Present situation of exercise therapy for patients with diabetes mellitus in Japan: a nationwide survey
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- Cite this article as:
- Sato, Y., Kondo, K., Watanabe, T. et al. Diabetol Int (2012) 3: 86. doi:10.1007/s13340-012-0065-z
This study was performed to investigate the actual situation and problems of exercise therapy in Japan.
A self-recording questionnaire was prepared and sent to 1,200 randomly selected diabetologists and non-specialist physicians of the Japan Medical Association. Responses were obtained from 403 physicians (34% response rate). Two subgroups of the physicians were extracted according to the rate of exercise guidance provided to patients at their initial visit to the clinic: more than 70% [high-rate of exercise guidance (HG) group, N = 212] and less than 50% [low-rate of exercise guidance (LG) group, N = 131].
The rate of exercise guidance was significantly lower (p < 0.001) than that of dietary guidance. About 65 and 53% of physicians in both groups responded that their “lack of time” and the “absence of an additional consultation fee,” respectively, were the main problems they faced for implementing exercise guidance to patients. Compared with the HG group, a higher number of physicians in the LG group responded that there were no specialized physical exercise educators in their clinics (p < 0.001). As to the reasons why patients do not perform exercise, 70% of physicians responded that patients “had no time to exercise” and “were not eager to perform exercise.”
The current survey revealed that, in Japan, the proportion of exercise guidance is low because physicians have no time, they receive no additional consultation fee, and specialized physical exercise educators are lacking. Although an improvement in these factors may lead to higher rates of exercise guidance, we consider that the preparation of specific exercise guidelines for type 2 diabetes patients is essential to effectively implement this therapy in clinical practice.
KeywordsExercise therapyNationwide surveyPhysical exercise educatorExercise guidelines
The number of diabetes patients is increasing worldwide, and Japan was ranked eighth in 2010 . A survey conducted by the Japanese Ministry of Health, Labour and Welfare in 2007 estimated that the number of people strongly suspected of or possibly being diabetic reached 22.1 million, showing that the need to prioritize type 2 diabetes treatment is increasing in Japan . Although dietary intervention combined with exercise is effective for the treatment of type 2 diabetes [3, 4], lifestyle improvement based on diet and exercise is a difficult practice . In Japan, a large number of studies have focused on the utility of exercise intervention for preventing and treating type 2 diabetes [6–8]. However, results of those studies are meaningless if actual prescription of effective exercise therapy is not put into practice by medical institutions. The purpose of this study was to perform a nationwide survey on the actual situation of exercise therapy in Japan and clarify the problems related with this practice.
From July 2008 to January 2009, a self-recording questionnaire was prepared and sent to 1,200 randomly selected physicians: 600 diabetologists and 600 non-specialist physicians from the Japan Medical Association. The questionnaire contained items such as “At what kinds of facilities do you mainly work?” “How many beds does your facility have?” (for subjects who work at a clinic, hospital or university hospital). “Does your facility have a special clinic for diabetic patients?” “Does your facility have admission to an educational program for diabetics?” “How many outpatients do you examine per week (including facilities where you do not mainly work and patients with diseases other than diabetes)?” “What proportion of the patients you examine are diabetics?” “What kind of treatment methods do you use for diabetic patients?” “What is the implementation rate of dietary and exercise guidance for patients at their initial visit to the clinic (including a guidance by staff other than doctors)?” “What kind of dietary and exercise guidance system does your facility use?" (multiple answer). “Does your facility have physical exercise educators?” “What do you feel are the problems related to the implementation of exercise guidance?" (multiple answer). “What do you think the reasons are that diabetic patients do not perform exercise therapy?” (multiple answer).
A request for cooperation explaining that individual results of the investigation would not be disclosed and that the collected data would be used solely for the purpose of this study was enclosed. This study was approved by the Ethics Committee of the Japan Diabetes Society and each institutional review board.
