Effectiveness of a Japanese-style health program in Minowa Town, Matsumoto city and Nagano city, Japan

Purpose – This study aims to establish a Japanese-style healthcare program customized for Japan and Asia under ISO 9001: 2008 (ISO: International Organization for Standardization) to improve problem areas and to inspect the effectiveness of the program. Furthermore, the authors wanted to create this health programusing the ISOwidely available in Asian countries andmake an international contribution. Design/methodology/approach – The authors implemented a 6to 10-month health program in Minowa Town, Matsumoto City andNagano City in Japan. This study assessed findings from pedometric, anthropometric and blood pressure measurements and physical fitness, blood chemistry and brain function tests. Findings – The comparisons were made by examining the interaction effects between groups of participants. Groups from three regions in Japan showed significant differences on the physical fitness tests; regarding the 10-meter obstacle walk, the results of the Minowa participants showed the greatest improvement and the Matsumoto participants showed the second greatest improvement. In the six-min walk, the time of theMinowa participants significantly improved. Research limitations/implications – This health education program, which has been conducted by the Japanese authors since 1998, measures anthropometry, brain function and physical fitness and performs blood tests before and after the program and it measures energy consumption with a pedometer during the program.With the aim of improving exercise via encouragement from friends and a sense of community with fellow participants, participants learn together with hands-on training in tai chi and aerobics about the importance of ongoing exercise and proper nutrition. This health education met the Health Education ISO in 2014. Practical implications – Since 2010, Nagano Prefecture, including Minowa Town, Matsumoto City and Nagano City, where our study was carried out, has been the area with the highest life expectancy rates in Japan. Social implications – The authors want to make this health promotion through ISO widely available in Asian countries and an international contribution. Originality/value – This study aimed to appropriately establish a Japanese-style healthcare program under the ISO 9001:2008 to improve problem areas and inspect its effectiveness.


Introduction
In line with the increase in the aging population worldwide, the prevalence of adults greater than 65 years of age are expected to increase from 22.7% in 2010 to 35.6% in 2020 in Japan (United Nation, 2010). To adapt to the aging society, it is necessary to extend healthy life expectancy. Notably, the social system of preventive care for senior citizens is not in women of 64.7 6 6.3 years of age. The 35 Nagano subjects were 5.2 6 4.6 years of age, including six men of 64.2 6 5.3 years of age and 29 women of 65.4 6 4.5 years of age. The 7 control subjects were 61.3 6 7.8 years of age, including three men of 66.0 6 5.0 years of age and 4 women of 57.8 6 9.5 years of age. In three regions in Japan, during these health programs, the subjects received a series of seminars regarding recreational activities for 90-120 min once or twice per month (Table 1). Only Minowa subjects performed training and aerobic exercises once a week for 120 min. There were 46 Minowa subjects and approximately nine instructors, thus, reflecting a ratio of five to one. There were 69 Matsumoto subjects and five instructors, thus, reflecting a ratio of 13.3 to 1. There were 35 Nagano subjects and approximately one instructor, reflecting a ratio of 35 to 1. The seven control subjects did not participate in any health education programs. There were no instructors for the control group. The purpose of this seminar was for participants to gather, unite and encourage each other and to record the data from the pedometers. In addition, the contents of this seminar were made into a program by local staff based on the health education that the region had obtained so far so that the information could be used in the future. Instead, the study was conducted as follows: The study assessed findings from pedometric, anthropometric and blood pressure measurements and physical fitness, blood chemistry and brain function tests. An approximate target of 7,000 steps per day was set. Because the results of the brain function, physical fitness, body weight and blood chemistry test values are significantly improved by exercise comprising 7,000 or more steps Watanabe et al., 2015;Murata et al., 2015), the latest guidelines based on the Helsinki Declaration was adopted by Shinshu University (UMIN000009309). Written informed consents were obtained from all the participants.

