[Policy Recommendations] Obesity Control Promotion Project 2023

The Next Steps for Engaging and Cooperatingwith Patients, Citizens, and Communities for
Implements of Obesity Control Measurements
March,2024

Table of contents
1. Objectives and background of the obesity project…………………………… 3
2. Definitions and references for terminology used in these recommendations… 4
3. Six key recommendations for obesity control (Overview)……………………… 5
4. The voices of people living with obesity and the patient journey……………… 7
5. Six key recommendations for obesity control (Details)………………………… 13
Recommendation 1…………………………………………………………… 13
Recommendation 2…………………………………………………………… 15
Recommendation 3…………………………………………………………… 18
Recommendation 4…………………………………………………………… 22
Recommendation 5…………………………………………………………… 25
Recommendation 6…………………………………………………………… 26
6. Issues related to off-label use of diabetes and obesity drugs
called GLP-1 agonists…………………………………………………………… 28
7. Acknowledgments……………………………………………………………… 29

1. Objectives and background of the obesity project
In both advanced industrial countries as well as in low- and middle-income countries, the number ofpeople with obesity is increasing. This has been accompanied by rapid growth in the number of people
with obesity-related chronic diseases. In 2022, it was estimated that the total number of people withobesity worldwide exceeded 1 billion.1 In Japan, all insurers have been obligated to conduct specificmedical checkups and provide specific health guidance for obesity since 2008, and progress has been
made in various measures to prevent and control chronic diseases. However, as made clear in the final
evaluation of the Second National Health Promotion Movement in the 21st Century, or “Health Japan
21 (Second Term),” life expectancies continue to increase, but there have been no improvements
in criteria related to lifestyle habits. For example, the number of people living with metabolic or premetabolic syndrome has not decreased.
Given these circumstances, Health and Global Policy Institute (HGPI) launched the Obesity Control
Promotion Project in 2022 to build interest toward obesity and related issues throughout society
and to advance more effective, organic countermeasures for this issue. In FY2022, we brought
together an advisory board of specialists in a broad variety of areas, hosted a public symposium,
crystallized discussion points to examine in the future, and compiled policy recommendations. The
main discussion points included the importance of defining obesity from a medical perspective andbroadly disseminating that definition throughout society; establishing various types of guidelines thatare rooted in science; diversifying intervention methods, including for both medical- and non-medical
interventions; encouraging multidisciplinary collaboration and launching initiatives that cut across fieldsof specialty; and expanding domestic research on obesity and related issues. Correlations have been
established among health and conditions like income and living environment, which are known as“Social Determinants of Health (SDH).”2 Without resorting to the concept of personal responsibility,
all of society must work to promote better health to prevent income and education disparities frombecoming health disparities.
In 2023, to deepen and implement the recommendations made in 2022, interviews were conductedwith patients suffering from obesity and with medical professionals. Advisory board meetings were also
held consisting of experts from industry, government, academia, and the private sector. Based on our
understanding of the actual conditions and issues surrounding people living with obesity taken from theperspectives in the medical field and within society, we propose the following obesity countermeasuresthat are required in society and medical care.

1. NCD Risk Factor Collaboration (NCD-RisC). “Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663
population-representative studies with 222 million children, adolescents, and adults.” Lancet (London, England), S0140-6736(23)027502. 29 Feb. 2024, doi:10.1016/S0140-6736(23)02750-2
2. WHO [Social determinants of health] https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Last retrieved on
March 13, 2024.

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2. Definitions and references for terminology used inthese recommendations
Terms used in these recommendations are defined below.
Body Mass Index (BMI)
Body Mass Index (BMI) is calculated using the formula of weight in kilograms divided by height inmeters squared (BMI =W [kg]/H [m]2).
Metabolic syndrome3• A person is diagnosed for metabolic syndrome when they present an increase in visceralfat (intra-abdominal fat) evaluated using waist circumference and meet two or more of threecriteria: high blood glucose, abnormal lipid metabolism, or high blood pressure.
• The person in question does not have to satisfy BMI criteria for obesity (BMI≥25).
Obesity (condition)
A state of excessive fat accumulation in adipose tissue with BMI≥25. The World Health Organization(WHO) considers a BMI of over 30 as obese, but standards used to determine obesity vary bycountry.
Obesity (disease)
A disease with a medical need for weight loss due to complications or potential complications
resulting from or related to the condition of obesity. Also referred to as “obesity disease.”
Severe obesity (condition)
Individuals who meet the criteria for the condition of obesity and with BMI≥35. This excludes people
with secondary obesity.4
Severe obesity (disease)
This is a disease that is diagnosed when an individual is determined to have severe obesity witha BMI≥35 according to the definition of obesity and has obesity-related health concerns or has
visceral fat accumulation.