Responses obtained from a total of 403 physicians (275 diabetologists and 128 non-specialist physicians; 33.6% response rate) were used for analysis. Physicians were divided into two groups according to the rate of exercise guidance given to patients at their initial visit to the clinic: (1) more than 70% (high rate of exercise guidance group: HG group) and (2) less than 50% (low rate of exercise guidance group: LG group). The considerations for defining physicians as HG and LG group were as follows: (1) in the distribution of the rate of exercise guidance to patients at their initial visit to the clinic, the 25th, 50th and 75th percentiles of the rate of exercise guidance were 30–50, 70–90 and over 90% of patients, respectively. (2) The aim of this analysis was to examine differences in the problems related with the implementation of exercise guidance between the high- and low-rate exercise guidance groups. Data concerning the system and contents of the medical examination were used in the comparative analysis.
SPSS software was used in the statistical analysis. We used Pearson’s Chi-square test to compare the categorical data, and compared continuous data using the Student’s t test (for parametric variables) and the Mann–Whitney U test (for non-parametric variables). Comparisons between the HG and LG group were done using Pearson’s Chi-square test.
Characteristics of subjects
Clinical characteristics of the subjects
Diabetologists (N = 275)
Non-specialist physicians (N = 128)
215 (78.2)/60 (21.8)
113 (88.3)/15 (11.7)
χ2 = 5.88
Age (years, mean ± SD)
50.3 ± 10.6
52.4 ± 9.8
t = −1.94
Working places (clinic/hospital/university hospital/others)
99 (36.0)/117 (42.5)/54 (19.6)/5 (1.8)
85 (66.9)/31 (24.4)/6 (4.7)/5 (4.0)
χ2 = 41.82
Numbers of beds (no/–19/–99/–499/500–)
88 (32.7)/11 (4.1)/17 (6.3)/72 (26.7)/81 (30.1)
73 (60.3)/10 (8.3)/7 (5.8)/24 (19.8)/7 (5.8)
U = 9900.5
Special clinic for diabetics (yes/no)
174 (64.2)/97 (35.8)
23 (18.0)/105 (82.0)
χ2 = 78.50
Admission to an educational program for diabetics (yes/no)
165 (74.0)/58 (26.0)
38 (46.9)/43 (53.1)
χ2 = 19.64
Number of outpatients per week (–19/–99/–199/200–)
9 (3.3)/104 (38.1)/87 (31.9)/73 (26.7)
7 (5.6)/38 (30.4)/35 (28.0)/45 (36.0)
U = 15899.5
Percentage of diabetic patients (%) (–29/–49/–89/90–)
38 (13.9)/46 (16.9)/128 (47.0)/60 (22.1)
105 (82.7)/17 (13.4)/5 (4.0)/0 (0.0)
U = 3429.0
Situation of dietary and exercise guidance for diabetic patients
Treatment method for diabetic patients (%, mean ± SD)
Diabetologists (N = 255)
Non-specialist physicians (N = 118)
24 ± 15.6
8.5 ± 8.9
Insulin + OHA
12.6 ± 10.2
6.5 ± 9.8
49.2 ± 16.4
64.7 ± 19.2
Diet and exercise only
14.2 ± 9.1
20.2 ± 15.6
Implementation rate of dietary and exercise guidance to patients
Provision of dietary/exercise guidance
Dietary guidance (N = 401)
Exercise guidance (N = 401)
Over 90% of patients
70–90% of patients
50–70% of patients
30–50% of patients
10–30% of patients
Not providing guidance (<10% of patients)
Dietary guidance system (multiple answers)
Diabetologists (N = 273)
Non-specialist physicians (N = 127)
Dietary guidance using dietary information slips
Individual dietary guidance without dietary information slips
Mass dietary guidance
No special systems for dietary guidance
Exercise guidance systems (multiple answers)
Diabetologists (N = 273)
Non-specialist physicians (N = 126)
Exercise guidance using exercise prescription
Individual exercise guidance without exercise prescription
Mass exercise guidance
No special systems for exercise guidance
Presence of physical exercise educators
Diabetologists (N = 259)
Non-specialist physicians (N = 125)
Problems of exercise therapy
Main problems related with the implementation of exercise therapy and reasons why patients do not perform exercise (multiple answers)
HG group (N = 202)
LG group (N = 131)
Main problems related with the implementation of exercise therapy
Lack of time to provide exercise guidance
No additional consultation fee for exercise guidance
Absence of specialized physical exercise educators
No appropriate guidelines for exercise therapy for diabetic patients
Absence of facilities and services to provide exercise guidance
Risk of accidents with implementation of exercise therapy
Lack of compliance by patients
HG group (N = 205)
LG group (N = 130)
Reasons why patients do not perform exercise
Lack of time
Patients are not eager to perform exercise
