at Discharge <Acute> Functional Specialization and Referral System According to Acute Phase, Rehab Phase, Nursing Care Phase and Home Care Phase of illness Decrease of Average Length of Stay   Reduce Admission Rate by Preventing the occurrence of Severe Diseases Outpatient Medical Expenditure Prevention of Lifestyle-Related Diseases (Medical Check-ups and Health Advice by Insurers etc. ) Reduce the incidence of diseases Home Visit for Patients with patients with duplicate care and Frequent Outpatient Visit Containment of Medical Expenditure Growth Inpatient Medical Expenditure Conversion of Long-term in-patients to Nursing Care Promotion of Terminal Care at Home

Control of Medical Expenditures involving All Stakeholders Patient (Insured) ・ Effort to Improve Lifestyle Control of Medical Expenditures involving All Stakeholders Patient (Insured) ・ Effort to Improve Lifestyle ・ Appropriate Physician Visit ・ Achieving Early Discharge, Reduction of he Number of Beds Providers ・ Creating Incentives for Patients to Pass Away at Home or Nursing Facilities by Improving Home Care Insurers National Government ・ Implementing Health Checkup and Health Education to Prevent Life-style Related Disease Effective Health Care Reduce Prevalence Rate of Life-style Related Disease Shorten average Length of Stay (LOS) Containment of Health Care Expenditures ・ Review of the universal fee schedule to produce effective health care ・ Budgetary steps for Prefectures to guide healthcare providers ・ Planning & implementing plan for Medical Prefectures Expenditures Control, and Health Promotion Planning, Health Care Planning, Long-term Care Insurance Planning Steps for Promoting Effective Health Care ・ Guidance of Municipalities ・ Promotion & Education of prevention of life-style related disease ・ Enhancing the provision of nursing care as a foundation of home care  

Development of Stages of Life-style Related Diseases and Medical Care Expenditure in 2004 Physical Development of Stages of Life-style Related Diseases and Medical Care Expenditure in 2004 Physical Inactivity Visceral Obesity Metabolic Syndrome 50% / Male 40 yrs+ 20% / Female Unhealthy Diet Smoking accelerates all stages of development and more damages Sleep Apnea Hypertension Diabetes 5, 939, 000 patients receive medical care Medical Exp: 8 Billion USD 2, 284, 000 p Med Exp: 12 B USD (7, 400, 000 Suspected + 8, 800, 000 Possible) Arteriosclerosis Cerebrovascular D. Ischemic H. D. 1, 374, 000 p Annual Death: 130, 000 Annual Occur: 234, 000 Med Exp: 17 B USD 911, 000 p Annual Death: 72, 000 Med Exp: 6. 8 B USD 47. 2 B USD Amputation from Diabetic Neuropathy Ann. Registry: 3, 000 Diabetic Nephropathy Vision Loss from Diabetic Retinopathy Ann. R. : 3, 000 Hemodialysis from Renal Failure (For Reference) Malignant Neoplasm 230, 000 p Annual Incr: 14, 000 Med Exp: 3. 4 B USD 1, 280, 000 p Annual Death: 305, 000 Med Exp: 21. 4 B USD

Medical Concerns on Hypertension Genetic Factor Insulin Resistance RAS Activity SNS Activity Salt Sensitivity Medical Concerns on Hypertension Genetic Factor Insulin Resistance RAS Activity SNS Activity Salt Sensitivity Drugs (30 -50% influence) Salt Intake Physical Inactivity Mental Stress Visceral Obesity Hypertension Cardiovascular/Renal Complications Status of the paralyzed after stroke Status of the sight-lost after retinal hemorrhage Life Style Modification Kamide K, et al. Jp Heat J 2004 Financial Concerns Numbers of Patients and Latent ones Cost of Medical Care Medical Expenditure in Future PREVENTION Public Health Approach Number and Status of Renal Failure and the Dialyzed Social Concerns

