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Nagoya Journal of Medical Science logoLink to Nagoya Journal of Medical Science
. 2024 May;86(2):262–279. doi: 10.18999/nagjms.86.2.262

Gender and age variations in the association between multigenerational cohabitation and self-rated health among middle-aged and older adults in Japan

Akane Nogimura 1,2, Takahiro Otani 1, Taiji Noguchi 1,3, Hiroko Nakagawa-Senda 1, Miki Watanabe 4, Tamaki Yamada 5, Sadao Suzuki 1
PMCID: PMC11219238  PMID: 38962421

ABSTRACT

Despite encouraging multi-generational cohabitation, the population of Japanese people living alone has increased. However, little is known about the association between health and multigenerational cohabitation. This study examined the relationship between self-rated health and living arrangements among Japanese adults using data from the Japan Multi-Institutional Collaborative Cohort Study (2013–2017). The analysis employed multivariate logistic regression to examine the associations. Our results showed no association between living arrangements and self-rated health when stratified by gender. Living alone was found to be associated with poor self-rated health among women aged 65 and above. A similar association may exist among men in the same age group. Among women aged < 65 years, two-generation cohabitation was associated with a good self-rated health, similar to those living alone. Among men aged < 65 years, neither living alone nor two-generation cohabitation was significantly associated with good self-rated health. We found no association between three- or plus-generation cohabitation and self-rated health. Therefore, our findings indicate associations between multigenerational cohabitation and self-rated health, but they vary by gender and age. Invested stakeholders in the public health field should consider the potential impact of living arrangements on health based on gender and age.

Key Words: health status, Japan, living arrangements, multi-generation cohabitation, self-rated health

INTRODUCTION

Living arrangements are defined by household composition or the number and identities of cohabitants. Households are key factors that determine individuals’ social roles through social integration, social support, and interaction.1 Generally, social support can improve health and buffer stress-related adverse effects.2 However, social relationships in household living arrangements differ from other social setups. Although household members provide care, comfort, and intimacy, they also cause frustration and conflict.3 This may vary depending on the household composition, including multigenerational cohabitation, and the health effects could be complex, requiring a deeper understanding of the relationship between living arrangements and health.

Living arrangements differ based on culture and time. Studies have reported that individuals in East Asian countries are more inclined to live with others compared to their counterparts in European countries.4 However, the number of people living alone in Japan has increased in recent decades. In the 1980s, more than 40% of people in Japan lived with their spouses and children, but this had declined5 to 27.9% by 2020. In the traditional Japanese family system, three generations live together: older adult parents, their children and grandchildren.6 Nevertheless, the percentage of people living in this arrangement has decreased7 from 15.3% in 1986 to 5.9% in 2016, while the percentage of people living alone has increased5,8 from 19.6% in 1980 to 35.7% in 2020. In light of these changes, the Japanese government began encouraging three-generation cohabitations or close living in 2006 to promote cooperation regarding care provision between children and their older adult parents.9 Conversely, in Western countries, the prevalence of intergenerational cohabitation has always been low. Several studies have demonstrated the association between living arrangements and health and have reported that living with a spouse may reduce morbidity10 and improve mental health,11,12 whereas living alone is not beneficial for mental health.11-14 Studies have also shown that people living with children are less likely to rate their health as poorly as those living alone.15 Although research has examined the health implications of living alone or with a spouse, few have focused on multigenerational cohabitation. Additionally, the association between living arrangements and health may vary by gender and age, but little is known. As living arrangements have changed rapidly across Japan, new evidence on the association between living arrangements, including multigenerational cohabitants, and health is needed.

Self-rated health (SRH), used in many epidemiological studies, has been suggested as a useful subjective measure of a person’s overall health status. It is commonly used in epidemiological studies as a simple and cost-effective method to assess an individual’s health status. Epidemiological studies have used SRH to predict mortality16-21 and morbidity.22-24 Previous studies have demonstrated SRH’s validity and reliability.17,18,23,25 SRH has demonstrated a correlation with various physical conditions,26-28 and can be influenced socioeconomic status (SES), psychosocial factors, lifestyle, cultural background, age, and gender.21,29-31 Various researchers have suggested that the relationship between living arrangements and SRH reflects the culture and should not be ignored.15,32,33

Accordingly, this study aimed to examine the association between living arrangements and SRH, focusing on multigenerational cohabitation and investigating differences by gender and age.