Patients do not like exercise
Absence of specialized physical exercise educators
Patients do not understand the efficacy of exercise
Patients do not understand diabetes mellitus
The current survey made clear that exercise guidance is proportionally less implemented than dietary guidance in Japan. In addition, lack of time, no additional consultation fee, and absence of specialized physical exercise educators were the three main factors responsible for the low rate of exercise guidance by physicians. Japanese medical institutions have nationally registered dieticians and nutritionists, and therefore, even when physicians have no time to provide dietary guidance to patients, nationally registered dieticians can do it and receive remuneration for their service. However, as there are no established health exercise trainers, in almost all cases physicians are required to provide exercise guidance. A higher rate of physicians in the LG group compared to those in the HG group considered the absence of specialized physical exercise educators a problem for the implementation of exercise therapy, indicating a strong relation between this factor and the low rate of exercise guidance. Taken together, these results suggest that professionals other than nationally registered dieticians are not involved in exercise guidance, and this factor results in the low rate of exercise guidance.
With regard to the reasons why patients do not perform exercise, most physicians indicated that patients have no time or are not eager to perform exercise. However, when patients were requested to point out the reasons why they do not perform exercise, in addition to the lack of time they also indicated physical (backache, knee joint pain, etc.) and psychological (shame, etc.) factors . Thus, we may infer that the real reasons why patients do not perform exercise do not necessarily correspond to what physicians think, and, therefore, it is necessary to access the background of each patient with the aim of increasing the rate of exercise therapy implementation through appropriate guidance . Initial countermeasures such as the presence of a physical exercise educator and a detailed approach may be meaningful.
Although several countries have established diabetes guidelines, detailed exercise guidelines for type 2 diabetes patients such as those of the ADA  do not exist in Japan, and this problem was pointed out by about half of both the HG and LG physicians. Compared to actions such as hiring specialized physical exercise educators, an increase in the time spent by physicians on exercise and the establishment of an insurance claim for exercise guidance by the government, our committee decided that the preparation of exercise guidelines will be more effective for increasing the rate of exercise guidance in medical institutions .
This study revealed the main problems related to the implementation of exercise therapy from the point of view of physicians. A future nationwide survey on the same subject, but emphasizing the point of view of the patients, is necessary to compare the results and establish the most appropriate measures to improve the implementation of exercise guidance. This study was the first survey conducted at the nationwide level on the situation of exercise therapy in Japan, which may be considered its major strength; however, the response rate was very low (33.6%). The use of the Internet and/or other communication means may be needed to increase the response rate in future studies.
In conclusion, the current nationwide survey revealed that, in Japan, the proportion of exercise guidance is low because physicians have no time, there is no additional consultation fee and specialized physical exercise educators are lacking. Although an improvement of these factors may lead to higher rates of exercise guidance, we consider that the preparation of specific exercise guidelines for type 2 diabetes patients is essential to effectively implement this therapy in clinical practice.
This study was supported by the Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society and the Manpei Suzuki Diabetes Foundation. We thank Dr. G. Bajotto for his suggestions regarding the English language. We are also grateful to all doctors (diabetologists and non-specialist physicians) who responded to the questionnaire.
Conflict of interest
The authors declare no conflict of interest.