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Tuesday, June 20, 2006

A swelling dispute over our waistlines

Could you be at risk of a fatal heart attack or just bad health warnings?


Staff writer

Japan's citizens are well-known for their slim figures, healthy eating habits and longevity.

News photo
The stomach on the left has an 87-cm circumference, the one on the right 95 cm. Which on would put you at risk of diabetes, a stroke or a heart attck? Both, according to the Health, Labor and Welfare Ministry.

Or so you would think.

The Japanese government dropped a bombshell in mid-May -- almost a sixth of the population have or risk developing metabolic syndrome, a condition that can lead to diabetes, a stroke or a fatal heart attack. The Health, Labor and Welfare Ministry insists that to avert the danger many men with waists larger than 85 cm and women whose waists measure more than 90 cm need to change their diet and hit the gym, and fast.

Or perhaps not. The ministry's alert triggered reams of criticism from members of the medical establishment and political opponents, who accuse it of trying to scare perfectly healthy citizens; They say the ministry just wants us to get into even better shape in an effort to save money on a public-health bill forecast to balloon as the nation grays.

Others say this "disease-mongering" will have the opposite effect -- unnecessary prescriptions and more taxpayers' money down the drain.

The health ministry readily admits that it wants to use the warning against metabolic syndrome as a "major part" of its approach to preventing lifestyle-related diseases.

But the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) issued a joint statement in September 2005, saying that metabolic syndrome is so sloppily defined that doctors should not use it as a diagnosis at all.

The term metabolic syndrome refers to a mix of conditions including fat around the waist, high blood pressure and high blood sugar. Internationally, the syndrome is defined differently from country to country and across various ethnic groups. The World Health Organization has its own definition, which takes into account, among other factors, waist size, fat/cholesterol levels and diabetic symptoms (caused by not enough insulin in the blood or the body's inability to use insulin to convert sugar into energy).

The size of your waistline is the No. 1 criteria for diagnosis in Japan. If it exceeds the threshold and you have at least two of the following -- high blood pressure, high cholesterol or fat levels, or high blood sugar -- then you have the syndrome. If your waistline exceeds guidelines and you only have one of the three components, you are considered "at risk."

The Japanese definition was compiled in April 2005 -- five months before the ADA-EASD statement -- by a committee representing eight researchers' groups with specialties from diabetes to obesity to arteriosclerosis.

But their definition, the only one in the world that sets a smaller waistline for men than women, is so controversial that Kazuko Kori, a Lower House member from the Democratic Party of Japan who accused the ministry of "disease-mongering" during a recent Diet committee, and in an interview with The Japan Times, has gone as far as to raise the specter of a possible conflict of interest between drug companies and the head of the committee.

Kori notes that Dr. Yuji Matsuzawa, a leading obesity expert and director of Sumitomo Hospital, has "supervised" leaflets produced by pharmaceutical companies, which contain references to certain drugs. Kori also said that Matsuzawa appeared as a guest speaker for a meeting sponsored by a drug company last year.

"The drug-induced AIDS case was exacerbated by an authoritative expert who put the profits of drug companies first and patients' lives second," she said. "Granted, it is only natural for profit-driven companies to seek profit. What I think is a problem is the sheer lack of critical thinking on the part of the government, its panels and experts serving on those panels. And it is us, the public, who would pay the bills from idiotic policies put forwarded by those 'experts.' "

Yasuhiko Ishii, deputy director of the office for lifestyle-related disease control at the health ministry, scoffed at the concern that the panel's academic integrity was compromised by industry. "We are not pushing for the use of drugs. Our stance is, 'First, exercise. Second, improve diet. Third, stop smoking. Then if the three don't work, take medicine as a last resort,' " he said.

Concerns about the waist limits, however, are shared by others. Dr. Mitsuhiko Noda, a diabetes specialist and director of the endocrinology and metabolism department at the state-run International Medical Center of Japan in Tokyo, supports the use of metabolic syndrome as a diagnosis but says the current definition "is so immature that it almost makes me think that some intention to change policies is behind [the government's move to play up the syndrome]."

"The sample data for calculating the waistline are too small to be taken seriously," he said, noting that only 196 women were included. "Without enough data, the (experts') panel should have withheld a consensus at that time. . . . With the current definition of 'metabolic syndrome,' it's as if they've dressed a beautiful princess in dirty clothes."

Yoichi Ogushi, professor of medical informatics at Tokai University's School of Medicine, warns that the government's excessive emphasis on combating the syndrome would lead to pointless exams and prescriptions. Japan already spends 300 billion yen a year on anticholesterol drugs, most of which, Ogushi says, are unnecessary because cholesterol levels considered dangerous in Japan are lower than international standards.

He also pointed to a recent statement from the International Diabetes Federation, a worldwide association of diabetes experts, which rejected Japan's waistline figures, instead recommending the nation use Chinese and South Asian values (90 cm for men and 80 cm for women) until more data becomes available.

Matsuzawa, the obesity expert who helped create the Japanese guideline, rebutted the critics. He admitted that samples used to define the proper measurement were small, but said that Japan alone had used CT-scanning, which shows the visceral fat (fat between organs) that triggers strokes and heart attacks, separate from subcutaneous fat (fat stored under the skin).

As for the IDF paper that recommended Chinese and South Asian values for Japanese, Matsuzawa said that Japanese people shouldn't be bundled together with other Asians because their diet is different. As for the ADA-EASD statement, he said that it is just one paper, noting that "a mountain of data" exists on metabolic syndrome as a predictor of cardiovascular diseases.

Furthermore, Matsuzawa called Kori's accusation against him in the Diet "defamatory," adding that his industry links -- which he said include advising drug companies -- are completely legal. "Our metabolic syndrome campaign has nothing to do with drug company marketing," he said. "I get asked to speak by a lot of people, and I feel it's an expert's social duty to fulfill such needs. That's why I make time for the speeches out of my busy schedule as a hospital director."

Still, Ogushi is adamant that academics' industry ties need to be made more transparent. Some medical journals overseas mandate that authors writing papers on clinical studies must disclose any financial conflicts of interest, including honorarium for speeches, stock ownership and consulting contracts -- a practice hardly common in Japan.

Though researcher groups in Japan do compile "clinical practice guidelines" -- an evidence-based guide for doctors and patients on how to treat diseases -- with grants from the drug industry, they hardly ever make it public, he said.

"Financial disclosure by politicians has advanced a little, as their influence peddling once became a big social problem," Ogushi said. "Now Cabinet ministers disclose their assets. . . . But when it comes to doctors serving on government panels, and for researchers' groups writing clinical practice guidelines, Japan has no disclosure rules whatsoever."



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