論文 - 野村　周平

Correction to: Tracking Japan’s development assistance for health, 2012–2016 (Globalization and Health, (2020), 16, 1, (32), 10.1186/s12992-020-00559-2)

Nomura S., Sakamoto H., Sugai M.K., Nakamura H., Maruyama-Sakurai K., Lee S., Ishizuka A., Shibuya K.

Globalization and Health （BioMed Central Ltd）  17 （ 1 ）  2021年12月

ISSN  1744-8603

　概要を見る

Following publication of the original article [1], the authors reported a conversion error that concerned the estimated amounts of development assistance for health (DAH) for 2012–2015; when the authors converted the current prices of 2012–2015 to the constant prices of 2016 using the gross domestic product (GDP) deflator, they erroneously multiplied the current prices by the GDP deflator instead of dividing them. Please find the details of this error in this correction. Firstly, the ‘Results’ in the article’s Abstract stated that “Japan’s DAH was estimated at 1,472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016”, while it should state that “Japan’s DAH was estimated at 853.87 (2012), 718.16 (2013), 824.95 (2014), 873.04 (2015), and 894.57 million USD (2016) in constant prices of 2016”. Secondly, the first sentence of the article’s Results section stated that “Japan’s DAH was estimated at 1, 472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016”, while it should state that “Japan’s DAH was estimated at 853.87 (2012), 718.16 (2013), 824.95 (2014), 873.04 (2015), and 894.57 million USD (2016) in constant prices of 2016”. In addition to the above mentioned parts of the article, the conversion error affected Table 1, Fig. 1a, Fig. 2a, and Additional file 2, for the data of 2012–2015; please find (the corrected version of) these files in this correction. The errors have now been corrected in the original article. Furthermore, the authors would like to assure the reader that the discussions proposed in their article were based on the part of the results not related to the conversion by the GBD deflator (i.e. percentage value rather than amount) and, therefore, that the miscalculated amounts of DAH mentioned above do not affect the interpretation or conclusions of the study. The authors thank you for reading this correction, and apologize for any inconvenience caused.

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A prospective evaluation of AI-augmented epidemiology to forecast COVID-19 in the USA and Japan

Arık S., Shor J., Sinha R., Yoon J., Ledsam J.R., Le L.T., Dusenberry M.W., Yoder N.C., Popendorf K., Epshteyn A., Euphrosine J., Kanal E., Jones I., Li C.L., Luan B., Mckenna J., Menon V., Singh S., Sun M., Ravi A.S., Zhang L., Sava D., Cunningham K., Kayama H., Tsai T., Yoneoka D., Nomura S., Miyata H., Pfister T.

npj Digital Medicine （Springer Science and Business Media {LLC}）  4 （ 1 ） 146 - 146 2021年12月

査読有り,  ISSN  2398-6352

　概要を見る

The COVID-19 pandemic has highlighted the global need for reliable models of disease spread. We propose an AI-augmented forecast modeling framework that provides daily predictions of the expected number of confirmed COVID-19 deaths, cases, and hospitalizations during the following 4 weeks. We present an international, prospective evaluation of our models’ performance across all states and counties in the USA and prefectures in Japan. Nationally, incident mean absolute percentage error (MAPE) for predicting COVID-19 associated deaths during prospective deployment remained consistently <8% (US) and <29% (Japan), while cumulative MAPE remained <2% (US) and <10% (Japan). We show that our models perform well even during periods of considerable change in population behavior, and are robust to demographic differences across different geographic locations. We further demonstrate that our framework provides meaningful explanatory insights with the models accurately adapting to local and national policy interventions. Our framework enables counterfactual simulations, which indicate continuing Non-Pharmaceutical Interventions alongside vaccinations is essential for faster recovery from the pandemic, delaying the application of interventions has a detrimental effect, and allow exploration of the consequences of different vaccination strategies. The COVID-19 pandemic remains a global emergency. In the face of substantial challenges ahead, the approach presented here has the potential to inform critical decisions.

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Analysis of the relationship between the HbA1c screening results and the development and worsening of diabetes among adults aged over 40 years: a 4-year follow-up study of 140,000 people in Japan – the Shizuoka study

Nomura S., Sakamoto H., Rauniyar S.K., Shimada K., Yamamoto H., Kohsaka S., Ichihara N., Kumamaru H., Miyata H.

BMC Public Health （Springer Science and Business Media {LLC}）  21 （ 1 ） 1880 - 1880 2021年12月