Pedometry
The daily numbers of walking steps and the amount of energy expenditure was measured with a pedometer (Acos Co. Ltd., Japan; AM500NE). The step value in one day (daily steps) is the total number of exercise steps of greater than four Mets and normal steps of less than four Mets. Exercise steps are defined as steps taken during expenditure > four METs (METs Cooking practice and weekly 2 h exercise High blood pressure lecture metabolic equivalent: energy expenditure during the acting amount of metabolite during sitting quietly). The pedometer enabled the data to be transferred and saved to the computer. These walking steps were measured from Jun 2013 to November 2014 in Japan. Notably, control did not wear a pedometer.

Anthropometry and blood pressure measurements
Weight and body mass index (BMI) were included in the anthropometry measurements. Weight measurement was determined by using body composition monitors with scales (Omron Healthcare Co., Ltd. JAPAN; HBF-359). Weight measurement was implemented at the time of fasting > 10 h from the last meal. Maximum and minimum blood pressures were measured through auscultation (mercury sphygmomanometer, Kenzumedico 0601B001, Japan) after the subjects had been sitting for 15 min in a room with an ambient temperature of 25˚C and relative humidity of approximately 50%.

Blood chemistry tests
The blood chemistry assessment comprised five components, namely: 1. Fasting blood glucose.

Triglycerides.
Blood chemistry measurements were taken after the fasting time, namely, > 10 h from the last meal. The subjects' blood chemistry was assessed before and after the health program.

Physical fitness tests
The physical fitness tests administered in this study were approved by the Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT) (Ministry of Education, Culture, Sports, Science and Technology, 1999). The physical fitness test (target age: 65-79 years) included six physical assessments, namely: 1. Grip strength for muscle strength.
3. Sit-and-reach flexibility for muscle flexibility.

4.
Eyes-open single-leg stance for balance ability.
6. A six-min walk for endurance.
The subjects' physical ability was assessed before and after the health program.

Brain function tests
The go/no-go tasks (Masaki and Moriyama, 1971;Terasawa et al., 2014aTerasawa et al., , 2014b, were used to estimate the inhibitory decision process and comprised three experimental stages, namely formation; differentiation and reverse differentiation. First, in the formation stage, subjects were instructed to squeeze a rubber ball in response to a red light that was randomly displayed. The formation stage consisted of five trials. Second, during the differentiation stage, subjects squeezed a rubber ball in response to a red light, but not a yellow light, when a red or yellow light was randomly displayed. Third, during the reverse differentiation stage, subjects squeezed a rubber ball in response to a yellow light, but not a red light, when a red or yellow light was randomly displayed. In each of the differentiation and reverse differentiation stages, the subjects completed 20 trials. Red and yellow lights were equally randomly displayed 10 times each. In this article, the term "miss" indicates an incorrect response, when study subjects did not squeeze a rubber ball when it should have been squeezed. The term "mistake" means an incorrect response, when subjects squeezed the rubber ball when it was not supposed to be squeezed. We administered the go/no-go tasks to assess the participants' brain function before and after the health program.

Statistical analyzes
A 2 Â 2 (before and after for each group: Minowa, Matsumoto, Nagano and control) two-way analysis of variance (ANOVA) with repeated measures was performed to evaluate the significance of the outcomes for anthropometry, blood pressure, physical fitness and the go/no-go task. When a significant interaction was found, a one-way ANOVA was performed to interpret the before and after results for the Minowa, Matsumoto, Nagano and control groups. Post hoc tests were performed by using the Tukey--Kramer correction. In addition, the number of steps for the Minowa, Matsumoto, Nagano and control groups and each difference between the before and after anthropometry measurements, blood pressure measurements, blood chemistry test results, physical fitness test results and brain function test results were analyzed with Pearson's correlation coefficient. The level of significance was set at p < 0.05. The statistical analyzes were performed by using SPSS Ver. 26 statistical package (IBM SPSS Inc., Tokyo, Japan).