MATERIALS AND METHODS

Study population

This cross-sectional study was conducted as a part of the Japan Multi-Institutional Collaborative Cohort (J-MICC) study which was initiated in 2005 with the aim of obtaining data for the prevention of lifestyle-related diseases.34,35 The present cross-sectional study enrolled 35–79 years Japanese adults who participated the study in the Okazaki area. The only exclusion criterion for this study was that the participants needed the cognitive and verbal abilities to answer the questionnaire without help. We collected data from 5,321 individuals (out of 7,580 invited to participate; response rate: 70.2%) who responded to the questionnaire between 2013 and 2017. We excluded participants who were under 45 years, those who provided an “other” response to the question about self-rated health, which was too small for data analysis, and those who did not answer items related to SRH, living arrangements, and all covariates. Our final sample comprised data from 4,347 respondents, including 2,362 respondents aged ≥ 65 years (valid response rate: 87.0%). All participants provided written informed consent, and the study protocol was approved by the Ethics Committee of Nagoya City University Graduate School of Medicine (approval no. 70-00-0058). This study was conducted in accordance with the guidelines of the Declaration of Helsinki.

Self-rated health

We assessed SRH by asking, “How do you rate your health in the last month?” and respondents could choose from the six options: “great,” “pretty good,” “rather good,” “not good,” “rather poor,” and “pretty poor.” For the analysis, we categorized those who answered “great,” “pretty good,” and “rather good” as having “good SRH,” and those who chose “not good,” “rather poor,” and “pretty poor” as having “poor SRH.”

Living arrangements

We categorized the participants’ living arrangements as follows: “living alone (living without family or roommates),” “living with spouse,” “two-generation household,” and “three or more generation household.” Two-generation cohabitation included (1) living with parents or in-laws and (2) living with children. Three-generation cohabitation included (1) living with a parent or parent-in-law and grandparent or grandparent-in-law, (2) living with a parent and child, or (3) living with a child and grandchild. We considered cohabitation of more than three generations similarly. In both cases, we did not distinguish between living with and without a spouse.

Covariates

We included these sociodemographic and health status data in the analyses as covariates: gender, age, marital status, employment status, educational attainment, need for home-based nursing care, and present illness(es) (ie, cancer, heart disease, and stroke). We used four age categories (45–54, 55–64, 65–74, and ≥75 years), three marital status categories (married, divorced or widowed, and never married), two employment status categories (employed and unemployed), and three educational attainment categories (<10, 10–12, or >12 years). We assessed the need for home-based nursing care and present illness (cancer, heart disease, or stroke). We selected these three diseases because they consistently rank among the top causes of death in Japan and have significant effects on health.8 Regarding the need for home-based nursing care and present illness, the respondents selected “yes” or “no” and “no illness” or “ill,” respectively. We assessed mental status36 using the K6, and dichotomized the score37 into ≥5 and <5.

Statistical analyses

All analyses were stratified by gender. First, we used descriptive statistics to summarize participants’ characteristics. Second, to examine the association between living arrangements and SRH, we used multivariate logistic regression analysis to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for poor SRH. We used two analytical models: crude and adjusted models, with covariates. For statistical analysis, we used the group living with a spouse as the reference group because many studies have shown that living with a spouse is associated with better health.15,16,38,39 Third, to examine differences by age group, we performed stratified analyses by age (< 65 and ≥ 65 years). The significance level for all analyses was set at p < 0.05. We used R, version 3.6.3 for Mac (https://www.r-project.org) for all statistical analyses.

