Dr. Takashi Kadowaki
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- Dr. Takashi Kadowaki
In Japan, the effort of NCD control had occurred at various levels, including the national level, municipality level, medical alliances, academic societies and associations, where each has a different and unique stance. I believe that these efforts will give birth to a synergistic effect in national NCD-control. I hope that Japanese NCD prevention initiatives will set a world example in combating NCD.
The issue of NCD in the super-aging Japan
Japan as a super-aging society is facing a huge problem of NCD today. The nation has expanded its efforts to combat NCD in the areas of cardiovascular disease, cancer, chronic respiratory disease and diabetes. The data of MHWL in 2007 showed approximate 22.1 million people in the nation suffered from diabetes, where 8.9 million people were diabetes patients, and 13.2 million people were at-risk. The rise of the prevalence of NCD is thought to have been related to the change in the lifestyle over the past decades. Although Asians are known to have lower insulin secretory capacity to compensate for insulin resistance, the traditional Japanese lifestyle that had been centered by the traditional food and work culture, where people exercised extensively, had spared the Japanese from the problem of diabetes in the past. However, today, the sedentary lifestyle that the Japanese have adopted over the past decades had resulted in rapid accumulation of visceral fat, in accompany with the poor insulin secretory capacity, was thought to have led to insulin resistance (a physiological condition in which cells (muscle cells and fat) fail to respond to the normal actions of the hormone insulin *insulin: a hormone made in the pancreas). Visceral fat obesity and metabolic syndrome are often comorbid with hypertension and dyslipidemia, and are considered as the major contributing factors to diabetes and cardiovascular diseases (e.g. cerebrovascular disease, ischemic heart disease etc.).
The Situation of NCD-Control in Japan
In the effort to prevent NCD, the country has established a basic health policy named “Healthy Japan 21” to promote overall/general health of the people based on the Law for Health Promotion. The national policy of NCD control has been focused on both the population approach and high risk approach, where the high risk patients are given specific support such as metabolic health checkup and lifestyle guidance, However the participant rate for this program is still low, although the attempts to prevent cardiovascular disease and diabetes by reducing visceral fat in the metabolic health checkup have shown to be successful in certain regions and occupational field. Also, we are still far below target where small number of people are able to exercise self-awareness for the needs of changing their lifestyles, or they could practice “motivation support” on lifestyle modification, or showing the capability to demonstrate persistency in “proactive support” to reach the final goal, MHLW is currently working on revising the plan and the quality of the scheme in preparing for the next roll out of metabolic health checkup in April, 2013.
Efforts of the national governmental, local governments and academic societies
MHLW had set 4 goals for diabetes. 1. Reduce the incidence of dialysis in diabetic nephropathy. 2. Increase the proportion of patients that receive ongoing treatment. 3. Decrease in the proportion of patients with poor glycemic control. 4. Minimize the new diagnosis of diabetes patients. In addition to the above, lifestyle modification, improve of the social environment, the problem of diet nutrition particularly physical activity, and exercise has been emphasized.
Every year, we have about 16,000 new dialysis patients. In recent 2 to 3 years, the growth had been flattened, or we may consider that there is a turning down trend in new diagnosis of dialysis. Japan’s effort is thought to have been fruitful in view that we have successfully reduced the number of dialysis patients. On the other hand, this could be an indication where the consciousness of healthy lifestyle was increased and diabetes management was improved. We also believe that the success in dialysis control is the results of the consensus reached through the promotional nationwide regional meeting and conferences for diabetes control by the combine effort of various key holders, such as “Healthy Japan 21”, metabolic checkup, Japan Medical Association, Japan Diabetes Society and Japan Diabetes Association. In the various campaigns of regional corporations and health care plans for diabetes, awareness was raised, thus led to early detection and early treatment of the disease.
At present, there are about 40% diabetes patients that are not receiving any treatment. Treatment interruption in diabetes patients results in elevated risk of complications. Although the rate of the number of patients receiving medical care had increased, there are still a lot more that we need to work on. In evaluating the efficacy of reducing the rate of medical consultation discontinuation in diabetes patients, efforts of defining process for clinical indicators of diabetes is made, the results of the study of strategies for the prevention of diabetes showed that interruption of treatment was reduced by about 60%.
In addition to the basic intervention of diet and exercise, the common use of incretin-related drugs, especially the DPP-4 inhibitors, is thought to have played a crucial role for the decrease in the rate of patients with poor glycemic control in Japan. Currently, 2 million out of 5 million people that are taking an oral hypoglycemic agent are on inhibitors DPP-4. Proper use of drugs with novel pharmacodynamic and pharmacokinetic mechanism such as inhibitors DPP-4 includes careful verification of the drug side effects and safety in each individual, which accumulating data base and clinical research are extremely important. As diabetes intervention is more effective in early detection, the Japan Diabetes Society had revised the diagnosis criteria for diabetes in July 2010 for early detection.
In this way, I think that the collaboration of different approaches by the centre government, local government, and the alliance of the local academic societies (e.g. Japan Medical Association, the Japan Diabetes Society, and the Diabetes Association of Japan), will create a certain impact to the diabetes control. Continuous efforts are necessary until a significant decrease to the desired number in/significant control diabetes nephropathy is achieved. Also, the corporation between Japan Diabetes Society and Japan Society of Nephrology had resulted in the collaboration approach of metabolic control and chronic kidney disease control. Such efforts might lead to the synergistic effect for diabetes control.
Sharing our NCD control experience with others
Although the number of diabetic patients seemed to increase, the growth rate is quite slow after adjusting age when the factor of rapid aging is considered. In that sense, the individual approaches at national, society, medical society and association levels seemed to have bared fruits. Japan has considered various health approaches to combat NCDs. The effort of NCD control in Japan is most probably to be success as there is a high level of awareness in the nation, and each municipality had worked out a fine-grained measure.
I believe that the approach for NCD prevention in Japan will probably set a world example in NCD control. As NCD is a common clinical condition in Asia, I believe that our experience can contribute to the NCD solution in Asia.