Diabetology International

, Volume 3, Issue 2, pp 86–91

Present situation of exercise therapy for patients with diabetes mellitus in Japan: a nationwide survey

Authors

    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Department of Health Science, Faculty of Psychological and Physical ScienceAichi Gakuin University
  • K. Kondo
    • Program of Health Science, Graduate School of Psychological and Physical ScienceAichi Gakuin University
  • T. Watanabe
    • Department of Nutrition and Health, Faculty of Psychological and Physical ScienceAichi Gakuin University
  • H. Sone
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Department of Endocrinology and MetabolismUniversity of Tsukuba Institute of Medicine
  • M. Kobayashi
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • University of Toyama
  • R. Kawamori
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Juntendo University
  • Y. Tamura
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Juntendo University
  • Y. Atsumi
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Saiseikai Central Hospital
  • Y. Oshida
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Research Center of Health, Physical Fitness and SportsNagoya University
  • S. Tanaka
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Department of Sport and Health ScienceOsaka Sangyo University
  • S. Suzuki
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Ohta General Hospital
  • S. Makita
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Saitama Medical University
  • I. Ohsawa
    • Research Committee for the Establishment of Therapeutic Exercise for Diabetics of the Japan Diabetes Society
    • Department of Health Science, Faculty of Psychological and Physical ScienceAichi Gakuin University
  • S. Imamura
    • Japan Medical Association
Original Article

DOI: 10.1007/s13340-012-0065-z

Cite this article as:
Sato, Y., Kondo, K., Watanabe, T. et al. Diabetol Int (2012) 3: 86. doi:10.1007/s13340-012-0065-z

Abstract

Purpose

This study was performed to investigate the actual situation and problems of exercise therapy in Japan.

Methods

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].

Results

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.”

Conclusions

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.

Keywords

Exercise therapyNationwide surveyPhysical exercise educatorExercise guidelines

Introduction

The number of diabetes patients is increasing worldwide, and Japan was ranked eighth in 2010 [1]. 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 [2]. 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 [5]. In Japan, a large number of studies have focused on the utility of exercise intervention for preventing and treating type 2 diabetes [68]. 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.

Methods

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.

Results

Characteristics of subjects

The average ages (SD) of diabetologists and non-specialist physicians were 50.3 (11) and 52.4 (10) years, respectively. The percentages of diabetologists working in clinics, general hospitals and university hospitals were 36, 43 and 20%, respectively. The percentages of non-specialist physicians working in the same institutions were 67, 25 and 5%, respectively. In addition, 64% of the diabetologists and 18% of the non-specialist physicians implemented special clinics for diabetics, and 74% of the diabetologists and 47% of the non-specialist physicians carried out admission to an educational program for diabetics (Table 1).
Table 1

Clinical characteristics of the subjects

 

Diabetologists (N = 275)

Non-specialist physicians (N = 128)

Test statistics

p value

N (%)

N (%)

Gender (male/female)

215 (78.2)/60 (21.8)

113 (88.3)/15 (11.7)

χ2 = 5.88

0.015

Age (years, mean ± SD)

50.3 ± 10.6

52.4 ± 9.8

t = −1.94

0.053

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

<0.001

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

<0.001

Special clinic for diabetics (yes/no)

174 (64.2)/97 (35.8)

23 (18.0)/105 (82.0)

χ2 = 78.50

<0.001

Admission to an educational program for diabetics (yes/no)

165 (74.0)/58 (26.0)

38 (46.9)/43 (53.1)

χ2 = 19.64

<0.001

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

0.258

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

<0.001

Some values in this column may not add up to the total number because of missing values

SD standard deviation

Diabetologists versus non-specialist physicians

Situation of dietary and exercise guidance for diabetic patients

Concerning the treatment method for diabetic patients, 37% of the diabetologists prescribed insulin (13% of them also prescribed oral hypoglycemic agents), 49% prescribed oral hypoglycemic agents, and 14% prescribed diet and exercise therapy only (Table 2). On the other hand, 15% of the non-specialist physicians prescribed insulin (7% of them also prescribed oral hypoglycemic agents), 65% prescribed oral hypoglycemic agents, and 20% prescribed diet and exercise therapy only (Table 2). The percentages of diabetologists prescribing insulin treatment and non-specialist physicians prescribing treatment with oral hypoglycemic agents were high (p < 0.001).
Table 2

Treatment method for diabetic patients (%, mean ± SD)

 

Diabetologists (N = 255)

Non-specialist physicians (N = 118)

t

p value

Insulin

24 ± 15.6

8.5 ± 8.9

10.04

<0.001

Insulin + OHA

12.6 ± 10.2

6.5 ± 9.8

5.50

<0.001

OHA

49.2 ± 16.4

64.7 ± 19.2

−8.03

<0.001

Diet and exercise only

14.2 ± 9.1

20.2 ± 15.6

−3.90

<0.001

OHA oral hypoglycemic agents, SD standard deviation

Diabetologists versus non-specialist physicians

As shown in Table 3, the rate of exercise guidance at the initial visit to the clinic was significantly lower (p < 0.001) than that of dietary guidance. The rate of exercise guidance to most of the patients at their initial visit to the clinic was 39%, roughly half of that for the implementation of dietary guidance. The rate of not providing exercise guidance (<10%) was 12%, while that of not providing dietary guidance was 1% (Table 3).
Table 3

Implementation rate of dietary and exercise guidance to patients

Provision of dietary/exercise guidance

Implementation rate

U

p value

Dietary guidance (N = 401)