RESULTS

Data from 2,472 males and 1,875 females were analyzed, and Table 1 presents the participants’ characteristics. The mean age of participants was 65.7 years for males (standard deviation [SD], 9.1) and 61.8 years for females (SD, 9.0). Most participants lived with their spouses (38.9% for males and 31.8% for females) or in two-generation households (39.0% for males and 40.3% for females). In total, 16.7% of males and 19.1% of females lived in three-generation (or more) households. Living alone was the least common among participants (5.4% for males and 8.7% for females).

Table 1.

Participants’ characteristics (n = 4,347)

Overall
(n = 4,347) 		Living arrangement
Living alone
(n = 297) 		Living with spouse
(n = 1,559) 		Two-generation cohabitation
(n = 1,721) 		Three or more generation cohabitation
(n = 770) 		p-value
n % n % n % n % n %
Self-rated health 0.295
Good 3,506 80.7 238 80.1 1,275 81.8 1,365 79.3 628 81.6
Poor 841 19.3 59 19.9 284 18.2 356 20.7 142 18.4
Gender <0.001
Men 2,472 56.9 133 44.8 962 61.7 965 56.1 412 53.5
Women 1,875 43.1 164 55.2 597 38.3 756 43.9 358 46.5
Age (years) <0.001
45–54 855 19.7 42 14.1 118 7.6 518 30.1 177 23.0
55–64 1,130 26.0 61 20.5 321 20.6 523 30.4 225 29.2
65–74 1,869 43.0 137 46.1 891 57.2 557 32.4 284 36.9
≥75 493 11.3 57 19.2 229 14.7 123 7.1 84 10.9
Marital status <0.001
Never married 146 3.4 75 25.2 4 0.3 61 3.5 6 0.8
Married 3,731 85.8 32 10.8 1,547 99.2 1,467 85.2 685 89.0
Widowed or divorced 470 10.8 190 64.0 8 0.5 193 11.2 79 10.3
Employment status <0.001
Unemployed 1,906 43.8 141 47.5 908 58.2 568 33.0 289 37.5
Employed 2,441 56.2 156 52.5 651 41.8 1,153 67.0 481 62.5
Educational attainment <0.001
<10 years 529 12.2 52 17.5 193 12.4 176 10.2 108 14.0
10–12 years 1,872 43.1 122 41.1 709 45.5 715 41.5 326 42.3
>12 years 1,946 44.8 123 41.4 657 42.1 830 48.2 336 43.6
Need home-based nursing care <0.001
No 3,879 89.2 292 98.3 1,480 94.9 1,509 87.7 598 77.7
Yes 468 10.8 5 1.7 79 5.1 212 12.3 172 22.3
Illness <0.001
No illness 3,520 81.0 239 80.5 1,191 76.4 1,468 85.3 622 80.8
Ill 827 19.0 58 19.5 368 23.6 253 14.7 148 19.2
K6 <0.001
<5 3,239 74.5 228 76.8 1226 77.9 1226 71.2 570 74.0
≥5 1,108 25.5 69 23.2 344 22.1 495 28.8 200 26.0
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Table 2 shows the association between living arrangements and SRH based on multivariable logistic regression analysis by gender (all results are shown in Supplementary Tables 1a and 1b). In both men and women, neither living arrangement was significantly associated with poor SRH compared to living with a spouse (adjusted model, in men: living alone, OR [95% CI] = 1.23 [0.67, 2.24], p = 0.496; two-generation cohabitation, OR [95% CI] = 1.22 [0.94, 1.59], p = 0.123; three or more generation cohabitation: OR [95% CI] = 0.96 [0.69, 1.35], p = 0.835; in women: living alone, OR [95% CI] = 0.85 [0.49, 1.49], p = 0.581; two-generation cohabitation, OR [95% CI] = 0.88 [0.66, 1.18], p = 0.409; three or more generation cohabitation, OR [95% CI] = 0.85 [0.60, 1.20], p = 0.357).

Table 2.