Status Quo: Hypertension in Japan • Receivers of medical services – 5, 939, 000 Status Quo: Hypertension in Japan • Receivers of medical services – 5, 939, 000 are under the medical care due to Hypertension. (2004) – 9. 2% of total “receivers” • Medical Expenditure for Hypertension – 946 BJY (=8, 085 MUSD) in 2004 • 19. 9% for Inpatient, 80. 1% for Outpatient – 7. 8% of Total Medical Expenditure (12, 106 BJY) • Latent Patients estimated – Patients are estimated 31, 000 – persons at risk are also estimated 20, 000 • Hypertension is not only the medical issue, but also the national financial one

Health adjusted Life Expectancy and Years Lost of Life Expectancy due to Hypertension Male Health adjusted Life Expectancy and Years Lost of Life Expectancy due to Hypertension Male 0 yrs 65 yrs 75 yrs 85 yrs Life Expectancy in 1995 77. 7 17. 6 10. 7 5. 8 Health Adjusted LE Hypertension 68. 3 16. 2 9. 4 4. 7 9. 4 1. 3 1. 1 Years Lost of Life Expectancy Female 0 yrs 65 yrs 75 yrs 85 yrs Life Expectancy in 1995 84. 6 22. 5 14. 2 7. 7 Health Adjusted LE Hypertension 77. 1 18. 7 12. 1 7. 6 7. 5 3. 8 2. 1 0. 1 Years Lost of Life Expectancy Segami, K(2006)

Life Table Analysis of Hypertension in Female Japanese Years of Life Lost from Hypertension Life Table Analysis of Hypertension in Female Japanese Years of Life Lost from Hypertension is 569, 237 personyears at 65 yrs of female. In other words, the differences of life expectancies are 3. 8 years from 22. 5 years at age 65. (From Life Table and Vital Statistics in 2000) By Segami, K 2006

Output: Suppressing increment of ME for the Elderly Health Promotion Suppressing Onset of Dis. Output: Suppressing increment of ME for the Elderly Health Promotion Suppressing Onset of Dis. Suppressing Aggravation of Dis. Medical expenditure per Capita Threshold of onset Risk Factors for Onset (Preventable) Total measures of controlling Visceral Obesity and Diabetes and other Risk Factors will cause suppressing the Medical Expenditure for the Elderly Aging (Preventive measures are effective for suppressing the Medical Expenditure of Diabetes, which will cause the complication after 25 yrs to 70% of patients. )

Depiction of Medical Expenditure Growth Necessity of Systematic Measures Countermeasures to Suppress Life Style Depiction of Medical Expenditure Growth Necessity of Systematic Measures Countermeasures to Suppress Life Style Related Diseases ①Spread of Integrated and Consistent Health Promotion by Insurers and Regional Officials (Significant is to increase their motivation. ) ②Complete and Efficient Medical Check ups (Based on evidence from mega cohort study. ) ③Individual Health Advice for High-Risk Groups (By well-trained Health Personnel. ) 1, 325 M USD to be allocated in 2007 Functional Specialization and Referral System of Medical Facility Acute Stage Rehabilitation Chronic Stage Home Care referral Nursing Care System Respect for Local Daily Activity of the elderly Systemic Approach to change Mechanism of delivery of Health Services

Schematic Image of Medical Coordination (in case of stroke) [Acute Illness] [Subacute/ Recovery Phase] Schematic Image of Medical Coordination (in case of stroke) [Acute Illness] [Subacute/ Recovery Phase] Community Emergency Care Services Rehab Function (Recovery Phase) (Transfer Coordination) Use of Longterm Care insurance (if necessary) (Discharge Coordination) (Referral (Care house, Coordination) Nursing home etc. ) (Discharge Coordination) Primary Care Function (Clinic, Hospital etc. ) Discharge Onset of Disease Living at Nursing Facility Care Function (Including Rehab) Discharge Home Care (Continuity care) Management, Education Living at Home Discharge