査読有り,  ISSN  1471-2458

　概要を見る

Background: Hemoglobin A1c (HbA1c) levels are routinely measured during health check-ups and are used as an indicator of glycemic control in Japan. However, only a few studies have followed up individuals to assess the risk of diabetes development and worsening based on HbA1c screening results. This study evaluated the relationship between HbA1c screening results and the risk of diabetes development and worsening. Methods: Data were collected from the Shizuoka Kokuho Database, a Japanese administrative claims database of insured individuals aged > 40 years. We included individuals available for follow-up from April 2012 to March 2018 who had not received any diabetes treatment before March 2014. HbA1c screening results were categorized into 4 groups based on the HbA1c levels at the 2012 and 2013 health check-ups: group A, those whose HbA1c levels were < 6.5% in 2012 and 2013; group B, those whose HbA1c levels > 6.5% in 2012 but < 6.5% in 2013; group C, those whose HbA1c levels were > 6.5% in 2012 and 2013; and group D, those whose HbA1c levels were < 6.5% in 2012 and > 6.5% in 2013. Logistic regression models were used to analyze diabetes development and worsening, defined as the initiation of diabetes treatment by March 2018 and the use of injection drugs by participants who initiated diabetes treatment by March 2018. Results: Overall, 137,852 individuals were analyzed. After adjusting for covariates, compared with group A, group B was more likely to initiate treatment within 4 years (odds ratio: 22.64; 95% confidence interval: 14.66–34.99). In patients who initiated diabetes treatment by March 2018, injection drugs were less likely used by group D than by group A (odds ratio: 0.28; 95% confidence interval: 0.12–0.61). Conclusions: Our study suggests that although HbA1c levels measured during health check-ups were correlated with the risk of diabetes development and worsening, HbA1c levels in a single year may not necessarily provide sufficient information to consider these future risks.

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Age-appropriate vaccination coverage and its determinants in children aged 12–36 months in Nepal: a national and subnational assessment

Rauniyar S.K., Iwaki Y., Yoneoka D., Hashizume M., Nomura S.

BMC Public Health （Springer Science and Business Media LLC）  21 （ 1 ） 2063 - 2063 2021年12月

査読有り

　概要を見る

Background: Vaccination is one of the effective ways to develop immunity against potential life-threatening diseases in children in early age. This study is focused on analysing the age-appropriate vaccination coverage at national and subnational levels and identify the factors associated with age-appropriate coverage in Nepal. Methods: 460 children aged 12–36 months were included in the study. The data was obtained from Nepal Demographic and Health Survey (NDHS) 2016–17. Age-appropriate coverage of Bacillus Calmette-Guerin vaccine (BCG), oral polio vaccine (OPV) doses 1–3, pentavalent vaccine (PE) doses 1–3, and first dose of measles, mumps, and rubella vaccine (MMR) were estimated using Kaplan Meier method. Multilevel logistic regression with random intercept was used to identify the factors associated with age-appropriate vaccination. Results: The crude coverage of the vaccines included in the study ranged from 91.5% (95% CI, 88.5–93.7) for PE3 to 97.8% (95.8–98.7) for BCG. Although the crude coverage of all the vaccines was above 90%, the age-appropriate coverage was significantly low, ranging from 41.5% (36.5–46.6) for PE3 to 73.9% (69.2–78.1) for PE1. Furthermore, high disparity in timely vaccination coverage was observed at regional level. Compared to the age-appropriate vaccination coverage in other provinces, Province 2 had the lowest coverage of all, followed by that in Province 6. The timeliness of vaccination was significantly associated with subnational regions i.e., provinces and the season of childbirth. Conclusion: Although the immunization program in Nepal has achieved the target of 90% crude coverage of all the childhood vaccines, the age-appropriate coverage is significantly low which undermines the effectiveness of the vaccines administered. Thus, along with crude coverage, timeliness of the vaccines administered should be taken into consideration and thoroughly monitored at national and subnational levels. Provincial government should formulate tailored strategies to ensure the timely administration of the childhood vaccines.

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How do Japanese rate the severity of different diseases and injuries?—an assessment of disability weights for 231 health states by 37,318 Japanese respondents

Nomura S., Yamamoto Y., Yoneoka D., Haagsma J.A., Salomon J.A., Ueda P., Mori R., Santomauro D., Vos T., Shibuya K.

Population Health Metrics （Springer Science and Business Media {LLC}）  19 （ 1 ） 21 - 21 2021年12月

査読有り,  ISSN  1478-7954

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Background: Disability weights (DWs) are weight factors that reflect the severity of health states for estimates of disability-adjusted life years. A new set of global DWs was published for the Global Burden of Diseases and Injuries (GBD) 2013 study, which relied on sampling from various world regions, but included little data for countries in East Asia. This study aimed to measure DWs in Japan using comparable methods, and compare the results with previous estimates from the GBD 2013 DW study. Methods: We conducted a web-based survey in 2019 to estimate DWs for 231 health states for the Japanese population. The survey included five new health states but otherwise followed the method of the GBD DW measurement study. The survey consisted of 15 paired comparison (PC) questions and 3 population health equivalence questions (PHE) per respondent. We analyzed PC data using probit regression and rescaled results to DW units between 0 (equivalent to full health) and 1 (equivalent to death). Findings: We considered 37,318 nationally representative respondents. The values of the resulting DWs ranged from 0.707 (95% uncertainty interval (UI) 0.527–0.842) for spinal cord injury at neck level (untreated) to 0.004 (UI 0.001–0.009) for mild anemia. High correlation between Japanese DW and GBD 2013 DW was observed, but there was considerable disagreement. Out of 226 comparable health states, 55 (24.3%) showed more than a factor-of-two difference, of which 41 (74.6%) had a higher value in Japanese DW. Many of the health states with higher DW in the Japan study were injuries, including amputation and fracture, and hearing and vision loss, while mental, behavioral, and substance use disorders generally tended to be lower. Conclusions: This study has created an empirical basis for assessment of Japanese DWs of health status. The findings from this study based on the Japanese population suggest that there might be contextual differences in rating the severity of health states compared to previous surveys conducted elsewhere.