Exercise guidance (N = 401)

N (%)

N (%)

Over 90% of patients

298 (74)

155 (39)

47,863.5

<0.001

70–90% of patients

43 (11)

57 (14)

50–70% of patients

29 (7)

58 (14)

30–50% of patients

12 (3)

31 (8)

10–30% of patients

14 (3)

52 (13)

Not providing guidance (<10% of patients)

5 (1)

48 (12)

Dietary guidance versus exercise guidance

The rates of diabetologists and non-specialist physicians who implemented dietary guidance using dietary information slips were 67 and 28%, respectively (p < 0.001) (Table 4). The rate of diabetologists who implemented mass dietary guidance was significantly higher than that of non-specialist physicians (p < 0.001). In addition, the rates of diabetologists and non-specialist physicians implementing individual dietary guidance without providing dietary information slips were 29 and 34%, respectively (p = 0.320). Irrespective of the medical doctor, dietary guidance was found to be provided to almost all patients (not shown in tables). However, the rate of non-specialist physicians with no special system for dietary guidance was significantly higher than that of diabetologists (p < 0.001) (Table 4).
Table 4

Dietary guidance system (multiple answers)

 

Diabetologists (N = 273)

Non-specialist physicians (N = 127)

χ2

p value

N (%)

N (%)

Dietary guidance using dietary information slips

184 (67.4)

35 (27.6)

55.53

<0.001

Individual dietary guidance without dietary information slips

79 (28.9)

43 (33.9)

0.99

0.320

Mass dietary guidance

76 (27.8)

10 (7.9)

20.47

<0.001

No special systems for dietary guidance

15 (5.5)

51 (40.2)

75.59

<0.001

Diabetologists versus non-specialist physicians

Table 5 shows that 45% of the diabetologists and 30% of the non-specialist physicians provided individual exercise guidance without prescribing exercise (p = 0.005). In addition, the rates of diabetologists who provided mass exercise guidance and exercise guidance using exercise prescription were significantly higher than those of non-specialist physicians (p < 0.001) (Table 5). On the other hand, 44% of the diabetologists and 65% of the non-specialist physicians had no special system for exercise guidance, revealing that more than half of the total number of patients did not receive systematized exercise guidance. Concerning the presence or absence of physical education educators in the clinics (Table 6), only 17% of the diabetologists responded that these professionals were present, and 92% of the non-specialist physicians responded that there were no physical exercise educators in their clinics (p = 0.014).
Table 5

Exercise guidance systems (multiple answers)

 

Diabetologists (N = 273)

Non-specialist physicians (N = 126)

χ2

p value

N (%)

N (%)

Exercise guidance using exercise prescription

25 (9.2)

3 (2.4)

6.07

0.014

Individual exercise guidance without exercise prescription

123 (45.1)

38 (30.2)

7.95

0.005

Mass exercise guidance

42 (15.4)

3 (2.4)

14.57

<0.001

No special systems for exercise guidance

119 (43.6)

82 (65.1)

15.93

<0.001

Diabetologists versus non-specialist physicians

Table 6

Presence of physical exercise educators

 

Diabetologists (N = 259)

Non-specialist physicians (N = 125)

χ2

p value

N (%)

N (%)

Yes

45 (17.4)

10 (8.0)

6.04

0.014

No

214 (82.6)

115 (92.0)

Diabetologists versus non-specialist physicians

Problems of exercise therapy

Table 7 shows the main problems related with the implementation of exercise guidance and the reasons why patients did not perform exercise in the HG and LG groups. 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 when implementing exercise guidance for 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 did not perform exercise, about 70 and 60% of physicians in both groups responded that patients “had no time to exercise” and “were not eager to perform exercise,” respectively. In addition, compared with the LG group, a higher number of physicians in the HG group responded that patients did not like to exercise (p = 0.039).
Table 7

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)

χ2

p value

N (%)

N (%)

Main problems related with the implementation of exercise therapy

 Lack of time to provide exercise guidance

130 (64.4)

87 (66.4)

0.15

0.701

 No additional consultation fee for exercise guidance

108 (53.5)

69 (52.7)

0.02

0.887

 Absence of specialized physical exercise educators

84 (41.6)

87 (66.4)

19.61

<0.001

 No appropriate guidelines for exercise therapy for diabetic patients

88 (43.6)

59 (45.0)

0.07

0.791

 Absence of facilities and services to provide exercise guidance

54 (26.7)

28 (21.4)

1.23

0.268

 Risk of accidents with implementation of exercise therapy

33 (16.3)

22 (16.8)

0.01

0.913

 Lack of compliance by patients

89 (44.1)

48 (36.6)

1.81

0.179

 

HG group (N = 205)

LG group (N = 130)

χ2

p value

N (%)

N (%)

Reasons why patients do not perform exercise

 Lack of time

146 (71.2)

84 (64.6)

1.61

0.204

 Patients are not eager to perform exercise

122 (59.5)

81 (62.3)

0.26

0.610

 Patients do not like exercise

96 (46.8)

46 (35.4)

4.27

0.039

 Absence of specialized physical exercise educators

60 (29.3)

51 (39.2)

3.68

0.055

 Patients do not understand the efficacy of exercise

70 (34.2)

43 (33.1)

0.03

0.864

 Patients do not understand diabetes mellitus

42 (20.5)

25 (19.2)

0.07

0.796

HG group versus LG group

Discussion

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 [9]. 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 [9]. 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 [10] 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 [11].

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.

Acknowledgments

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.

Copyright information

© The Japan Diabetes Society 2012