(Works referenced)
Japan Society for the Study of Obesity (JASSO). Guidelines for the Management of Obesity Disease 2022. Life
Science Publishing Co., Ltd. Tokyo. 2022.
3. The criteria for metabolic syndrome in Japan were defined in 2005 through joint efforts from eight academic societies: the JapaneseSociety of Internal Medicine, the Japan Atherosclerosis Society, the Japan Diabetes Society, the Japanese Society of Hypertension,
Japan Society for the Study of Obesity (JASSO), the Japanese Circulation Society, the Japanese Society of Nephrology, and theJapanese Society on Thrombosis and Hemostasis. Ministry of Health, Labour and Welfare, “Lifestyle disease management based on
an analysis of health checkup data and health insurance claims.” https://www.mhlw.go.jp/bunya/kenkou/seikatsu/pdf/ikk-j.pdf. Last
retrieved on February 29, 2024.
4. Secondary obesity is defined as obesity with a clear cause and includes endocrine obesity, drug-induced obesity, genetic obesity, andhypothalamic obesity.

43. Six key recommendations for obesity control(Overview)
Recommendation 1 : Strengthen primary prevention of obesity and other lifestyle diseases by
educating people about healthy lifestyles and creating a society with few health risks throughcollaboration among government agencies and the private sector.

• Along the life course, engage in health promotion tailored to each age group and provide
education and awareness for the prevention of obesity and other lifestyle diseases.
• Reinforce education systems related to lifestyle habits for young and school-aged children inaccordance with modern needs and the current social environment.
• Expand education and lifestyle interventions for people who have a family history of obesity andwho are at high risk of developing obesity.
• Structure industries in a manner that is based on collaboration among government agencies
and the private sector and that incentivizes companies to contribute to healthy behavior among
citizens.

Recommendation 2 : Enact highly effective secondary prevention policies generated by promoting
and enhancing health data in specific health checkups and specific health guidance.

• Enable the effective use of limited resources by providing appropriate interventions for each stage
through health checkups. Such interventions should not be limited to specific health guidance but
include a broad stratification of interventions that includes perspectives on medical interventions.
• Continue reinforcing healthcare provider collaboration and systems for effective feedback basedon health checkup results to ensure that people with obesity who need medical intervention
receive timely and appropriate care.
• While promoting collaboration among the various bodies conducting health checkups andmedical examinations, establish an integrated health checkup system so people can accessspecific health checkups and specific health guidance tailored to their personal needs regardlessof factors like insurance coverage or employment status.
• Promote health data in health checkups and use evaluations that are based on data to provide
more effective specific health checkups and specific health guidance.

Recommendation 3 : Establish community healthcare provision and support systems that involve
collaboration among industry, Government, academia, and civil society and that are tailored
to individual challenges and needs to provide appropriate interventions to people who are
overweight or obese.
• After defining multi-disciplinary clinical practice guidelines for providing people with obesity with
tailored interventions that fit their conditions (such as BMI, presence of underlying diseases, etc.),
broadly distribute those guidelines and raise awareness among health professionals.
• Establish systems to provide various interventions in communities and build industry, Government,
academia, and civil society networks that form a foundation for healthcare collaboration to ensure
people with obesity receive the support they need in a timely manner.
• As part of measures for lifestyle disease control, design incentives that will encourage family
doctors to take part in obesity treatment.

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Recommendation 4 : Establish healthcare provision systems and pursue nationwide equity somultidisciplinary interventions can be delivered to people with severe obesity.

• Strengthen systems for collaboration across multiple departments and professions to provide afoundation for the provision of multidisciplinary treatment.
• Establish specialized, holistic obesity treatment systems at integrated centers for obesity
treatment and design incentives for achieving this.

Recommendation 5 : Generate evidence on the effectiveness of measures for controlling obesityand other chronic diseases to advance obesity policy and create better and more equitable
healthcare provision systems.

• Generate evidence on the effectiveness of measures for obesity and lifestyle disease control, andhow treating obesity reduces societal costs.
• Gather and compile data for the entire life course to build a centralized data infrastructure toadvance research on measures for obesity and chronic diseases.