Pedometry
Minowa Matsumoto Nagano 9,351.6 6 562.4 and 6,059.1 6 506.7 in November; 8,342.7 6 531.8 and 5,527.1 6 511.2 in December; 8,223.3 6 524.1 and 5,826.1 6 504.9 in January; and 7,991.4 6 517.1 and 5,515.7 6 489.4 in February, respectively. The average number of daily steps increased from May to October and decreased from November to February. Few changes in the average number of exercise steps, which ranged from 7,500-9,500 steps, were observed during any month. For the 10-month analysis, the average numbers of daily and exercise steps were 8,753.6 6 492.3 and 5,592.2 6 448.2, respectively.
For the participants from Matsumoto City in Japan, the numbers of daily and exercise steps per day were 7,048.6 6 360. ). The average number of daily steps increased from June to August and decreased from September to November. Few changes in the average number of exercise steps, which ranged from 4,500-5,500 steps, were observed during any month. There was a six-month period between the start to finish of the health education program and the average numbers of daily and exercise steps for Nagano participants were 5,258.4 6 559.5 and 2,782.2 6 544.3, respectively. Overall, the average number of daily steps and exercise steps were significantly higher in Minowa subjects than in Matsumoto subjects followed by Nagano subjects (p < 0.01) ( Table 2). The participants in Japan had a rainy season from summer to autumn, namely, from June to November. The rain probably had a negative effect on the participants' number of steps during that time.

Anthropometry and blood pressure measurements
For the subjects in the Minowa group and Matsumoto, the results from before and after the program showed that weight (before: 59.5 kg 6 1.6; after: 58.5 kg 6 1.6, p < 0.006 and before: 59.6 kg 6 1.3; after: 59.3 kg 6 1.3, p < 0.001, respectively) and BMI (before: 23.0 kg/ m 2 6 0.5; after: 22.7 kg/m 2 6 0.5, p < 0.004 and before: 23.1 6 0.4; after: 23.0 kg 6 0.3, p < 0.001, respectively) significantly decreased after the program. Moreover, for the subjects in the Minowa group, the results from before and after the program showed that systolic blood pressure (before: 133.0 mmHg 6 1.9; after: 125.5 mmHg 6 2.0, p < 0.001) and diastolic blood pressure (before: 80.4 mmHg 6 1.2; after: 76.1 mmHg 6 1.1, p < 0.001) significantly decreased after the program. In subjects in the Nagano and control groups, for weight, BMI and blood pressure, no significant differences were observed after the program. The interaction of the two-way ANOVA was not significantly different for anthropometry and blood pressure measurements (Table 3).

Blood chemistry tests
For subjects in the Minowa group, a comparison of blood chemistry measurement results from before and after the program showed no significant differences in HDL, LDL and triglyceride levels. Fasting blood glucose (before: 103.1 mg/dl 6 2.7; after: 100.0 mg/ dl 6 2.2, p = 0.015) and HbA1c (before: 5.5% 6 0.1; after: 5.3% 6 0.1, p < 0.001) significantly decreased after the program. For subjects in the Matsumoto group, a comparison of blood chemistry measurement results from before and after the program showed no significant differences. For subjects in the Nagano group, a comparison of blood chemistry measurement results from before and after the program showed that LDL (before: 130.9 mg/dl 6 5.5; after: 119.6 mg/dl 6 5.4, p = 0.003) significantly decreased after the program. For subjects in the control group, a comparison of blood chemistry measurement results from before and after the program showed that HbA1c (before: 5.8% 6 0.1; after: 5.9% 6 0.1, p < 0.043) significantly increased after the program. The interaction of the two-way ANOVA was not significantly different for the blood chemistry tests (Table 3).