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Projections of disability-adjusted life years for major diseases due to a change in vegetable intake in 2017–2040 in Japan

Tanaka S., Yoneoka D., Ishizuka A., Ueda P., Nakamura K., Uneyama H., Hayashi N., Shibuya K., Nomura S.

BMC Public Health 21 （ 1 ） 770 - 770 2021年12月

査読有り

　概要を見る

Background: Low vegetable intake is one of the key dietary risk factors known to be associated with a range of health problems, including cardiovascular diseases (CVDs), cancer, and diabetes and kidney diseases (DKDs). Using data from Japan’s National Health and Nutrition Surveys and the Global Burden of Diseases study in 2017, this study aimed to forecast the impact of change in vegetable intake on disability-adjusted life years (DALYs) between 2017 and 2040 for three diseases. Methods: We generated a three-component model of cause-specific DALYs, including changes in major behavioural and metabolic risk predictors, the socio-demographic index and an autoregressive integrated moving average model to project future DALY rates for 2017–2040 using the data between 1990 and 2016. Data on Vegetable consumption and risk predictors, and DALY rate were obtained from Japan’s National Health and Nutrition Surveys and the Global Burden of Diseases Study in 2017. We also modelled three scenarios of better, moderate and worse cases to evaluate the impact of change in vegetable consumption on the DALY rates for three diseases (CVDs, cancer, and DKDs). Results: Projected mean vegetable intake in the total population showed a decreasing trend through 2040 to 237.7 g/day. A significant difference between the reference scenario and the better case scenario was observed with un-overlapped 95% prediction intervals of DALY rates in females aged 20–49 years (− 8.0%) for CVDs, the total population for cancer (− 5.6%), and in males (− 8.2%) and females (− 13.7%) for DKDs. Conclusions: Our analysis indicates that increased vegetable consumption would have a significant reduction in the burdens of CVDs, cancer and DKDs in Japan. By estimating the disease burden attributable to low vegetable intake under different scenarios of future vegetable consumption, our study can inform the design of targeted interventions for public health challenges.

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National genotype prevalence and age distribution of human papillomavirus from infection to cervical cancer in Japanese women: a systematic review and meta-analysis protocol

Palmer M., Katanoda K., Saito E., Martellucci C.A., Ostuki S., Nomura S., Ota E., Brotherton J.M.L., Hocking J.

Systematic Reviews （Springer Science and Business Media LLC）  10 （ 1 ） 135 - 135 2021年12月

査読有り

　概要を見る

Background: Despite prophylactic human papillomavirus (HPV) vaccination being a safe, effective and cost-effective public health intervention for the prevention of cervical cancer, the HPV vaccine is not actively recommended or promoted by the Ministry of Health Labour and Welfare in Japan. With already very low levels of cervical screening below 30%, and vaccination levels that are below levels that award any population effect at 0.3% of the eligible population, cervical cancer mortality is higher than other similar high-income countries at 4.4/100,000 (2900) deaths per year in 2015. There is limited population-based or nationally representative data for HPV genotype distribution in Japan, thus making an assessment of the burden of vaccine-preventable cervical cancer difficult. Therefore, this systematic review and meta-analysis aims to determine the HPV genotype prevalence and age distribution of HPV infection in women with a cytological or histological diagnosis of normal through cervical cancer in Japan. We anticipate this information will guide and enhance programme interventions to reduce vaccine-preventable cervical cancer mortality in Japan. Methods: PubMed, Embase and the Japan Medical Abstract Society Database will be searched from the date of establishment to March 2021 to identify original research articles that report the prevalence of HPV genotypes in Japanese women with normal cervical cytology, low grade, high grade and cancerous cervical lesions. No exclusion criteria relating to language or publication date will be applied. The quality of the studies will be assessed using the Joanna Briggs checklist for prevalence studies. Randomised control trials, cohort studies, cross-sectional and prevalence studies will be considered eligible. Study findings will be combined using a traditional random-effects or fixed-effects meta-analysis to summarise pooled prevalence and 95% confidence intervals depending on heterogeneity. Subgroup analyses and meta-regression will be used to investigate heterogeneity, and sensitivity analyses will be conducted to assess the robustness of the findings. Discussion: To our knowledge, this is the first systematic review protocol that includes both Japanese and English peer-reviewed articles for the determination of genotype-specific HPV prevalence in cytological or histological confirmed normal cervical specimens, low- and high-grade intraepithelial lesions and cervical cancers by age in Japan. We anticipate this information will guide and enhance programme interventions to reduce vaccine-preventable cervical cancer mortality in Japan. Systematic review registration: PROSPERO CRD42018117596

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Impact of domestic travel restrictions on transmission of COVID-19 infection using public transportation network approach

Murano Y., Ueno R., Shi S., Kawashima T., Tanoue Y., Tanaka S., Nomura S., Shoji H., Shimizu T., Nguyen H., Miyata H., Gilmour S., Yoneoka D.

