Diabetes is a global health concern affecting millions. The 2021 International Diabetes Federation (IDF) report suggests a rapid increase in diabetes prevalence with the condition affecting 537 million (one in ten) adults globally. By 2045, it is estimated that 783 million (one in eight) adults will be living with diabetes.1
Recently there has been a rapid growth in diabetes in Japan. As per IDF 2021 estimates, 11 million adults in Japan have diabetes. The high prevalence of diabetes is associated with a significant economic burden and can be attributed to lifestyle changes and increased longevity.2,3
This article highlights the current scenario of diabetes in Japan with insights from Dr. Kumiko Hamano, an Endocrinologist from Kanto Rosai Hospital, Japan on the role that patients and clinicians can play by working together for better outcomes.
Diabetes in Japan – Assessing the Current Situation
In Japan, aging and obesity contribute to the increase in diabetes prevalence. Of this, the rapidly aging population is a major concern, which makes disease management a challenge.4
Apart from disease management, the economic impact of diabetes in Japan is significant. In the fiscal year 2018, medical costs for diabetes reached 1.21 trillion yen or 2.8% of Japan’s total medical costs. Untreated patients, therapy drop-outs, and the cost of treating diabetic complications contribute to the escalating costs of medical care.5
What is the Reason for Increase in Diabetes Burden in Japan?
A westernized diet is touted to be a major reason making Japanese people more prone to developing type 2 diabetes. Traditional Japanese food includes low fat and calorie content, but a shift in people’s preference for processed food especially food high in animal fat and calories is reported to have increased abdominal adiposity, eventually resulting in type 2 diabetes.4
Public awareness and education are important in diabetes – yet there is a lack of standard diabetes education support tools for people with diabetes in Japan. Alongside this, a lack of time and enthusiasm among the people and stigma related to the disease are some additional barriers. While employee-based and community-based diabetes screening tests are regularly carried out in Japan, there is still a lack of systems for treating them immediately after screening resulting in the loss of the most important period of the therapy and the development of complications.6,7
Diabetes Management in Japan – Unmet Needs
Diabetes shows no symptoms in the early stages and people often avoid going for regular checkups. As a result, in Japan, diagnosis is made mainly in people in their middle age, and treatment is eventually delayed.
The second challenge is the aging population. With the accelerated aging of society, the number of elderly patients with diabetes continues to rise in Japan. In the aged population, the disease is advanced, and treatment is usually insufficient. The elderly may have several health issues apart from diabetes and are also more susceptible to severe hypoglycemia which impairs cognitive function and can increase the risk of cardiovascular events.8
Polypharmacy is another problem. Management of diabetes and its complications can lead to the addition of several medications to the drug regimen, contributing to polypharmacy. In Japan, around 65% of hospitalized patients with type 2 diabetes report using six or more medications. Polypharmacy is associated with a higher risk of drug interactions, adverse events, and non-adherence, all of which can negatively impair the person’s quality of life.9
More needs to be done when it comes to patient-centric care for diabetes. As per Dr. Hamano, in Japan, the clinics are usually busy and insufficient time is allotted for medical interviews and extensive physical examinations per patient.
Strategies to Improve the Current Situation
Curbing the increasing prevalence of diabetes requires the implementation of effective preventive strategies, mainly screening people at high risk for diabetes, increasing awareness, and promoting a healthy lifestyle.
Government Initiatives to Screen Diabetes
In April 2008, the Japanese Ministry of Health, Labor, and Welfare introduced a nationwide health screening and intervention program specifically targeting metabolic syndrome. The program included annual health check-ups (covered as primary beneficiaries under the health insurance system) focused on abdominal obesity and cardiometabolic risk factors, for individuals, or their family members, aged 40–74 years.10
The program resulted in a substantial and sustained improvement in abdominal obesity and reversal of metabolic syndrome, however, as per Dr. Hamano, such national programs are not sufficient to decrease or prevent type 2 diabetes because people are not motivated to prevent diabetes.11
Assessing the Patient’s Roles
Diabetes is a lifestyle-related disease, so education is important. It is crucial for diabetic patients to be aware of the nature, treatment, risk factors, and complications of the disease. Diabetes education and knowledge to control diabetes at the right time can minimize the chances of complications and reduce morbidity and mortality.12
As per Dr. Hamano, education needs to start very early at school. Educational initiatives targeting younger Japanese on a change in diet, nutrition, and physical activities should be prioritized.