Physical fitness tests
For subjects in the Minowa group, a comparison of the physical fitness test results from before and after the program showed no significant differences for the eyes-open single-leg stance ability and the grip strength (before: 33.6 kg 6 1.5; after: 37.3 kg 6 1.5, p < 0.001), number of sit-ups (before: 11.9 times 6 0.9; after: 15.4 times 6 0.9, p < 0.001), sit-andreach flexibility (before: 42.6 cm 6 1.3; after: 47.4 6 1.1, p = 0.002) and 10-meter obstacle walk (before: 6.8 sec. 6 0.1; after: 5.2 sec. 6 0.1, p = 0.004) and six-min walk (before: 622.8 m 6 6.9; after: 719.9 times 6 9.2, p = 0.005) results significantly improved after the program. For subjects in the Matsumoto group, a comparison of the physical fitness test results from before and after the program showed no significant difference in grip strength and eyes-open single-leg stance ability and the number of sit-ups (before: 11.9 times 6 0.9; after: 13.9 times 6 0.9, p < 0.001) and 10-meter obstacle walk (before: 4.7 sec. 6 0.1; after: 3.8 sec. 6 0.1, p < 0.001) and six-min walk (before: 651.1 m 6 7.7; after: 679.9 times 6 9.5,   p < 0.001) results significantly improved after the program. However, sit-and-reach flexibility (before: 44.2 cm 6 1.0; after: 41.6 6 1.1, p < 0.001) significantly decreased after the program. For subjects in the Nagano group, a comparison of the physical fitness test results from before and after the program showed that only the number of sit-ups (before: 9.6 times 6 0.9; after: 11.1 times 6 1.1, p = 0.035) significantly improved after the program. However, other results from before and after the program showed no significant differences. For subjects in the control group, a comparison of all of the results from before and after the program for the physical fitness tests showed no significant differences.
The sit-and-reach flexibility, 10-meter obstacle walk and six-min walk interactions in the twoway ANOVA were significantly different (sit-and-reach flexibility; p = 0.007, 10-meter obstacle walk; p < 0.001 and six-min walk; p < 0.001); thus, a one-way ANOVA was conducted to interpret the before and after results for all groups. The sit-and-reach flexibility results showed no significant differences; however, the 10-meter obstacle walk results for the Minowa participants significantly improved (10-meter obstacle walk before vs after, Minowa, p < 0.001) and the six-min walk time for the Minowa and Matsumoto participants significantly increased (six-min walk before vs after, Minowa and Matsumoto, p < 0.001).

Brain function tests
For subjects in the Minowa group, a comparison of brain function as assessed by the go/nogo tasks from before and after the program showed no significant differences in formation and reverse differentiation. Differentiation reaction times (before: 409.6 ms 6 8.6; after: 380.1 ms 6 9.1, p = 0.021) and average reaction times (before: 392.8 ms 6 7.3; after: 367.1 ms 6 8.0, p = 0.02) significantly decreased after the program. In contrast, the total number of mistakes (before: 2.8 times 6 0.4; after: 1.9 times 6 0.3, p < 0.001) and errors of miss and mistake (before: 2.9 times 6 0.4; after: 2.1 times 6 0.4 p < 0.016) significantly decreased after the program. For subjects in the Matsumoto group, a comparison of brain function as assessed by the go/no-go tasks from before and after the program showed no significant differences in formation, reverse differentiation and average reaction times. Differentiation reaction times (before: 381.0 ms 6 6.8; after: 402.8 ms 6 10.0, p < 0.038) significantly increased after the program. In contrast, the total number of mistakes (before: 4.2 times 6 0.3; after: 2.7 times 6 0.4, p < 0.001) and errors (before: 4.4 times 6 0.3; after: 3.0 times 6 0.4 p < 0.001) significantly decreased after the program. For subjects in the Nagano and control groups, a comparison of brain function as assessed by the go/no-go tasks from before and after the program showed no significant differences in reaction time and the total number of misses, mistakes and errors.
The interaction of the two-way ANOVA was not significantly different for the brain function tests (Table 3).

Pearson's correlation coefficient
The number of steps for the Minowa, Matsumoto, Nagano groups and the differences between the before and after results for the anthropometry measurements, blood pressure measurements, blood chemistry tests, physical fitness tests and brain function tests were analyzed with pearson's correlation coefficient. The results showed a significant relationship between the number of steps (average: 6,847) and systolic blood pressure (r = À0.33, p < 0.001), diastolic blood pressure (r = 0.34, p < 0.001) and grip strength (r = À0.34, p < 0.001). Additionally, the Minowa group showed a significant relationship between the number of steps (average: 8,754) and systolic blood pressure (r = À0.37, p = 0.016), diastolic blood pressure (r = À0.40, p = 0.008) and sit-ups (r = À0.35, p = 0.022), but the Matsumoto group did not. Although there was a correlation between the number of steps (average: 5,258) and the number of mistakes (r = À0.49, p = 0.122) and errors (r = À0.57, p = 0.067) in the go/no-go task in the Nagano group, no significant relationship was found.