Scientific Reports （Springer Science and Business Media LLC）  11 （ 1 ） 3109 - 3109 2021年12月

査読有り

　概要を見る

The international spread of COVID-19 infection has attracted global attention, but the impact of local or domestic travel restriction on public transportation network remains unclear. Passenger volume data for the domestic public transportation network in Japan and the time at which the first confirmed COVID-19 case was observed in each prefecture were extracted from public data sources. A survival approach in which a hazard was modeled as a function of the closeness centrality on the network was utilized to estimate the risk of importation of COVID-19 in each prefecture. A total of 46 prefectures with imported cases were identified. Hypothetical scenario analyses indicated that both strategies of locking down the metropolitan areas and restricting domestic airline travel would be equally effective in reducing the risk of importation of COVID-19. While caution is necessary that the data were limited to June 2020 when the pandemic was in its initial stage and that no other virus spreading routes have been considered, domestic travel restrictions were effective to prevent the spread of COVID-19 on public transportation network in Japan. Instead of lockdown that might seriously damage the economy, milder travel restrictions could have the similar impact on controlling the domestic transmission of COVID-19.

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Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic

Santomauro D.F., Mantilla Herrera A.M., Shadid J., Zheng P., Ashbaugh C., Pigott D.M., Abbafati C., Adolph C., Amlag J.O., Aravkin A.Y., Bang-Jensen B.L., Bertolacci G.J., Bloom S.S., Castellano R., Castro E., Chakrabarti S., Chattopadhyay J., Cogen R.M., Collins J.K., Dai X., Dangel W.J., Dapper C., Deen A., Erickson M., Ewald S.B., Flaxman A.D., Frostad J.J., Fullman N., Giles J.R., Giref A.Z., Guo G., He J., Helak M., Hulland E.N., Idrisov B., Lindstrom A., Linebarger E., Lotufo P.A., Lozano R., Magistro B., Malta D.C., Månsson J.C., Marinho F., Mokdad A.H., Monasta L., Naik P., Nomura S., O'Halloran J.K., Ostroff S.M., Pasovic M., Penberthy L., Reiner R.C., Reinke G., Ribeiro A.L.P., Sholokhov A., Sorensen R.J.D., Varavikova E., Vo A.T., Walcott R., Watson S., Wiysonge C.S., Zigler B., Hay S.I., Vos T., Murray C.J.L., Whiteford H.A., Ferrari A.J.

The Lancet （Elsevier BV）  398 （ 10312 ） 1700 - 1712 2021年11月

ISSN  01406736

　概要を見る

Background: Before 2020, mental disorders were leading causes of the global health-related burden, with depressive and anxiety disorders being leading contributors to this burden. The emergence of the COVID-19 pandemic has created an environment where many determinants of poor mental health are exacerbated. The need for up-to-date information on the mental health impacts of COVID-19 in a way that informs health system responses is imperative. In this study, we aimed to quantify the impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders globally in 2020. Methods: We conducted a systematic review of data reporting the prevalence of major depressive disorder and anxiety disorders during the COVID-19 pandemic and published between Jan 1, 2020, and Jan 29, 2021. We searched PubMed, Google Scholar, preprint servers, grey literature sources, and consulted experts. Eligible studies reported prevalence of depressive or anxiety disorders that were representative of the general population during the COVID-19 pandemic and had a pre-pandemic baseline. We used the assembled data in a meta-regression to estimate change in the prevalence of major depressive disorder and anxiety disorders between pre-pandemic and mid-pandemic (using periods as defined by each study) via COVID-19 impact indicators (human mobility, daily SARS-CoV-2 infection rate, and daily excess mortality rate). We then used this model to estimate the change from pre-pandemic prevalence (estimated using Disease Modelling Meta-Regression version 2.1 [known as DisMod-MR 2.1]) by age, sex, and location. We used final prevalence estimates and disability weights to estimate years lived with disability and disability-adjusted life-years (DALYs) for major depressive disorder and anxiety disorders. Findings: We identified 5683 unique data sources, of which 48 met inclusion criteria (46 studies met criteria for major depressive disorder and 27 for anxiety disorders). Two COVID-19 impact indicators, specifically daily SARS-CoV-2 infection rates and reductions in human mobility, were associated with increased prevalence of major depressive disorder (regression coefficient [B] 0·9 [95% uncertainty interval 0·1 to 1·8; p=0·029] for human mobility, 18·1 [7·9 to 28·3; p=0·0005] for daily SARS-CoV-2 infection) and anxiety disorders (0·9 [0·1 to 1·7; p=0·022] and 13·8 [10·7 to 17·0; p<0·0001]. Females were affected more by the pandemic than males (B 0·1 [0·1 to 0·2; p=0·0001] for major depressive disorder, 0·1 [0·1 to 0·2; p=0·0001] for anxiety disorders) and younger age groups were more affected than older age groups (−0·007 [–0·009 to −0·006; p=0·0001] for major depressive disorder, −0·003 [–0·005 to −0·002; p=0·0001] for anxiety disorders). We estimated that the locations hit hardest by the pandemic in 2020, as measured with decreased human mobility and daily SARS-CoV-2 infection rate, had the greatest increases in prevalence of major depressive disorder and anxiety disorders. We estimated an additional 53·2 million (44·8 to 62·9) cases of major depressive disorder globally (an increase of 27·6% [25·1 to 30·3]) due to the COVID-19 pandemic, such that the total prevalence was 3152·9 cases (2722·5 to 3654·5) per 100 000 population. We also estimated an additional 76·2 million (64·3 to 90·6) cases of anxiety disorders globally (an increase of 25·6% [23·2 to 28·0]), such that the total prevalence was 4802·4 cases (4108·2 to 5588·6) per 100 000 population. Altogether, major depressive disorder caused 49·4 million (33·6 to 68·7) DALYs and anxiety disorders caused 44·5 million (30·2 to 62·5) DALYs globally in 2020. Interpretation: This pandemic has created an increased urgency to strengthen mental health systems in most countries. Mitigation strategies could incorporate ways to promote mental wellbeing and target determinants of poor mental health and interventions to treat those with a mental disorder. Taking no action to address the burden of major depressive disorder and anxiety disorders should not be an option. Funding: Queensland Health, National Health and Medical Research Council, and the Bill and Melinda Gates Foundation.

