Yasuto Kawakami, M.D.
Director of Public Health Center, Kobe City

In the context of rising health care provision costs, and high instances of lifestyle related diseases and health-related suicides, Yasuto Kawakami, M.D. outlined preventive measures to improve the health of citizens in Kobe.

With a rapidly increasing aged population and financial burdens on the health care system, the 2002 New Kobe Healthy 21 plan brought a shift from therapeutic to preventive medicine. 

The top three causes of death among aged people in the city are malignant neoplasm (cancer) 33%, cardiac disease (heart) 15% and cerebrovascular disease 10%, and suicide rates are also high. In this light, the plan incorporates specific aims to decrease the number of early deaths, and prolong the health and improve the quality of life of citizens. Concretely, this is to be achieved by focusing on the prevention of lifestyle related diseases, cancer and suicide, through increased awareness, health checks and other preventive measures. 

In 2004, lifestyle related diseases accounted for a massive one third of public medical expenses (10.4 trillion yen). The city realized the need for guidance and check-ups for metabolic syndrome, as the disease is a preventable lifestyle related condition which, if untreated, leads to stress, debilitating illnesses, and even suicide. High stress rates and deteriorating diets bring a higher prevalence of metabolic syndrome, and it is believed that one in two males and one in five females in Japan are suffering from or at risk of the syndrome. Its various stages are categorized as follows:

- Level 1 - inappropriate diet (excess ingestion of energy, salt, fat etc.); lack of exercise; smoking; excessive alcohol consumption; extreme stress. 

- Level 2 - obesity; hyperglycemia; hypertension; hyperlipidemia. 

- Level 3 - adiposis (esp. visceral type); diabetes mellitus; hypertension; hyperlipdemia. 

- Level 4 - ischemic heart disease (myocardial infarction, angina pectoris); cerebral accident (hemorrhage, infarction etc); complications of diabetes mellitus (blindness, dialysis etc.). 

- Level 5 - hemiplegia; difficulties of daily life; dementia. 

The domino effect of metabolic syndrome means that it can eventually lead to dementia, nervous breakdown, or cerebral disease. Its diagnosis is based on an abdominal circumference measuring over 85cm in men, 90cm in women, plus two out of three of hyperlipidemia, hypertension (high blood pressure) or hyperglycemia. The large abdominal circumference with one disorder classifies a person as ‘at risk’ of metabolic syndrome. 

If covered by National Health Insurance, citizens are offered checkups and medical guidance at a reduced rate of 500 yen (the price of a cheap lunch), in a scheme that aims to reach 283,000 people over a five-year period. These checkups examine history of pharmacotherapy, smoking habits etc.; physical measurements (body height, body weight, BMI, abdominal circumference); physical condition and blood pressure measurement; blood lipid (neutral fat, HDL cholesterol, LDL cholesterol); hepatic function; blood sugar levels (fasting blood glucose, ＨｂＡ１ｃ); renal function (urinary acid, serum creatinine); and urine (sugar, protein, occult blood). Metabolic testing and motivational support are given to encourage citizens to change their lifestyle as they approach old age. 　 

Rates of cancer in Kobe, especially stomach cancer, are higher than national levels, and the city has a high rate of Hepatitis C. Cerebral and cardiac disease rates, however, are below the national level. According to the Health, Labor and Welfare Ministry’s Study Group Report on the Assessment of Efficacy for Medical Checks of Cancer, medical checkups reduce the rates of stomach cancer by 40-60％, cervical cancer by 80％, and large intestinal cancer by 60％. So, the city is now carrying out medical checkups for stomach cancer, uterine cancer, breast cancer, lung cancer, large intestinal cancer and prostate cancer. The aims are to increase the overall medical checkup rate by 50% within 5 years; to reduce the age-adjusted mortality rate by 20% in persons aged under 75 within ten years; and to completely eliminate underage smoking within 3 years. The National Plan for Promotion of Basic Planning against Cancer also targets an increased checkup rate to 50% of citizens. 

The Supporting Manual for Non-smoking, issued by the Health, Labor and Welfare Ministry, outlines how smoking increases the risk of oral and pharyngeal cancer, lung cancer, laryngeal cancer, ischemic heart disease, cerebrovascular disease, chronic obstructive lung diseases such as chronic bronchitis and pulmonary emphysema, periodontal disease etc. Kobe City is active in its implementation of anti-smoking related health campaigns, non-smoking and separate public areas for smokers, as well as a system of 1000 yen fines for those caught smoking in the downtown area. These have helped to reduce the number of smokers in the city to below the national average. 

There is also a focus on prevention of passive-smoking, as a person whose spouse smokes more than 20 cigarettes per day is almost twice at risk of lung cancer. The Public Health Center target is to reduce the number of smokers in the city by more than 50% of the year-2000 rate; smokers with babies from a current 46% to less than 20%; minors and gravidas from 2.2% and 5.4%, respectively to 0%; to increase the rate of citizens aware of the connection between cigarettes and gum disease from the present rate of 61.4% to more than 80%, and the rate of communal facilities implementing non-smoking or separate smoking areas from 99% to 100%. 

Since a sharp rise during the economic downturn of 1998, the suicide rate in Japan has consistently been at over 30,000 deaths per year. The highest incidence of suicide is among citizens aged 60-69 years, and 60% of those cases are due to health issues. By raising citizen awareness on both the circumstances that can lead to suicide and outward signs of suicide contemplation, the objective is to reduce the suicide rate in Kobe City by 20% by 2016. A local government survey of 10,000 Kobe citizens worryingly showed that 70% suffer from mental fatigue or stress, especially those aged 40-49 years. 

A clear link can be seen between stress levels, lifestyle related diseases, and ultimately poor mental and physical health in later life. Through a preventive focus of increased public awareness, check-ups and early diagnosis, Kobe City health authorities aim to break the link early, so that health can be part of the achievement of old age.