Pedometry
Walking improves the human body's defense against diseases and contributes to health improvement (Hamer and Chida, 2008;Golay et al., 2013;Pernar et al., 2017;Hornbuckle et al., 2016). The MHLW of Japan supports the current physical activity guidelines (Ministry of health, labor and welfare, 2000). There are no data for the control group in this study because it has been reported that the control group members who have a pedometer significantly increase their activity (Rooney et al., 2003). However, in another study (Terasawa et al., 2019), control group members were given pedometers with tapes that hid the monitor so they could not see the number of steps they took. They walked two weeks and the average number of steps was 5,220.
An investigation in 2011 by the Japanese MHLW showed that the average number of steps was 7,841 for men and 6,883 for women of 20-64 years of age and 5,628 for men and 4,584 for women of 65 years of age and over. "Kenkou Nippon 21" recommends 9,000 steps for men and 8,500 steps for women of 20-64 years of age and 7,000 steps for men and 6,000 steps for women of 65 years of age and over by 2020 (Ministry of health, labor and welfare, 2000). In the Minowa group (average age: 62.7), the average numbers of daily and exercise steps were 8,753.6 6 492.3 and 5,592.2 6 448.2, respectively. In the Matsumoto group (average age: 66.0), the average numbers of daily and exercise steps were 6,529.4 6 328.1 and 4,032.5 6 275.8, respectively. In the Nagano group (average age: 65.0), the average numbers of daily and exercise steps were 5,258.4 6 559.5 and 2,782.2 6 544.3, respectively.
The number of steps in the Minowa and Matsumoto groups exceeded the target number of steps recommended by the MHLW for women, but in the Nagano group, both men and women fell short of the target. It has been reported that fast walking promotes the prevention of dementia (Nakamura et al., 1996;Babaei et al., 2013); however, the Minowa group's number of exercise steps was 64% of normal walking, the Matsumoto group's was 62% of normal walking and the Nagano group's was 53% of normal walking. The Minowa group had the highest percentage of normal walking. However, in all areas, more than half of the normal walking included exercise steps.

Anthropometry and blood pressure measurements
The Minowa and Matsumoto groups showed significant decreases in weight and BMI, but the Nagano and the control groups did not. The Minowa group showed a significant decrease in systolic and diastolic blood pressure, but the Matsumoto, Nagano and control groups did not. There is a possibility that the above results reflect the number of daily and exercise steps of the Minowa, Matsumoto, Nagano and control groups: 8,753.6 6 492.3 and 5,592.2 6 448.2, 6,529.4 6 328.1 and 4,032.5 6 275.8 and 5,258.4 6 559.5 and 2,782.2 6 544.3, respectively. That is, if the number of daily steps is more than 8,700, weight, BMI, systolic and diastolic blood pressure may show significant decreases and if the number of steps is more than 6,500, weight and BMI may show significant decreases.

Blood chemistry tests
The Minowa group showed significant decreases in fasting blood glucose and HbA1c, but the Matsumoto and control groups did not show significant differences in any of the blood test items. The Nagano group showed a significant decrease in LDL but no significant differences in the other items. In our previous surveys, there were cases that showed significant decreases in LDL corresponding to the number of steps. However, in this survey, the Nagano group showed a significant decrease in LDL, although the number of steps of the Nagano group was smaller than that of the Matsumoto group.
For subjects in control, HbA1c levels significantly increased after the program. Regular exercise improves blood glucose and lipid metabolism (Balducci et al., 2010;Zahra et al., 2010).