Recommendation 6 : Break away from the tendency to favor certain body shapes and sizes andthe concept of personal responsibility for obesity, foster understanding of obesity as a medical
condition, and eliminate stigma that prevents timely and appropriate medical interventions.
• Leave attitudes that are centered on personal responsibility in the past and raise awareness thatobesity is impacted by genetic factors and social determinants of health (SDH) in addition tolifestyle habits.
• Distinguish obesity as a disease that requires medical attention from other forms of obesity or
metabolic syndrome and spread accurate definitions and recognition.
• Foster acceptance of different body shapes and sizes and eliminate social stigma and self-stigma
for people living with obesity.

Figure 1: Six key recommendations for obesity control and each phase of action
Obesitycontrolphase

Six key
actionsfor obesity
control

Health promotion(1) Provide lifestyleeducation and create a low
health risk society

Specific
health checkups andhealth guidanceCommunity medicine(2) Establish a highly
effective healthcheckup system based on data

Advanced medical care(4) Achieve equity inmultidisciplinary treatment(3) Strengthen function of family doctors, hospital-clinic cooperation,and regional cooperation(5) Strengthen systems for generating evidence and conducting research(6) Eliminate stigma

Health and Global Policy Institute (2023)

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4. The voices of people living with obesity and thepatient journey
In pursuit of HGPI’s mission of “achieving citizen-centered health policy,” in these recommendations, wehave gathered voices of people living with obesity, which are voices that have not been fully reflectedin the past. These recommendations were compiled after examining the actual circumstances facedby people living with obesity and issues from their perspectives, creating a patient journey, and holding
discussions with our advisory board.

■ Voices of the parties most affected (Overview)

Interviews were held with four people living with obesity. Items revealed included the challengesof living with obesity due to stigma; a lack of understanding toward obesity as a disease amongindividuals and in society; the difficulty of accessing healthcare; the effectiveness of multidisciplinary
treatment at health institutions specializing in obesity; and challenges related to treatment adherence.
All four participants experienced different circumstances that resulted in obesity, tended towardobesity in childhood, and saw their condition progress to obesity due to stress and life events. Whilethey and their family members were concerned about the fact that they were obese, they did notknow that obesity is a disease. They also did not know that there are ways of treating obesity or did
not feel the need for treatment. This meant poor health checkup results did not lead them to obesity
treatment. In addition, even if they felt physically unwell, self-stigma and past experiences in which
health professionals blamed them for being obese created high psychological hurdles toward visiting
health institutions. Some participants reported they gave up on attempts to improve their condition
through non-pharmacological therapies like exercise and dieting after failing to get results, which
made it difficult for them to reach medical treatment.
Participants had various reasons for visiting health facilities specializing in obesity treatment. Twoof the four participants had done their own research, one had required emergency care, and one
was referred by a health institution. All participants lost weight and achieved better health after
receiving multidisciplinary and holistic treatment. Treatments also had positive impacts on their daily
lives or approach to living itself, such as by helping them experience positive feelings and optimism
or successfully find employment. It was also clear that the participants experienced difficulty andstress in balancing major changes in appetite during treatment, adhering to non-pharmacologicaltherapies, visiting multiple clinics, and balancing employment. In the face of these circumstances, allparticipants expressed appreciation for the support provided by and presence of obesity treatment
coordinators, who work closely with patients to coordinate with parties like health professionals andprovide consultations on topics like physical condition and lifestyle.

■ Methods used to recruit participants and conduct interviews

In-person interviews were conducted between September 2023 and November 2023 with fourindividuals who had been diagnosed with severe obesity and were undergoing multidisciplinary
treatment in facilities specializing in obesity treatment. These interviews were conducted withparticipant consent and with consideration toward maintaining their privacy.

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The characteristics of the four interview participants are described below.
Patient A: Male, 40s
Patient B: Female, 50s
Patient C: Female, 30s
Patient D: Male, 40s■ Circumstances and voices of people living with obesity (Details)
1. Difficulties and circumstances before starting obesity treatment

All four participants tended toward obesity during childhood and their school years. We also
asked them about stress, life events, and other events that further accelerated their condition. Ourfindings suggested that people require intervention during childhood and the periods during whichpeople are likely to gain weight.
While some participants said they had used private training facilities or had maintained exercise
regimens before starting obesity treatment, they said they suspended these efforts after failing toachieve positive effects or after developing feelings that their efforts were ineffective.
All four participants were experiencing some form of obesity-related physical, social, or emotional
distress or strong feelings of difficulty toward daily life.
Voices of affected parties“I have always been large, even as a child. My parents and I both knew that my weight was notnormal, but they did not do anything about it. When I was looking for employment, the stressprevented me from losing weight. (Eating) made me feel physically full, and being full makes me
feel like my heart is also full.” (Patient C)“I have always had a heavy figure since childhood, but after I had an accident, the pain made me
stay in the house more.” (Patient B)“I feel very lonely. I want to have fun. But I can’t do anything without money. I can’t work because I
am not in good shape due to my obesity. That makes it hard.” (Patient D)“I was obsessed with my weight. I was so heavy that I could barely look at myself. Even the firstday I was able to go to the hospital, my own body was screaming out.” (Patient C)“It seems that my family was concerned toward my obesity, but they never said anything like, ‘Go
to the hospital.’” (Patient A)