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Developing and validating regression models for predicting household consumption to introduce an equitable and sustainable health insurance system in Cambodia

Nakamura H., Amimo F., Yi S., Tuot S., Yoshida T., Tobe M., Rahman M.M., Yoneoka D., Ishizuka A., Nomura S.

International Journal of Health Planning and Management （Wiley）  36 （ 6 ） 2094 - 2105 2021年11月

査読有り,  ISSN  07496753

　概要を見る

Background: Financial protection is a challenge for low- and middle-income countries, where the fiscal space is limited, and majority of the population is engaged in the informal economy. This study developed and validated household consumption predictive models for Cambodia to collect contributions according to one's ability to pay. Methods: This study used nationally representative survey data collected annually between 2010 and 2017, involving 38,472 households. We developed four alternative models: the manually selected linear model, the linear model with stepwise technique, the mixed effects linear model, and the model with regularisation technique. Subsequently, we performed out-of-sample cross-validation for each model, and evaluated the model prediction performance. Results: Overall, observed and predicted household consumptions were linearly related in all four models. While the prediction performance of the models did not substantially differ, the stepwise linear model showed the best performance. The regularisation and the mixed effects were not particularly effective in these regressions. The household consumption was better predicted for those with lower consumption, and the predictivity declined as the consumption level increased. Conclusions: This study suggests the possibility of predicting household consumption at a reasonable level. This would maximise the contribution revenue, optimise the government subsidy, and ensure equity in healthcare access.

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Suicide by gender and 10-year age groups during the COVID-19 pandemic vs previous five years in Japan: An analysis of national vital statistics

Eguchi A., Nomura S., Gilmour S., Harada N., Sakamoto H., Ueda P., Yoneoka D., Tanoue Y., Kawashima T., Hayashi T.I., Arima Y., Suzuki M., Hashizume M.

Psychiatry Research （Elsevier {BV}）  305   114173 - 114173 2021年11月

査読有り,  ISSN  01651781

　概要を見る

Using daily vital statistics data from the Japanese Ministry of Health, Labour and Welfare, we provide the first weekly and age-group-specific estimates of the additional suicide burden during the COVID-19 pandemic in Japan by gender, from January through November 2020. Our results indicate that compared with the previous five years, suicide cases in 2020 in Japan have increased from late July to November for women in all age groups and for men in the 20–29 and 80+ years age group. Targeted interventions based on age and gender might be more effective in reducing suicide during the COVID-19 pandemic in Japan.

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Global, regional, and national mortality among young people aged 10–24 years, 1950–2019: a systematic analysis for the Global Burden of Disease Study 2019

Ward J.L., Azzopardi P.S., Francis K.L., Santelli J.S., Skirbekk V., Sawyer S.M., Kassebaum N.J., Mokdad A.H., Hay S.I., Abd-Allah F., Abdoli A., Abdollahi M., Abedi A., Abolhassani H., Abreu L.G., Abrigo M.R.M., Abu-Gharbieh E., Abushouk A.I., Adebayo O.M., Adekanmbi V., Adham D., Advani S.M., Afshari K., Agrawal A., Ahmad T., Ahmadi K., Ahmed A.E., Aji B., Akombi-Inyang B., Alahdab F., Al-Aly Z., Alam K., Alanezi F.M., Alanzi T.M., Alcalde-Rabanal J.E., Alemu B.W., Al-Hajj S., Alhassan R.K., Ali S., Alicandro G., Alijanzadeh M., Aljunid S.M., Almasi-Hashiani A., Almasri N.A., Al-Mekhlafi H.M., Alonso J., Al-Raddadi R.M., Altirkawi K.A., Alvis-Guzman N., Amare A.T., Amini S., Aminorroaya A., Amit A.M.L., Amugsi D.A., Ancuceanu R., Anderlini D., Andrei C.L., Androudi S., Ansari F., Ansari I., Antonio C.A.T., Anvari D., Anwer R., Appiah S.C.Y., Arabloo J., Arab-Zozani M., Ärnlöv J., Asaad M., Asadi-Aliabadi M., Asadi-Pooya A.A., Atout M.M.d.W., Ausloos M., Avenyo E.K., Avila-Burgos L., Quintanilla B.P.A., Ayano G., Aynalem Y.A., Azari S., Azene Z.N., Bakhshaei M.H., Bakkannavar S.M., Banach M., Banik P.C., Barboza M.A., Barker-Collo S.L., Bärnighausen T.W., Basu S., Baune B.T., Bayati M., Bedi N., Beghi E., Bekuma T.T., Bell A.W., Bell M.L., Benjet C., Bensenor I.M., Berhe A.K., Berhe K., Berman A.E., Bhagavathula A.S.