Odds ratios for poor self-rated health adjusted by living arrangements and covariates

Men
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 1.19 0.73 1.87 0.472 1.23 0.67 2.24 0.496
Two-generation cohabitation 1.24 0.98 1.57 0.071 * 1.22 0.94 1.59 0.132
Three or more generation cohabitation 0.98 0.71 1.33 0.890 0.96 0.69 1.35 0.834
Women
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 0.97 0.63 1.47 0.881 0.85 0.49 1.49 0.581
Two-generation cohabitation 1.06 0.82 1.37 0.675 0.88 0.66 1.18 0.409
Three or more generation cohabitation 1.00 0.72 1.37 0.987 0.85 0.60 1.20 0.357
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OR: odds ratio

CI: confidence interval

Adjusted covariates: age, marital status, employment status, educational attainment, need for home-based nursing care, illness, and K6.

Table 3 shows the results of the stratified analysis by age (all results are shown in Supplementary Tables 2a, 2b, 3a, and 3b). For men aged 65 years and older, neither living arrangement was significantly associated with poor SRH. However, for women, living alone was significantly associated with poor SRH (OR [95% CI] = 2.46 [1.03, 6.05], p = 0.045), whereas other living arrangements were not. For men aged < 65 years, living arrangements were not significantly associated with poor SRH. For women, compared with those living with a spouse, two-generation cohabitation was inversely associated with poor SRH (OR [95% CI] = 0.66 [0.45, 0.98], p = 0.036). Although not statistically significant, living alone was associated with good SRH (OR [95% CI] = 0.44 [0.18, 1.02], p = 0.064). Cohabitation of three or more generations was not significantly associated with good SRH.

Table 3.

Odds ratios of participants stratified by age for poor self-rated health adjusted by living arrangements and covariates

Over 65 years
Men
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 1.68 0.962 2.83 0.061 1.83 0.82 4.04 0.136
Two-generation cohabitation 1.15 0.85 1.56 0.367 1.19 0.85 1.65 0.303
Three or more generation cohabitation 0.86 0.56 1.28 0.463 0.85 0.54 1.31 0.482
Women
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 1.21 0.70 2.04 0.486 2.46 1.03 6.05 0.045 *
Two-generation cohabitation 1.32 0.87 2.00 0.193 1.35 0.85 2.12 0.204
Three or more generation cohabitation 1.15 0.69 1.89 0.584 1.21 0.70 2.05 0.489
Under 65 years
Men
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 0.55 0.18 1.39 0.246 0.59 0.17 1.72 0.363
Two-generation cohabitation 1.34 0.87 2.11 0.206 1.31 0.83 2.12 0.264
Three or more generation cohabitation 1.15 0.67 1.99 0.610 1.15 0.65 2.04 0.639
Women
Crude Adjusted
OR 95% CI p-value OR 95% CI p-value
Living arrangements
Living with spouse Reference Reference
Living alone 0.76 0.36 1.53 0.465 0.44 0.18 1.02 0.064
Two-generation cohabitation 0.80 0.57 1.14 0.212 0.66 0.45 0.98 0.036 *
Three or more generation cohabitation 0.80 0.52 1.21 0.289 0.69 0.43 1.10 0.123
Open in a new tab

OR: odds ratio

CI: confidence interval

Adjusted covariates: age, marital status, employment status, educational attainment, need for home-based nursing care, illness, and K6.

DISCUSSION

This study examined the association between living arrangements and SRH. For men, no association was found between living arrangements and SRH in either the middle- or older-age groups. For women, living alone was associated with poor SRH among those aged 65 years and older, whereas it was inversely associated among those under 65 years of age. Additionally, among women aged < 65 years, two-generation cohabitation was inversely associated with poor SRH. Cohabitation among three or more generations was not associated with SRH in either age group. Our findings indicate that the association between living arrangements and health may differ by gender and age, providing additional knowledge about the complexity of the roles of family and cohabitants in an individual’s health.