2. Points of contact with health checkups and health facilities

Among the four interview participants, two had received health checkups. While both of theparticipants who underwent health checkups received results that said they were obese, they
did not attend subsequent medical consultations at health institutions. Rather, they accepted theresults as nothing out of the ordinary, indicating that their level of concern about their condition
was by no means high.

8Among the four interview participants, three had no recent history of seeing their family doctor
when starting treatment at specialized obesity treatment facilities. In particular, one participant said
she had been heavyset since childhood and did not visit health facilities often. We also observed
the other three participants had high thresholds for visiting health facilities.
Voices of affected parties“When my health checkup results said I was obese, I thought, ‘It always says that.’” (Patient A)“To tell the truth, I think I would never visit a hospital because I was told I was overweight. If myresults do not clearly state, ‘You have a disease called obesity, please visit a hospital,’ I would notgo.” (Patient B)“I am robust and don’t catch colds or get sick, so I had no reason to visit hospitals.” (Patient A)“I think it feels a bit awkward to go to the hospital. There is also the fact that I’d have to make an
appointment.” (Patient B)

3. Events that led participants to their first visit to a specialized obesity treatment facility

One participant was referred to a specialized obesity facility due to an emergency conditionand one participant was referred by a local health institution. The other two participants visited
specialized obesity facilities after gathering information on their own.
Prior to visiting a specialized obesity facility, these two participants felt physically unwell due toobesity. However, they did not initially recognize that obesity is a disease or that it was a factor
for their poor physical condition. Also, neither party had a positive attitude toward medical
examinations for various reasons. These included self-stigma toward obesity and related diseases,
being made to feel guilty about their condition at hospitals, and the difficulty of attending medical
examinations due to work schedules or financial situations. One participant said they had received
medical examinations at over five local health institutions at the recommendation of family
members, but had not been instructed on obesity. Both patients and healthcare professionals
have observed that the lack of information about obesity can lead to delays in initiating appropriate
treatment.
One participant had experienced an increasing amount of pain due to a past injury and visited anorthopedist for surgery. They were diagnosed as obese and encouraged to lose weight, which ledthem to find a facility specializing in obesity treatment. The other participant felt that obesity was
making living difficult. When they learned that surgery was a treatment option, they looked up a
hospital and eventually found an obesity treatment facility.
Voices of affected parties“I didn’t know that obesity was a disease or that it is covered by insurance.” (Patient A)“I didn’t even know being fat was a disease. I thought it was strange that I kept getting heavier
even though I wasn’t eating very much.” (Patient D)“I thought having money would be better than going to a hospital, so even when my physicalcondition was poor, I put up with it.” (Patient D)

9“(When I was examined by my family doctor) I was only told to lose weight, but nothing was done
to address my condition, and I was just told to do my best and to please lose weight on my own.
That is why I looked for a facility specializing in treating obesity on my own to ask them for help.”(Patient B)

4. Treatment

A. Internal therapy and non-pharmacological treatment methods
While regularly visiting a hospital for treatment, two of the four participants had past experiencesuspending treatment on their own. They said their worsening physical condition was thereason they resumed treatment.
All four participants had been engaged in continuous non-pharmacological treatment forobesity, such as dieting and exercise, as well as in treatment for complications. Regarding
the challenges of maintaining treatment, they mentioned economic difficulties, the difficulty ofbalancing work and hospital visits or hospitalizations, and the difficulty of stress management
during treatment. During these discussions, participants noted the support they received fromphysicians, nurses, dietitians, and obesity treatment coordinators who were very patient andkind, demonstrating the importance of psychological support during treatment.
One participant developed obesity due to a congenital disease that they are currently being
treated for, but they have yet to experience significant improvement. They have high hopes
for new pharmaceuticals to help them lose weight. While they felt somewhat resigned to thelimitations of current treatments and their situation, they also expressed the will to try various
new things if they will lead to weight loss.
Voices of affected parties“Of the three meals I eat per day, two are protein and one is a normal meal. I am drinking liquid
first thing in the morning and it feels like I’m in hell. I stopped eating meat. It is not working and
I am at the end of my rope. However, if I stop treatment, I go back to square one. I want to get
certified and get a job. I wish I could take medicine (for obesity).” (Patient D)“It was because the obesity treatment coordinator stayed with me and provided support that I
was able to continue. I am truly grateful.” (Patient A)“Many people with obesity have low self-esteem, so (healthcare providers) don’t get angry atthem if they gain weight, accept them as they are, and are thrilled when they lose weight. This
makes me very happy, and I am so thankful.” (Patient C)“I heard that weight loss programs are very hard and some people end up feeling depressed,
and that the diet is especially hard. At times like that, I feel like the healthcare staff was kind andencouraging.” (Patient D)