Physical fitness tests
The Minowa group showed significant improvement in grip strength, the number of sit-ups, sit-and-reach flexibility and 10-meter obstacle walk and six-min walk results but not in eyesopen single-leg stance ability. The maximum value for the eyes-open single-leg stance was set at 120 sec. The Minowa group's initial value for eyes-open single-leg stance was 102 sec, which was already a high value, the highest among all of the other areas. This may be the reason why it did not show significant improvement. The Matsumoto group showed significant improvements in the number of sit-ups, 10-meter obstacle walk and six-min walk, but sit-and-reach flexibility decreased. The Nagano group showed significant improvement in the number of sit-ups. The control group showed no significant improvement for any item.
The sit-and-reach flexibility, 10-meter obstacle walk and six-min walk interaction from the two-way ANOVA was significantly different; thus, a one-way ANOVA was conducted to interpret the before and after results for all groups. The sit-and-reach flexibility results showed no significant differences; however, regarding the 10-meter obstacle walk, the results of the Minowa participants improved significantly and more than any other group and the Matsumoto group had the second greatest improvement; In the six-min walk, the time of the Minowa participants significantly improved. We speculate that these results for the physical fitness measurements are related to the number of steps.
In addition, the walking speed and distance of the participants with dementia was significantly slower and shorter than the healthy participants (Nakamura et al., 1996;Babaei et al., 2013).
The Japanese MEXT has conducted physical fitness tests on people of 6-79 years of age since 1999. Physical fitness tests on people of 65-79 years of age included grip strength, sit-ups, sit-and-reach flexibility, eyes-open single-leg stance, 10-m obstacle walk and sixmin walk. We have chosen these physical fitness tests for the healthy elderly people. In Japan, this test is called the "new physical fitness test," and it involves more than 5,000 data points from people 65 to 79 years old recruited every year from 2000 to the present, as a result of which this data set is unprecedented worldwide (Ministry of Education, Culture, Sports, Science and Technology, 1999). In addition, the Japanese MHLW conducts physical fitness tests for the care of people > 65 years, namely, grip strength, eyes-open single-leg stance, timed up and go test and six-m normal and maximum walk times (Ministry of health, labor and welfare, 2009). Increased exercise momentum leads to improved physical fitness tests results (Leite et al., 2015;Shao et al., 2014).

Brain function tests
Go/no-go tasks are frequently used to investigate response inhibition, an essential executive function implemented by the prefrontal cortex and these tasks recruit a variety of cognitive components in addition to response inhibition (Masaki and Moriyama, 1971;Terasawa et al., 2014aTerasawa et al., , 2014bDiamond, 2013;Chikazoe, 2010).
For subjects in the Minowa group, the go/no-go tasks from before and after the program showed no significant differences in formation and reverse differentiation. However, the differentiation reaction times and average reaction times significantly decreased after the program. In contrast, the total number of mistakes and errors significantly decreased after the program.
For subjects in the Matsumoto group, a comparison of brain function as assessed by the go/no-go tasks from before and after the program showed no significant differences in formation, reverse differentiation and average reaction times. Differentiation reaction times significantly increased after the program. In contrast, the total number of mistakes and errors significantly decreased after the program.
For subjects in the Nagano and control groups, a comparison of brain function as assessed by the go/no-go tasks from before and after the program showed no significant differences in reaction time and total number of misses mistakes and errors.
Go/no-go tasks studies in the literature have suggested that a health program could improve brain function, including working memory (Masaki and Moriyama, 1971;Terasawa et al., 2014aTerasawa et al., , 2014bDiamond, 2013;Chikazoe, 2010); in those studies, subjects performed regular exercises in the first stage where go/no-go task reaction times increased significantly and the numbers of error responses decreased significantly. In the second stage, go/no-go task reaction times decreased significantly and the number of error responses decreased significantly.
The Minowa group's reaction time became significantly faster and the number of errors significantly decreased after the program, both of which are the characteristics of the second stage of improvement. The Matsumoto group's reaction time became significantly slower and the number of errors significantly decreased after the program, from which we speculate that the Matsumoto group was in the first stage of improvement. The average number of daily steps was 8,753.6 for the Minowa group, 6,529.4 for the Matsumoto group and 5,258.4 for the Nagano group. From the above results, there is a possibility that the improvement in the go/no-go results may not occur with a daily amount of activity of 5,258.4 steps.