The Lancet （Elsevier BV）  398 （ 10311 ） 1593 - 1618 2021年10月

査読有り,  ISSN  01406736

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Background: Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10–24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods: We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10–24 years by age group (10–14 years, 15–19 years, and 20–24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10–24 years with that in children aged 0–9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10–24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings: In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39–1·59) worldwide in people aged 10–24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10–14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15–19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1–4 years (2·4%), and around a third less than in females aged 1–4 years (2·5%). The proportion of global deaths in people aged 0–24 years that occurred in people aged 10–24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%. Interpretation: Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10–24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Funding: Bill & Melinda Gates Foundation.

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Salt intake reduction using umami substance-incorporated food in the United States

S Nomura, S Tanaka, A Eguchi, T Kawashima, D Yoneoka, Y Tanoe, ...

2021年10月

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Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990–2050

Micah A.E., Cogswell I.E., Cunningham B., Ezoe S., Harle A.C., Maddison E.R., McCracken D., Nomura S., Simpson K.E., Stutzman H.N., Tsakalos G., Wallace L.E., Zhao Y., Zende R.R., Abbafati C., Abdelmasseh M., Abedi A., Abegaz K.H., Abhilash E.S., Abolhassani H., Abrigo M.R.M., Adhikari T.B., Afzal S., Ahinkorah B.O., Ahmadi S., Ahmed H., Ahmed M.B., Ahmed Rashid T., Ajami M., Aji B., Akalu Y., Akunna C.J., Al Hamad H., Alam K., Alanezi F.M., Alanzi T.M., Alemayehu Y., Alhassan R.K., Alinia C., Aljunid S.M., Almustanyir S.A., Alvis-Guzman N., Alvis-Zakzuk N.J., Amini S., Amini-Rarani M., Amu H., Ancuceanu R., Andrei C.L., Andrei T., Angell B., Anjomshoa M., Antonio C.A.T., Antony C.M., Aqeel M., Arabloo J., Arab-Zozani M., Aripov T., Arrigo A., Ashraf T., Atnafu D.D., Ausloos M., Avila-Burgos L., Awan A.T., Ayano G., Ayanore M.A., Azari S., Azhar G.S., Babalola T.K., Bahrami M.A., Baig A.A., Banach M., Barati N., Bärnighausen T.W., Barrow A., Basu S., Baune B.T., Bayati M., Benzian H., Berman A.E., Bhagavathula A.S., Bhardwaj N., Bhardwaj P., Bhaskar S., Bibi S., Bijani A., Bodolica V., Bragazzi N.L., Braithwaite D., Breitborde N.J.K., Breusov A.V., Briko N.I., Busse R., Cahuana-Hurtado L., Callander E.J., Cámera L.A., Castañeda-Orjuela C.A., Catalá-López F., Charan J., Chatterjee S., Chattu S.K.

The Lancet 398 （ 10308 ） 1317 - 1343 2021年10月

ISSN  01406736

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Background: The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. Methods: We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. Findings: In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7–8·8) or $1132 (1119–1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5–0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0–25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448–1591) per person in 2050, although spending across countries is expected to remain varied. Interpretation: Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. Funding: Bill & Melinda Gates Foundation.

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Mobility Patterns in Different Age Groups in Japan during the COVID-19 Pandemic: a Small Area Time Series Analysis through March 2021

Nomura S., Tanoue Y., Yoneoka D., Gilmour S., Kawashima T., Eguchi A., Miyata H.

Journal of Urban Health （Springer Science and Business Media {LLC}）  98 （ 5 ） 635 - 641 2021年10月

査読有り,  ISSN  10993460

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In the COVID-19 era, movement restrictions are crucial to slow virus transmission and have been implemented in most parts of the world, including Japan. To find new insights on human mobility and movement restrictions encouraged (but not forced) by the emergency declaration in Japan, we analyzed mobility data at 35 major stations and downtown areas in Japan—each defined as an area overlaid by several 125-meter grids—from September 1, 2019 to March 19, 2021. Data on the total number of unique individuals per hour passing through each area were obtained from Yahoo Japan Corporation (i.e., more than 13,500 data points for each area). We examined the temporal trend in the ratio of the rolling seven-day daily average of the total population to a baseline on January 16, 2020, by ten-year age groups in five time frames. We demonstrated that the degree and trend of mobility decline after the declaration of a state of emergency varies across age groups and even at the subregional level. We demonstrated that monitoring dynamic geographic and temporal mobility information stratified by detailed population characteristics can help guide not only exit strategies from an ongoing emergency declaration, but also initial response strategies before the next possible resurgence. Combining such detailed data with data on vaccination coverage and COVID-19 incidence (including the status of the health care delivery system) can help governments and local authorities develop community-specific mobility restriction policies. This could include strengthening incentives to stay home and raising awareness of cognitive errors that weaken people's resolve to refrain from nonessential movement.