B. Surgical treatments
Among the four participants, three have undergone surgery. The reason they chose surgery
was their expectations toward its effects. One participant did not undergo surgery because theirfamily opposed it. Their reasons for doing so were that it would not provide a complete cure10and that they would have difficulty accepting their body image after surgery.
The three participants who underwent surgery were asked if anything changed afterward. All
three viewed the surgery and its outcome in a positive light. They talked about enjoying life andfeeling cheerful and optimistic.
Some participants were able to accept the post-surgical changes in appetite or feelings ofhunger in their daily lives, but one participant experienced rebound.
Voices of affected parties“I think it was a good thing I had the surgery. My life has become much more enjoyable. Since
my surgery, I have not felt any irritation over not being able to eat.” (Patient A)“After my surgery, it was very easy to change jobs. I think this may have been partially due togood timing, but I thought ‘Do people always get hired this quickly?’” (Patient C)“I’ve always liked eating. Even when I see something and think it looks delicious, I have
gradually become used to the effects of my medicine. Now that I am used to it, I am able tocome to terms with how much I should eat, thinking ‘Well, it should be okay if I have about thismuch.’” (Patient B)“After all that, I still want to eat. However, the feeling of being hungry has really disappeared.”(Patient C)
C. Peer support
When we asked participants about the need for peer support or patient groups, some said they
do not feel they are necessary. Others said that hearing from others about their experienceswith the surgery helped them to be more mentally prepared.
Voices of affected parties“Even if there were opportunities for people living with obesity to talk with each other, they are
generally shy people, so I don’t think conversations would go anywhere. I think we would only
enjoy griping about the hard parts of being obese, such as we can’t use Japanese-style toilets.”(Patient A)

5. Reflections and challenges on obesity as a disease

During the interviews, we asked participants about challenges with obesity and obesity treatment,
what they need from society, and the term “obesity disease.” They felt that it will be necessary to
broadly inform society that obesity is a disease that requires medical intervention. While we wereable to infer that some were concerned that the term “obesity disease” would lead to more stigma
in society, others were optimistic that clearly identifying it as a disease would make that definitioneasy to communicate to everyone.

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Voices of affected parties“I think it would be good if treating obesity became normal, and I would like to see moreconsultation services that could guide people to obesity treatment.” (Patient A)“I think it would make a big difference to have even just one person (providing consultations on
obesity) like at a cancer consultation office. It would make people feel safer if there was always
someone to watch over them.” (Patient C)“I feel embarrassed toward the term, ‘obesity.’ I feel like people look at me and think I must eat a
lot because I am fat.” (Patient B)“Because it will make it easier to understand for us and for others, visualizing obesity (byusing the term “obesity disease”) will be a good thing. There is something about it that wasembarrassing to me, too. I think there will be many benefits to referring to obesity as a disease.”(Patient C)“It is a good thing if the opinions of patients are accepted and patients are given patientcentered team treatment by teams with good horizontal cooperation.” (Patient C)

Figure2: Experiences and challenges of four people living with obesity

Key

Obesity treatment barriers from affected parties’ perspectives
Main obesity treatment

Phases from perspectivesof affected parties

Information gatheringand action

Awareness

Disappointment withsurgery

Surgery

Underwentorthopedic
surgeryFound
workeasilyReboundReluctance toward
inpatient programs Psychological hurdles to surgeryMaderegularhospitalvisitsPhysicalcondition
improved

Repeatedtreatment

Genetic test
revealed
condition iscongenital

Visit to obesity
specialist

MaderegularhospitalvisitsSurgery concern

Visit to integrated obesity treatment center

CheckupFamilyVisited hospital
doctorfor poor physicalcondition, but told
“It’s a cold”
Specialist