The theoretical understanding of the visceral obesity as the starting point of most of The theoretical understanding of the visceral obesity as the starting point of most of those diseases Countermeasures toward the more effective prevention of these diseases Insulin Resistance Diabetes Care 19, 287, 1996 Diabetes, Hyperlipidemia Left Ventricular Dysfunction Metabolism 36, 54, 1987 Am J Cardiol 64, 369, 1989 Bio-active Mediators from Adipose Tissue Visceral Obesity Hypertension 16, 484, 1990 Hypertension 27, 125, 1996 Coronary Diseases Atherosclerosis 107, 239, 1994 Int J Obesity 21, 580, 1997 Sleep Apnea J Int Med 241, 1997 All by Prof. Matsuzawa Y. et al With complimentary regards

Prevention of Onset and Progression of Lifestyle-Related Diseases High Blood Pressure High Blood sugar Prevention of Onset and Progression of Lifestyle-Related Diseases High Blood Pressure High Blood sugar High Blood Lipid ○High blood glucose, High blood pressure, Hyperlipidemia do not progress separately. These are like ”The tips of a single iceberg”. Visceral fat ○Medication (ex. Hypoglycemic agent) merely reduces the size of ”one tip of the iceberg”. Malfunction of Metabolism ○It is necessary to reduce the size of “whole iceberg” by improving life style, such as adherence to physical exercise and improved diet. Improvement of Life Style Adherence to physical exercise Increase of energy consumption, Cardiovascular activity Improved Diet ・Adherence to Exercise ・Improved Diet ・Quitting Smoking Reducing caloric intake, Balanced Nutrition Activation of Metabolism / Reduction of visceral fat (Good Hormone↑ , Bad Hormone↓ ) Continuation 1. Exercise 2. Diet Appropriate blood sugar, pressure, lipid Reduction in weight and waist circumference Feeling of Well Being    One medication merely reduces the size of one tip of iceberg. It does not cure the whole disease. Smaller Iceberg! 3. Non-Smoking   Drug is last resort

Comprehensive Implementation of Medical Expenditure Control 1. Ensuring a Balance between rising health care Comprehensive Implementation of Medical Expenditure Control 1. Ensuring a Balance between rising health care costs and the public financial burden Rising Health Care Costs Moderation in Health Care Cost in the mid-andlong term (Decrease the number of metabolic syndrome patients, at-risk group, decrease the Average Length of Stay etc. ) Review of the coverage policies of public health insurance etc. (Short-term Policies) Evaluate from both perspective Ensuring consistency with the New Health Promotion Plan, new Health Care Planning Incremental Effects Evaluate from an economic perspective Ensuring Secure and Reliable Health System Moderating Public Burden Present a clear estimate of medical spending in the future including mid-& long-term prospects for about 5 years = Use as a way to examine the rising health care costs after a certain period of time Examine the effectiveness of the control policies by comparing the estimated and actual costs Future review of policies

Comprehensive Implementation of Medical Expenditure Control 2. Promoting Plans for Medical Expenditures Control The Comprehensive Implementation of Medical Expenditure Control 2. Promoting Plans for Medical Expenditures Control The national government and prefectures must work together in; • Promulgating systematic measures to control medical expenditures, including of long-term hospitalization those regarding lifestyle-related disease prevention and those for rectifying the problem. (2) Taking steps to support plan implementation. Formulating such plans in a manner consistent with health promotion plans and long-term care insurance will ensure coordination between policy actions. (3) Conducting examinations to verify that the plan is being implemented. * Excerpt from Outline of Health Care Reform Policy

For Longevity and Healthier Life • Death is inevitable, but a life of protracted For Longevity and Healthier Life • Death is inevitable, but a life of protracted ill-health is not. • A half but most, in future, of cardiovascular diseases do/will not result in sudden death. • Rather, they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly. • Prevention and control of Cardiovascular disease helps people to keep longer and healthier lives.