The results of this study showed that, among those under 65 years of age, women living in two-generation cohabitation were likely to have a likelihood of better SRH. A previous study reported that middle-aged women in multigenerational cohabitation had less health anxiety, and among those women, cohabitation with parents was associated with healthy behaviors.40 Our results were consistent with this idea. Although this study could not identify cohabitants of different generations because of the survey design, living with other people, such as parents or children other than spouses, might play a role in the household for women and improve their self-esteem. Additionally, emotional and social support from cohabitants has been suggested to contribute to health.41 This might be important in promoting health, especially for middle-aged women.

In this study, no significant association was found between three generation or more cohabitation and SRH among middle or older adults regardless of gender. This could be attributed to a lack of data, as detailed information about living arrangements, was not adequately surveyed. There are many forms of cohabitation involving three or more generations: living with parents or parents-in-law, grandparents or grandparents-in-law, living with parents and children, and living with children and grandchildren. The different compositions of cohabitants may have resulted in varying health effects. In a European cohort study, grandmothers caring for their grandchildren showed good SRH, whereas grandfathers did not.42 Studies have investigated the relationship between family structure and depression among older people and found that men had a lower risk of depression when living with their spouses but an increased risk of depression when living with their parents. Conversely, women had a lower risk of depression when living with their children or parents.11 It is assumed that men are less likely to be cared for by their family members, which might be associated with poorer health. Previous studies have shown that the association between cohabitants and health is complex and may vary by gender. Additionally, each person’s role in the family differs depending on culture, family situation, family structure, and individual characteristics, all of which may affect SRH.43-47 Therefore, further studies are needed with a detailed assessment of the type of cohabitants and family situations.

Our results indicated that older women living alone had higher odds of poor SRH, whereas middle-aged women living alone had a potentially positive association with SRH. Several studies on living arrangements have focused on the relationship between living alone and health; they have shown that living alone is a risk factor for poor health among older people,15,48 which is consistent with our results. The prevalence of older people living alone may be attributed to factors such as the family member loss through death or separation. In particular, the financial situation of older women living alone is often difficult and may lead to health loss. In contrast, among middle-aged women, living alone was inversely associated with poor SRH. These findings contradict prior evidence that living alone is associated with worse overall health45 and lower psychological well-being.49 Younger individuals may choose to live alone due to contemporary trends, including delayed or absence of marriage, divorce, and evolving attitudes toward traditional family structures.50 For example, Japanese society once held a prevalent social prejudice against single adults and pressured people—especially women—to marry, but this prejudice has waned over time.51 Alternatively, who opt for living alone, either to assert their independence or due to favorable economic circumstances, may experience better health compared to those living under multigenerational cohabitation. This could be even more true for younger people, who have fewer health concerns than older generations.52 Furthermore, women who live alone tend to lead healthier lives and have a lower mortality rate than men,53 even after adjusting for marital status.54 However, they might decide to live with others as they age or develop health issues.

For men, there was no significant association between living arrangements and health, although living alone was marginally associated with poor SRH. The association between living arrangements and SRH differed according to gender and age. Some studies have suggested that caring for a family and having social support might significantly affect women’s health compared to men’s.55 The link between living arrangements and health might be more apparent financially unstable women with diverse household roles than for men. However, as with women, the association may vary depending on the type of cohabitant and family situation; therefore, further research based on detailed surveys is needed.

This study has some limitations. First, the data did not allow for the differentiation between the different types of three-generation cohabitation. We could not verify whether participants who reported living with their parents or children lived with them. Future research should focus on more detailed family structure when surveying. Second, our data does not examine the financial status of individuals. Considering that financial status can influence both health outcomes and decisions regarding living arrangements, unadjusted economic status could have served as a potential confounding factor in our study. Therefore, future studies should include SES data. Third, our cross-sectional design did not allow us to examine causality, which failed to indicate an association between living arrangements and long-term health. Therefore, further longitudinal studies are warranted. Fourth, the correlations related to multiple comparisons. As this is an exploratory study, it was assumed that corrections for multiple comparisons should not be applied. Therefore, caution should be exercised when interpreting the results. Finally, our participants are not representative of the entire Japanese population. Our sample recruited from the people who visited the public health center for annual health check-ups, which might potentially limit the generalizability of our findings.