StoppedregularhospitalvisitsEmergency hospitalization,
regular hospital visits begin

Suspicion
towardease ofweight gain

Could notundergosurgery due
to mental
healthGatherinfo

Few facilities offering
multidisciplinary support

Difficulty finding work
Mental health challenges

Too little info

Psychologicalhurdles to hospitals
Lack of support fromother departments
Visit to hospital
specializing
in obesity

Linked to checkup

Hospital

Could notundergoorthopedic
surgery due toobesity

Emergencytransport

Visit to university
hospital

Affected party 4
Mr. D
40s, maleObesity treatment:
Focused oninternal therapy

CheckupCould notmake regular
hospital visits
due to poor
physicalcondition

Linked to checkup

Affected party 3
Ms. C
30s, female
Obesity treatment:
Surgical procedure

Hospital

Too little info

Affected party 2
Ms. B
50s, female
Obesity treatment:
Surgical procedure

Checkup

Difficulty balancing work and treatment

Obesity coordinator support is present

Characteristics
Affected party 1
Mr. A
40s, maleObesity treatment:
Surgical procedure

Post
treatment

Treatment

Limitations of Would like toinsurancefind work if
coverage for treatment iscompletedtreatment

Health and Global Policy Institute (2023)

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5. Six key recommendations for obesity control (Details)
The symptoms experienced by people living with obesity vary, as does the severity of those symptoms.
Additionally, policies for managing obesity that target people living with obesity and those close tothem should include those parties. They should also include measures to prevent overweight andobesity as well as integrated measures that surpass healthcare and target society as a whole. Basedon our recognition of these circumstances, we have generated six recommendations from two
perspectives: measures aimed at preventing obesity or its progression; and the ideal structureof treatment for people living with obesity and related social support and measures. These
recommendations are detailed below. Please note that recommendations 1, 2, and 6 discuss “measures
aimed at preventing obesity or that aim to prevent the condition from progressing” while “the ideal
structure of treatment for people living with obesity and related social support and measures” iscovered by recommendations 3, 4, 5, and 6.
measures aimed at preventing obesity or its progression

Recommendation 1 : Strengthen primary prevention of obesity and other lifestyle diseases by
educating people about healthy lifestyles and creating a society with few health risks throughcollaboration among government agencies and the private sector.
Challenges
Various measures to educate the public on and raise awareness toward healthy lifestyle habits
have been implemented in Japan. These include the National Health Promotion Movement in
the 21st Century (Health Japan 21), the Health Promotion Act, and the Basic Act on Food andNutrition Education. However, the final evaluation of the second term of Health Japan 21 reported
that the numbers of people with or at risk of metabolic syndrome are increasing. There are also
genetic factors that are closely related to obesity. We also know that people are more likely to gain
weight at certain points in the life course, so we must reinforce measures that are in line with thelife course and target people with family histories of obesity and who are at high risk.
The education children receive in early childhood and at school plays a central role in shaping
lifelong daily habits. A number of efforts to educate children about life habits are currently
underway, such as nutrition education, but expectations are high for efforts to further promote
education that take into account factors like changes in household environments in recent years.
At the same time, it has been pointed out that the systemic basis for furthering nutrition educationis the Basic Act on Food and Nutrition Education, an ideological law. This means it is difficult to
expand such education in real-world school settings and promote educational equity. In addition
to educational interventions, it will also be important to consider measures for information andenvironments that may promote unhealthy lifestyles, starting with how to design advertisements toavoid promoting overeating or unbalanced nutrition.