The speaker appreciates your kind attention. See you soon. The speaker appreciates your kind attention. See you soon.

Something else • Lest of all, just for your sight…. Something else • Lest of all, just for your sight….

Status Quo: Cardiovascular diseases in Japan Background of policy-making toward the prevention of the Status Quo: Cardiovascular diseases in Japan Background of policy-making toward the prevention of the metabolic syndrome

Population, Birth, and Death in Japan In 2006 Population 12 7, 720 T Over Population, Birth, and Death in Japan In 2006 Population 12 7, 720 T Over 65 yrs 26, 400 T (20. 7%) Death est. 1, 600 T 3 20 0

Increment of Cardiovascular Deaths CVD + Stroke: 303, 000 and 28% of total deaths Increment of Cardiovascular Deaths CVD + Stroke: 303, 000 and 28% of total deaths in 2005 15. 9% 15. 5% 15. 3% 12. 5% 13. 8% CVD + Stroke:Inpatient 310 T、Outpatient 850 T Mal Neoplasm:Inpatient 140 T、Outpatient 110 T 30. 1% 31. 1% 30. 7% 41. 8% 40. 2%

Annual Incident rate of the first physician visits (per 100, 000) Annual Incident Rate Annual Incident rate of the first physician visits (per 100, 000) Annual Incident Rate of Cardiovascular Diseases

1 year after Cerebrovascular Events Death 48, 511(20. 7%) Annual Occurrence 234, 352 (100%)  1 year after Cerebrovascular Events Death 48, 511(20. 7%) Annual Occurrence 234, 352 (100%)  Alive 185, 841(79. 3%) To be decreased in future Institutionalized 13, 195(5. 6%) Bed-bound at Home 17, 469(7. 4%) Home help needed 30, 850(13. 2%) Independent(Partially) 67, 460(28. 8%) Recovery 57, 053(24. 3%) To be increased

Outline of Health Care Reform Policy (Government and Ruling Parties Council on Health Care Outline of Health Care Reform Policy (Government and Ruling Parties Council on Health Care Reform (December 1 st, 2005) Ⅰ Guiding Principles for the Reform 1. Ensuring safe and reliable healthcare while emphasizing prevention 2. Comprehensive Implementation of Cost Containment 3. Creating a new health insurance system accounting for the aging of society Ⅱ Ensuring safe and reliable healthcare while emphasizing prevention 1. Ensuring safe and reliable healthcare 2. Emphasizing prevention Ⅲ  Comprehensive Implementation of Cost Containment Ⅳ  Creating a new health insurance system accounting for the aging of society Ⅴ  Reviewing the universal fee-schedule etc. Ⅵ  Reform timing

Ⅱ. Ensuring safe and reliable healthcare while emphasizing prevention Basic structure Ⅱ - 1. Ⅱ. Ensuring safe and reliable healthcare while emphasizing prevention Basic structure Ⅱ - 1. Policy Outline “Ensuring Safe and Reliable Healthcare” → (1) Establishing a new structure capable of providing safe, secure and high-quality health care upon the consumers’ perspective Ⅱ - 2. of the Policy Outline “Prevention as a centerpiece” → (2) Establishing a new structure focused on prevention of lifestyle-related diseases