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Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

Paulson K.R., Kamath A.M., Alam T., Bienhoff K., Abady G.G., Abbas J., Abbasi-Kangevari M., Abbastabar H., Abd-Allah F., Abd-Elsalam S.M., Abdoli A., Abedi A., Abolhassani H., Abreu L.G., Abu-Gharbieh E., Abu-Rmeileh N.M.E., Abushouk A.I., Adamu A.L., Adebayo O.M., Adegbosin A.E., Adekanmbi V., Adetokunboh O.O., Adeyinka D.A., Adsuar J.C., Afshari K., Aghaali M., Agudelo-Botero M., Ahinkorah B.O., Ahmad T., Ahmadi K., Ahmed M.B., Aji B., Akalu Y., Akinyemi O.O., Aklilu A., Al-Aly Z., Alam K., Alanezi F.M., Alanzi T.M., Alcalde-Rabanal J.E., Al-Eyadhy A., Ali T., Alicandro G., Alif S.M., Alipour V., Alizade H., Aljunid S.M., Almasi-Hashiani A., Almasri N.A., Al-Mekhlafi H.M., Alonso J., Al-Raddadi R.M., Altirkawi K.A., Alumran A.K., Alvis-Guzman N., Alvis-Zakzuk N.J., Ameyaw E.K., Amini S., Amini-Rarani M., Amit A.M.L., Amugsi D.A., Ancuceanu R., Anderlini D., Andrei C.L., Ansari F., Ansari-Moghaddam A., Antonio C.A.T., Antriyandarti E., Anvari D., Anwer R., Aqeel M., Arabloo J., Arab-Zozani M., Aripov T., Ärnlöv J., Artanti K.D., Arzani A., Asaad M., Asadi-Aliabadi M., Asadi-Pooya A.A., Jafarabadi M.A., Athari S.S., Athari S.M., Atnafu D.D., Atreya A., Atteraya M.S., Ausloos M., Awan A.T., Quintanilla B.P.A., Ayano G., Ayanore M.A., Aynalem Y.A., Azari S., Azarian G., Azene Z.N., Darshan B.B., Babaee E., Badiye A.D., Baig A.A., Banach M.

The Lancet （Elsevier {BV}）  398 （ 10303 ） 870 - 905 2021年09月

査読有り,  ISSN  01406736

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Background: Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods: We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings: Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3–74·0) in 2000 to 37·1 (33·2–41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8–29·5) in 2000 to 17·9 (16·3–19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05–10·30) in 2000 and 5·05 million (4·27–6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53–4·02]) in 2000 to 48% (2·42 million; 2·06–2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71–0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27–1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35–2·58; 37% [95% UI 32–43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation: Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. Funding: Bill & Melinda Gates Foundation.

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Reasons for being unsure or unwilling regarding intention to take COVID-19 vaccine among Japanese people: A large cross-sectional national survey

Nomura S., Eguchi A., Yoneoka D., Kawashima T., Tanoue Y., Murakami M., Sakamoto H., Maruyama-Sakurai K., Gilmour S., Shi S., Kunishima H., Kaneko S., Adachi M., Shimada K., Yamamoto Y., Miyata H.

The Lancet Regional Health - Western Pacific （Elsevier {BV}）  14   100223 - 100223 2021年09月

査読有り,  ISSN  2666-6065

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Background: Identifying and understanding reasons for being unsure or unwilling regarding intention to be vaccinated against coronavirus disease (COVID-19) may help to inform future public health messages aimed at increasing vaccination coverage. We analyzed a broad array of individual's psychological dispositions with regard to decision-making about COVID-19 vaccination in Japan. Methods: A nationally representative cross-sectional web survey was conducted with 30053 Japanese adults aged 20 years or older at the end of February 2021. In addition to the question on the individual's intention to be vaccinated against COVID-19, respondents were asked about their sociodemographic, health-related, and psychological characteristics as well as information sources about COVID-19 and their levels of trust. Also, those who responded ‘not sure’ or ‘no’ regarding intention to take COVID-19 vaccine were asked why. Multinomial logistic regression with sparse group Lasso (Least Absolute Shrinkage and Selection Operator) penalty was used to compute adjusted odds ratios for factors associated with the intention (not sure/no versus yes). Findings: The percentages of respondents who answered ‘not sure’ or ‘no’ regarding intention to be vaccinated against COVID-19 vaccine were 32.9% and 11.0%, respectively. After adjusting for covariates, the perceived risks of COVID-19, perceived risk of a COVID-19 vaccine, perceived benefits of a COVID-19 vaccine, trust in scientists and public authorities, and the belief that healthcare workers should be vaccinated were significantly associated with vaccination intention. Several sources of information about COVID-19 were also significantly associated with vaccination intention, including physicians, nurses, and television, medical information sites with lower odds of being unsure or unwilling, and internet news sites, YouTube, family members, and scientists and researchers with higher odds. The higher the level of trust in television as a source of COVID-19 information, the higher the odds of responding ‘not sure’ (odds ratio 1.11, 95% confidence interval 1.01–1.21). We also demonstrated that many respondents presented concerns about the side effects and safety of a COVID-19 vaccine as a major reason for being unsure or unwilling. To decide whether or not to get the vaccine, many respondents requested more information about the compatibilities between the vaccine and their personal health conditions, whether other people had been vaccinated, the effectiveness of vaccines against variants, and doctors’ recommendations. Interpretation: Our findings suggest that public health messaging based on the sociodemographic and psychological characteristics of those who are unsure or unwilling regarding intention to be vaccinated against COVID-19 vaccine may help to increase vaccine uptake amongst this population. Funding: The present work was supported in part by a grant from the Ministry of Health, Labour and Welfare of Japan (H29-Gantaisaku-ippan-009).