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Recommendation
Along the life course, engage in health promotion tailored to each age group and provide
education and awareness for the prevention of obesity and other lifestyle diseases.
Another important action will be strengthening primary prevention in a manner that takes thesurrounding environment for and health issues faced by each age group along the life course
into account. We now know that people tend to gain weight at certain points in life, such as
after completing compulsory education or during the perinatal period. Measures that focus on
these periods will be necessary. It will also be effective to consider interventions that reflect thecharacteristics of each age group. This might include taking advantage of the fact that young
people are digital natives and utilizing apps to raise awareness toward body weight management.
Reinforce education systems related to lifestyle habits for young and school-aged
children in accordance with modern needs and the current social environment.
Lifestyle education fulfills a major role in childcare and educational settings, which is wherechildren are provided with the foundation for lifelong habits. Efforts for this age group should begin
with developing a curriculum. Over the medium to long term, the objective should be to optimize
the curriculum overall so it reflects the modern disease profile and can contribute to the preventionof a variety of lifestyle diseases.
In addition to developing a curriculum, we must also reinforce systems for providing education.
Initiatives for better nutrition education have been introduced in recent years. In their capacity
as experts on nutrition, dieticians have been placed at schools and daycare facilities to serve as
nutrition teachers. While encouraging the lateral spread of best practices like this, steps should betaken to accelerate the reinforcement of nutrition education in schools.
Education must be provided early in life to help people learn about the various health harms andrisks that are elevated by unhealthy daily habits and obtain a concrete understanding of healthy
dietary and exercise habits that can contribute to their prevention.
Expand education and lifestyle interventions for people who have a family history ofobesity and who are at high risk of developing obesity.
Genetic factors have been found to affect the development of obesity in around 70% of cases. In
other words, unhealthy lifestyles are not the only factor that results in obesity. Preventive measuresand intensive interventions for families with a high prevalence of obesity will be necessary.
Structure industries in a manner that is based on collaboration among government
agencies and the private sector and that incentivizes companies to contribute to healthy
behavior among citizens.
Starting with products and advertisements that encourage overeating and unbalanced nutrition,
modern society frequently exposes people to products, environments, and information and canelevate health risks. We must establish systems of structuring industries to promote activities
that contribute to better health while continuing to allow for free economic activity. In the foodindustry, in response to a report from the Study Group for the Promotion of a Sustainable Food

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Environment that Naturally Promotes Health, in FY2023, the Ministry of Health, Labour andWelfare (MHLW) launched a joint initiative with industry and academia that aims to “facilitate theconsumption of nutritionally-conscious foods, regardless of items like degree of consumer healthconsciousness.” We must accumulate good examples of collaboration among government
agencies and the private sector like this one and, in the future, structure industries in a mannerthat takes health impacts into full consideration.
measures aimed at preventing obesity or its progression

Recommendation 2 : Enact highly effective secondary prevention policies generated by promoting
and enhancing health data in specific health checkups and specific health guidance.
Challenges
According to the Act on Assurance of Medical Care for Elderly People that came into effect inApril 2008, health insurers are obligated to conduct specific health checkups and provide specifichealth guidance, creating a health checkup system that is unique to Japan. Over fifteen years
have passed since that law came into effect and this system has generated some results. For
example, awareness toward metabolic syndrome has increased, facilities providing specific healthcheckups and specific health guidance have been established throughout Japan, and there has
been growth in uptake for these checkups and consultations. One item that is examined as a risk
factor for lifestyle disease during specific health checkups is visceral fat, and expectations are highfor this to help control obesity. However, as previously mentioned, an increasing number of people
are living with or at risk of metabolic syndrome, and some have pointed out that the system islimited in its ability to prevent metabolic syndrome as well as optimize healthcare costs, which was
the reason it was established.
Enhancing the preventive effects of specific health checkups and specific health guidance forlifestyle diseases will require increasing implementation rates for both. While this rate for specifichealth checkups reached a record high in FY2021 and medical consultation rates are trending
upward, among eligible parties, uptake was only 56.5% for specific health checkups and 24.6%
for specific health guidance.5 By gender and age, men in their 40s had the highest checkup rate,
which suggests factors like differences in insurance coverage can impact uptake.
In addition to improving uptake, it will also be important to enhance quality for both specifichealth checkups and specific health guidance to make them more effective at preventing lifestylediseases. Even when people are provided with health guidance and recommendations to visit
health institutions for follow-up medical examinations, there are cases in which these do not lead
to behavioral change. There are also cases in which people who are of eligible age for specifichealth checkups are only diagnosed as obese when visiting a health institution for serious
symptoms. Even when people do visit health institutions for medical examinations, they may not
5. Ministry of Health, Labour and Welfare, “Regarding the implementation status of specific health checkups and specific health guidance,
FY2021.” https://www.mhlw.go.jp/content/12400000/001093812.pdf. Last retrieved on February 21, 2024.