(1) Establishing a new structure capable of providing safe, secure and high-quality health care (1) Establishing a new structure capable of providing safe, secure and high-quality health care upon the consumers’ perspective - Enabling people to obtain sufficient healthcare information Assistance in healthcare decision-making by providing healthcare information - Information collection and release by prefectures --> Instituting a structure under which a medical institution can register its available healthcare service offerings with the prefecture, which then disseminates such information in an easy-to-understand way. - Clearly presenting to residents and patients at the regional level, in the form of a health care planning, the healthcare services which are available, as well as the details of inter-institution coordination. - Widening the range of information advertised. - Enabling people to receive safe and high-quality healthcare Provision of unfragmented healthcare by promoting specialization and coordinating provision of healthcare services - Establishing a system of regional healthcare coordination for respective fields of healthcare, such as stroke, cancer and pediatric emergency care, by reconsidering the health care planning. - Providing, within a system of regionally coordinated healthcare, unfragmented healthcare through the wider application of networked critical pathways. * Regional coordinated critical pathways A treatment plan up until a patient goes home after being treated in an acute-care hospital and then a rehabilitation hospital. Information-sharing between the patient and his or her medical institution leads to the provision of efficient and high -quality healthcare as well as the patient's peace of mind Ensuring appropriate healthcare provision even takes into account a patient’s care after discharge or transfer. - Enabling people to recover quickly and return home Improved quality of life (QOL) for patients through well-developed home healthcare services

Forecast of Medical Expenditure (Estimate based on reform plan, January 2006) FY 2006 (Budget) Forecast of Medical Expenditure (Estimate based on reform plan, January 2006) FY 2006 (Budget) Projection after reform 27. 5 (trillion) FY 2010 FY 2015 FY 2025 31. 2 37 48 (trillion) % of National Income 7. 3% 7. 4% ~ 7. 7% 8. 0% ~ 8. 5% 8. 8% ~ 9. 7% % of GDP 5. 4% ~ 5. 6% 5. 8% ~ 6. 1% 6. 4% ~ 7. 0% Without Reform (status quo) 28. 5 (trillion) 33. 2 40 (trillion) 56 (trillion) % of National Income 7. 6% 7. 9% ~ 8. 2% 8. 7% ~ 9. 2% 10. 3% ~ 11. 4% % of GDP 5. 5% 5. 8% ~ 5. 9% 6. 3% ~ 6. 6% 7. 5% ~ 8. 2% National Income 375. 6 (trillion) 403 ~ 420 (trillion) 432 ~ 461 (trillion) 492 ~ 540 (trillion) GDP 513. 9 (trillion) 558 ~ 576 (trillion) 601 ~ 634 (trillion) 684 ~ 742 (trillion) (Assumption of the estimate)  1. “Without Reform” refers to the projected expenditures under the current health insurance law with an unrevised universal fee schedule.    The increase of Medical Expenditure per capita is extrapolated from past data (2. 1% for people below 70 and 3. 2% for people above 70)  2. “After Reform” refers to the Budget in 2006 and when the revision of health insurance law etc. and the revision of the universal fee schedule are implemented  3. Nominal Economic Growth used in the calculation of National Income and GDP is based on two cases, “Basic Case” and “Risk Case”.   Both cases are using the same assumption of “Reform and Prospect 2005 (Draft)” (until 2011) and “Recalculation for Pension Finance 2004” (from 2012) Changes in Nominal Economic Growth 2006 2007 Basic Case 2. 0% 2. 5% Risk Case 2. 0% 1. 9% 2008 2. 9% 2. 1% 2009 3. 1% 2. 2% 2010 3. 1% 2011 3. 2% 2012~ 1. 6% 1. 3%

Status Quo: Diabetes in Japan Background of policy-making toward the prevention of the metabolic Status Quo: Diabetes in Japan Background of policy-making toward the prevention of the metabolic syndrome

Prevalence of Diabetes in Japan 40 Female Diabetes Suspected Diabetes Diagnosed 20〜 29 30〜 Prevalence of Diabetes in Japan 40 Female Diabetes Suspected Diabetes Diagnosed 20〜 29 30〜 39 Male 35 Prevalence Rate 30 25 20 15 10 5 0 40〜 49 Age 50〜 59 60〜 69 70〜 2002 Diabetes Survey by Ministry of Health

Mortality Rate from Renal Failure (per 100, 000 capita) Correlation between Physician Visits for Mortality Rate from Renal Failure (per 100, 000 capita) Correlation between Physician Visits for Diabetes and Mortality from Renal Failure (Correlation Coefficient: 0. 721) Incident Rate of the first Physician Visits from Diabetes (per 100, 000 capita)