Despite these limitations, our findings have practical implications for policymakers, public health specialists, and other scholars. Specifically, we highlight the need to pay more attention to living arrangements in health-related research and decision-making. Japanese culture is heavily influenced by Confucianism; therefore, the notions of filial duty to parents and multigenerational cohabitation are generally considered good and virtuous.39 However, our findings raise questions about whether multigenerational cohabitation will positively affect the health of all Japanese people. As lifestyles, gender roles, and family structures change, living alone may not necessarily be associated with loneliness, social isolation, or lower socioeconomic status, especially among younger adults.38 Thus, we recommend against prescribing a particular living arrangement in favor of considering the support appropriate to various living arrangements, which vary according to individual people, families, communities, and circumstances.

CONCLUSION

This cross-sectional study examined the association between living arrangements, including multigenerational cohabitation, and SRH as a function of gender and age among Japanese adults. The results showed that two-generation cohabitation was inversely associated with poor SRH among middle-aged women but not in older women. Additionally, living alone was associated with poor SRH among older women, it was associated with better SRH among middle-aged women. Among men, living arrangements were not associated with health in either age group. Our findings suggest that the association between living arrangements and health varies by gender and age.

CONFLICTS OF INTEREST

The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

DATA AVAILABILITY STATEMENT

The data sets used in this study are available upon request. Details are available on the J-MICC study website (http://www.jmicc.com/).

ACKNOWLEDGMENTS

We express our sincere thanks to the medical staff of the Okazaki City Medical Association, Public Health Center, for their help with arranging the testing and their contributions to the study. We are also appreciative to all those who participated in the surveys.

FUNDING SOURCES

The J-MICC Study and the J-MICC Okazaki Study were supported by Grants-in-Aid for Scientific Research for Priority Areas of Cancer (no. 17015018) and Innovative Areas (no. 221S0001); by a Grant-in-Aid from the Japan Society for the Promotion of Science (JSPS) KAKENHI Grants (no. 16H06277); by the Japanese Ministry of Education, Culture, Sports, Science and Technology; and in part by a Grant-in-Aid from the JSPS KAKENHI Grants (Basic Research C: nos. 19590643 and 23590806; Research Activity Start-up: no. 19K24277). This study is supported by the JSPS KAKENHI Grants (21K17322 and 22KJ3208).

Supplementary Materials

Supplementary Table 1a

Odds ratio of male participants for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s001.pdf (396.3KB, pdf)
Supplementary Table 1b

Odds ratio of female participants for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s002.pdf (396.2KB, pdf)
Supplementary Table 2a

Odds ratio of male participants over 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s003.pdf (396KB, pdf)
Supplementary Table 2b

Odds ratio of female participants over 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s004.pdf (396.2KB, pdf)
Supplementary Table 3a

Odds ratio of male participants under 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s005.pdf (396KB, pdf)
Supplementary Table 3b

Odds ratio of female participants under 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s006.pdf (396.2KB, pdf)

Abbreviations

CI

confidence interval

J-MICC

Japan Multi-Institutional Collaborative Cohort

OR

odds ratio

SRH

self-rated health

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table 1a

Odds ratio of male participants for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s001.pdf (396.3KB, pdf)
Supplementary Table 1b

Odds ratio of female participants for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s002.pdf (396.2KB, pdf)
Supplementary Table 2a

Odds ratio of male participants over 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s003.pdf (396KB, pdf)
Supplementary Table 2b

Odds ratio of female participants over 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s004.pdf (396.2KB, pdf)
Supplementary Table 3a

Odds ratio of male participants under 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s005.pdf (396KB, pdf)
Supplementary Table 3b

Odds ratio of female participants under 65 years for poor self-rated health adjusted by living arrangements and covariates

2186-3326-86-0262-s006.pdf (396.2KB, pdf)

Data Availability Statement

The data sets used in this study are available upon request. Details are available on the J-MICC study website (http://www.jmicc.com/).

Articles from Nagoya Journal of Medical Science are provided here courtesy of Nagoya University School of Medicine/Graduate School of Medicine

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