Patients also play a vital role in monitoring their diabetes. Diabetes self-monitoring can be useful for diabetes management, especially for the prevention of chronic complications. However, there are accessibility issues with blood sugar monitoring in Japan – it’s only distributed by the hospital under reimbursement, says Dr. Hamano. So, the patients have very limited resources to manage their disease.13
Compounding the problem, patients in Japan are hardly involved in any decision-making process. Due to a lack of scientific knowledge of their disease, patients often might make misjudged decisions that could be detrimental. Increasing patient involvement in disease management is critical.
Clinician’s Role in Managing Diabetes
Role of biomarkers for cardiovascular disease management in type 2 diabetes
Individuals with type 2 diabetes have a significantly elevated risk of developing cardiovascular disease. Cardiovascular biomarkers are useful tools for determining patient prognosis in type 2 diabetes and may inform therapeutic mechanisms of action.
In type 2 diabetes, N-terminal (NT)-pro hormone BNP (NT-proBNP), released from stressed cardiomyocytes is strongly associated with heart failure diagnosis and adverse cardiovascular events. The CANVAS study highlights the use of NT-proBNP for identifying the risk of developing cardiovascular diseases in type 2 diabetes patients. Patients with type 2 diabetes mellitus are at high risk for cardiovascular events including heart failure, especially when blood levels of NT-proBNP are elevated, but treatment with canagliflozin reduces this risk. The PONTIAC study concluded that NT-proBNP is an excellent marker to select diabetic patients at risk of cardiac events. Patient pre-selection using NT-proBNP concentration may also help identify diabetes patients who can benefit from intensified multifactorial intervention.14,15
The 2021 joint Consensus Statement from the Japanese Circulation Society and the Japan Diabetes Society also emphasizes the importance of biomarker measurement in the diagnosis of cardiovascular diseases in people with type 2 diabetes.16
Using NT-proBNP to identify cardiovascular disease risk in type 2 diabetes – Dr. Hamano’s clinical practice
Heart failure symptoms are masked in the early phase of the disease – patients usually present with subjective complaints that may be confused with aging or just fatigue. Hence, diagnosis of heart failure in the early stage is often delayed. Biomarkers such as natriuretic peptides have high sensitivity and specificity and measuring these biomarkers can help differentiate heart failure from other conditions. Dr. Hamano has been using NT-proBNP measurement for routine practice since 2007. She measures NT-proBNP in type 2 diabetic patients, mainly those who have more than 10 years of the disease and established cardiovascular risks.
As per Dr. Hamano, starting early routine check-ups of NT-proBNP can help prevent cardiovascular disease more effectively. It should be measured at least once when diagnosed with type 2 diabetes because they possibly may be having diabetes long before being diagnosed with type 2 diabetes.
Measuring NT-proBNP in routine clinical practice can also help detect silent ischemia and save lives. As per Dr. Hamano, measurement of NT-proBNP has been instrumental in identifying high-risk patients such as those with triple vessel disease and referral to cardiologists at the appropriate time has saved many lives.
Diagnostic Innovations Can Bring Patients to the Core of Healthcare
Diagnostic innovations can bring patients to the core of healthcare and improve clinical outcomes for individuals living with diseases such as diabetes. Such innovations would be useful for the younger generations and may become mainstream in the future. Individualizing patient care is important when managing diabetes– the individual’s lifestyle, mental state, education, economical level, and social background should always be considered.