Pearson's correlation coefficient
The number of steps for the Minowa, Matsumoto, Nagano groups and the differences between the before and after results for the anthropometry measurements, blood pressure measurements, blood chemistry tests, physical fitness tests and brain function tests were analyzed with pearson's correlation coefficient. The results showed a significant relationship between the number of steps and systolic blood pressure, diastolic blood pressure and grip strength. Additionally, the Minowa group showed a significant relationship between the number of steps and systolic blood pressure, diastolic blood pressure and sit-ups, but the Matsumoto group did not. Although there was a correlation between the number of steps and the number of mistakes and errors in the go/no-go task in the Nagano group, no significant relationship was found. The factors that led to this condition in Minowa may be that the subjects and the instructors had enough time to build positive and meaningful relationships, which led to increased motivation and thus, an increased number of daily steps. In the control condition, the subjects initially taped the pedometer so that the step value was invisible and not influenced by the instructor. Then, the instructors removed the tape from the pedometer, set the goal of the number of steps, printed out the number of steps on a graph and met with the subjects and provided individual guidance. As a result, the step value of the group gradually but significantly increased from 5,221 steps in the control condition to 8,457 steps in the final condition (Terasawa et al., 2019). Only Nagano showed a significant correlation between the number of steps and the results of the go/nogo tests. Overall, in our previous surveys, the measured values of the go/no-go tests performed at the beginning of the intervention (before health education) show a short reaction time and a large number of errors in the first stage. In the second stage, after subjects continue to exercise, the results show a significantly longer reaction time and a significantly smaller number of errors. It has been reported that with further continued exercise, the results show a shorter reaction time and a significantly smaller number of errors in the third stage Watanabe et al., 2015;Murata et al., 2015). It may be possible that Nagano followed the same second stage shown in the previous surveys and that the number of steps and the go/no-go test results showed a significant correlation, while Matumoto and Minowa may have followed the same third stage shown in the previous surveys, with no significant correlation between the number of steps and the go/no-go test results.

Conclusions
This study aimed to appropriately establish a Japanese-style healthcare program under the ISO 9001:2008, to improve problem areas and inspect its effectiveness. Furthermore, we want to make this health promotion through ISO widely available in Asian countries and an international contribution. The 46 Minowa subjects was 46 were of 62.7 6 4.7 years of age (mean 6 SD). The 69 Matsumoto subjects were of 66.0 6 5.8 years of age. The 35 Nagano subjects were of 65.2 6 4.6 years of age. The seven control subjects were of 61.3 6 7.8 years of age. That study assessed findings from pedometric, anthropometric and blood pressure measurements and physical fitness, blood chemistry and brain function tests. In the Minowa group (average age: 62.7), the average numbers of daily and exercise steps were 8,753.6 6 492.3 and 5,592.2 6 448.2, respectively. In the Matsumoto group (average age: 66.0), the average numbers of daily and exercise steps were 6,529.4 6 328.1 and 4,032.5 6 275.8, respectively. In the Nagano group (average age: 65.0), the average numbers of daily steps were 5,258.4 6 559.5 and 2,782.2 6 544.3, respectively. The factors that led to this condition in Minowa may be that the subjects and the instructors had enough time to build positive and meaningful relationships, which led to increased motivation and thus, an increased number of daily steps. Thus, the number of daily steps, which shows the amount of daily activity, was significantly correlated with blood pressure and the results of physical fitness tests in Minowa. Groups from three regions in Japan showed significant differences on the physical fitness tests; regarding the 10-meter obstacle walk, the Minowa participants showed the greatest improvement and the Matsumoto participants showed the second-largest improvement. On the six-min walk, the time of the Minowa participants significantly improved.

Future research issues
We could not fully control the following factors in this study. The participant groups in the 2 countries had differences in the size of the groups and in their surrounding environment, including customs, climate and culture. Further work is necessary to consider these differences and to examine larger and equally sized subject groups.