Mortality Rate from Pneumonia (per 100, 000 capita) Correlation between Physician Visits for Diabetes Mortality Rate from Pneumonia (per 100, 000 capita) Correlation between Physician Visits for Diabetes and Mortality from Pneumonia (Correlation Coefficient: 0. 638) Incident Rate of the first Physician Visits from Diabetes (per 100, 000 capita)

Status Quo: Hypertension in Japan Background of policy-making toward the prevention of the metabolic Status Quo: Hypertension in Japan Background of policy-making toward the prevention of the metabolic syndrome

Status Quo: Hypertension in Japan • Receivers of medical services – 5, 939, 000 Status Quo: Hypertension in Japan • Receivers of medical services – 5, 939, 000 are under the medical care due to Hypertension. (2004) – 9. 2% of total “Patients”. • Medical Expenditure, burden of cardiovascular diseases – 946, 000, 000 JY (=8, 085 MUSD) in 2004 for Hypertension » 187, 9 BJP for Inpatient » 758, 1 BJP for Outpatient – 7. 8% of Total Medical Expenditure (12, 105, 600 MJY)

Mortality Rate of from Renal Failure (per 100, 000 capita) Correlation between Physician Visits Mortality Rate of from Renal Failure (per 100, 000 capita) Correlation between Physician Visits for Hypertension and Mortality from Renal Failure (Correlation Coefficient: 0. 753) Incident Rate of the first Physician Visits by Hypertension (per 100, 000 capita)

Mortality Rate from Cerebral Infarct (per 100, 000 capita) Correlation between Physician Visits for Mortality Rate from Cerebral Infarct (per 100, 000 capita) Correlation between Physician Visits for Hypertension and Mortality from Cerebral Infarct (Correlation Coefficient: 0. 653) Incident Rate of the first Physician Visits by Hypertension (per 100, 000 capita)

Decrease of Mortality in 5 years (1997 -2002) from Cerebral Hemorrhage Correlation between Physician Decrease of Mortality in 5 years (1997 -2002) from Cerebral Hemorrhage Correlation between Physician Visits for Hypertension And Decreases of Mortality in 5 years (1997 -2002) from Cerebral Hemorrhage and other minor Cerebral D. (Correlation Coefficient: -0. 327 ) Incidence of the first Physician Visits for Hypertension

Correlation among these diseases Background of policy-making toward the prevention of the metabolic syndrome Correlation among these diseases Background of policy-making toward the prevention of the metabolic syndrome

The prevention from the starting point as the most appropriate countermeasure Countermeasures toward the The prevention from the starting point as the most appropriate countermeasure Countermeasures toward the more effective prevention of these diseases • To prevent Visceral Obesity, Risk Factor Control by individual behavior changes; – Spread of Integrated and Consistent Health Promotion by Insurers and Regional Officials (Significant is to increase their motivation. ) – Complete and Efficient Medical Check ups (Based on evidence from mega cohort study. ) – Individual Health Advice for High-Risk Groups (By well-trained Health Personnel. ) • 1, 325 M USD to be allocated in 2007

What can we do as the population approach? What can we do as the population approach?

From the desk plan to the social movement The dawn of the national policy From the desk plan to the social movement The dawn of the national policy on Metabolic syndrome Group – Stepping in to the academic round-table conference on making the Japanese version of diagnostic standard of metabolic syndrome – The achievement of agreement among the high officials in the Ministry of Health on what -to-do – Involvement of the stakeholders – Discussions on the Ministerial Council – The appropriation to the budget compilation of the National Government and exploitation – To the deliberations on Congress

The dawn of the national policy on Metabolic syndrome Group • The characteristics of The dawn of the national policy on Metabolic syndrome Group • The characteristics of the Japanese version of metabolic syndrome: Abdominal perimeter Male: 85 cm, Female: 90 cm (From the employee based cohort study with MRI, only accomplished in Japan)