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Tracking development assistance for health: A comparative study of the 29 development assistance committee countries, 2011–2019

Nomura S., Sakamoto H., Ishizuka A., Shibuya K.

International Journal of Environmental Research and Public Health （MDPI AG）  18 （ 16 ） 8519 - 8519 2021年08月

査読有り,  ISSN  16617827

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Development assistance for health (DAH) is an important part of financing healthcare in low-and middle-income countries. We estimated the gross disbursement of DAH of the 29 Development Assistance Committee (DAC) member countries of the Organisation for Economic Co-op-eration and Development (OECD) for 2011–2019; and clarified its flows, including aid type, channel, target region, and target health focus area. Data from the OECD iLibrary were used. The DAH def-inition was based on the OECD sector classification. For core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA). The total amount of DAH for all countries combined was 18.5 billion USD in 2019, at 17.4 USD per capita, with the 2011–2019 average of 19.7 billion USD. The average share of DAH in ODA for the 29 countries was about 7.9% in 2019. Between 2011 and 2019, most DAC countries allocated approximately 60% of their DAH to primary health care, with the remaining 40% allocated to health system strengthening. We expect that the estimates of this study will help DAC member countries strategize future DAH wisely, efficiently, and effectively while ensuring transparency.

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Hospital admission for type 2 diabetes mellitus under the Universal Coverage Scheme in Thailand: A time- And geographical-trend analysis, 2009-2016

Laowahutanon T., Nakamura H., Tachimori H., Nomura S., Liabsuetrakul T., Lim A., Rawdaree P., Suchonwanich N., Yamamoto H., Ishizuka A., Shibuya K., Miyata H., Chongsuvivatwong V.

PLoS ONE （Public Library of Science ({PLoS})）  16 （ 7 July ） e0253434 - e0253434 2021年07月

査読有り,  ISSN  1932-6203

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Background Descriptive analyses of 2009-2016 were performed using the data of the Universal Coverage Scheme (UCS) which covers nearly 70 percent of the Thai population. The analyses described the time and geographical trends of nationwide admission rates of type 2 diabetes mellitus (T2DM) and its complications, including chronic kidney disease (CKD), myocardial infarction, cerebrovascular diseases, retinopathy, cataract, and diabetic foot amputation. Methods and findings The database of T2DM patients aged 15-100 years who were admitted between 2009 and 2016 under the UCS and that of the UCS population were retrieved for the analyses. The admitted cases of T2DM were extracted from the database using disease codes of principal and secondary diagnoses defined by the International Classification of Diseases 9th and 10th Revisions. The T2DM admission rates in 2009-2016 were the number of admissions divided by the number of the UCS population. The standardized admission rates (SARs) were further estimated in contrast to the expected number of admissions considering age and sex composition of the UCS population in each region. A linearly increased trend was found in T2DM admission rates from 2009 to 2016. Female admission rates were persistently higher than that of males. In 2016, an increase in the T2DM admission rates was observed among the older ages relative to that in 2009. Although the SARs of T2DM were generally higher in Bangkok and central regions in 2009, except that with CKD and foot amputation which had higher trends in northeastern regions, the geographical inequalities were fairly reduced by 2016. Conclusion Admission rates of T2DM and its major complications increased in Thailand from 2009 to 2016. Although the overall geographical inequalities in the SARs of T2DM were reduced in the country, further efforts are required to improve the health system and policies focusing on risk factors and regions to manage the increasing T2DM.

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Prediction of disability-adjusted life years for diseases due to low fruit intake in 2017-2040 in Japan

Yoneoka D., Nomura S., Tanaka S., Ishizuka A., Peter U., Rauniyar S.K., Nakamura K., Uneyama H., Hayashi N., Shibuya K.

Public Health Nutrition （Cambridge University Press (CUP)）  24 （ 10 ） 3156 - 3166 2021年07月

査読有り,  ISSN  13689800

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Abstract Objective: The current study aimed to predict disability-adjusted life years (DALY) rate in Japan through 2040 with plausible future scenarios of fruit intake for neoplasms, cardiovascular diseases (CVD) and diabetes and kidney diseases (DKD). Design: Data from National Health and Nutrition Surveys and the Global Burden of Diseases study in 2017 were used. We developed an autoregressive integrated moving average model with four future scenarios. Reference scenario maintains the current trend. Best scenario assumes that the goal defined in Health Japan 21 is achieved in 2023 and is kept constant afterwards. Moderate scenario assumes that the goal is achieved in 2040. Constant scenario applies the same proportion of 2016 for the period between 2017 and 2040. Setting: DALY rates in Japan were predicted for the period between 2017 and 2040. Participants: Population aged more than than 20 years old. Results: In our reference forecast, the DALY rates in all-ages group were projected to be stable for CVD and continue increasing for neoplasms and DKD. Age group-specific DALY rates for these three disease groups were forecasted to decrease, with some exceptions. Among men aged 20-49 years, DALY attributable to CVD differed substantially between the scenarios, implying that there is a significant potential for reducing the burden of CVD by increasing fruit intake at the population level. Conclusions: Our scenario analysis shows that higher fruit intake is associated with lower disease burden in Japan. Further research is required to assess which policies and interventions can be used to achieve an increase in fruit intake as modelled in the scenarios of the current study.

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