15

receive information about their results in a manner that properly encourages them to take action,
which can prevent them from reaching appropriate treatment. It will be necessary to investigate
the causes of cases where people do not receive an intervention despite having received a
specific health checkup, and to implement further measures to address this.
Recommendation
Enable the effective use of limited resources by providing appropriate interventions
for each stage through health checkups. Such interventions should not be limited to
specific health guidance but include a broad stratification of interventions that includes
perspectives on medical interventions.
Evidence has been established for a variety of interventions to treat obesity, ranging from nonpharmacological therapies to pharmacological therapies and surgery, and requiring the effective useof a diversity of healthcare resources. In particular, because specialized health institutions, healthprofessionals, and pharmaceuticals are limited, we should further stratify intervention classifications
from what is currently used to determine need and, for each level, appropriately connect thoseclassifications to community healthcare services, health guidance, and specialized advanced therapies.
To conduct that stratification, it will be necessary to properly classify the degree of need forintervention based on items covered in health checkups. According to existing metabolic
syndrome criteria, even some cases of obesity with a high level of need for medical intervention
may not be considered eligible for intervention. For example, people who are diagnosed withobesity when visiting a health institution for advanced kidney disease are likely to benefit from theinclusion of comorbid conditions like abnormal urine protein levels or visceral fat accumulation
within criteria for providing recommendations for additional medical examinations. Obesity must
be incorporated into such recommendation criteria so people with a high need for intervention canbe guided to appropriate treatments without going overlooked.
Continue reinforcing healthcare provider collaboration and systems for effective
feedback based on health checkup results to ensure that people with obesity who need
medical intervention receive timely and appropriate care.
When a health checkup determines that someone is obese, that person must be informed thatobesity requires medical intervention and introduced to a health institution for the necessary
examinations. However, providing recommendations for examinations at health institutions
based on specific health checkup findings do not always lead to appropriate interventions at
health institutions. For example, people do not always seek medical examinations based onsuch recommendations, nor are they always examined at the department or health institutionthat was intended when the recommendation was made. In the short term, addressing theseissues may require making it easier for people to seek medical examinations by providing easy-tounderstand explanations regarding which department or facility to visit, or by providing them withinformation on the definition and significance of obesity as a disease using familiar formats. This
may take the form of specific written feedback or, in some cases, involve the use of illustrations or
pictures. Examples of how to write feedback in a way that is easy to understand are already being
investigated, so steps need to be taken to develop a system for providing it automatically.

16

Furthermore, information such as the backgrounds for medical examination recommendations
or medical checkup results is not sufficiently shared with health institutions. This leads to anotherissue in which people are not provided with care that is based on their checkup results. Therefore,
in the long term, it will be necessary to reinforce systems for health and medical collaboration.
This includes establishing systems that enable information sharing in the form of personal healthrecords (PHRs) among the parties responsible for providing specific health checkups and specifichealth guidance (health insurers and facilities that provide medical checkups) and the parties thatprovide medical care (health institutions, local medical associations, etc.).
While promoting collaboration among the various bodies conducting health checkups
and medical examinations, establish an integrated health checkup system so people canaccess specific health checkups and specific health guidance tailored to their personalneeds regardless of factors like insurance coverage or employment status.
Improving the uptake rate for specific health checkups will be an essential step in improving theireffectiveness in preventing obesity. In addition to specific health checkups and specific healthguidance stipulated by the Act on Assurance of Medical Care for Elderly People, regular medical
checkups are provided in accordance with the Industrial Safety and Health Act, and a number of
medical checkups including cancer screening are conducted under the Health Promotion Act. As
we can see, medical examinations are conducted for various reasons in different forms and byvarious parties with different obligations, so the situation is diverse and complex. In this context,
the parties conducting these checkup or examination programs are making a variety of efforts
to improve uptake. For example, some municipalities (which provide National Health Insurance(NHI) and are the main source of medical checkups) have improved access and recommendation
effectiveness by conducting or recommending specific health checkups together with cancer
screenings and other examinations. In addition, through collaborative health initiatives, in which
employers and insurers work together to provide health services, some employee insurance
schemes have established systems for providing health guidance during working hours. Efforts
such as these, which are tailored to the needs of users, have shown to be effective at improving
uptake, and need to be appropriately evaluated and promoted.
Due to the complex structure of the existing system, some issues are difficult to solve. For
example, there is a great amount of variance in the rate at which regular medical checkups are
conducted for employees under the Industrial Safety Act and their dependents (who that Act
has no authority over) or people covered by NHI. Also, dependents are instructed to attend
health checkups at facilities designated by insurers, so there are times when they cannot
receive checkups close to where they live. As this shows, disparities in insurance coverage andemployment status can lead to disparities in uptake rates. Furthermore, the fact that healthcheckups are conducted under different systems and by different parties can lead to fragmented
data and hinder efforts to properly evaluate each program. Given these challenges, we should
examine the establishment of an integrated legal system for the overall optimization of healthcheckups in the future.

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Promote health data in health checkups and use evaluations that are based on data toprovide more effective specific health checkups and specific health guidance.
It is important to lead people who have metabolic syndrome or obesity to behavioral change
through specific health guidance. Health guidance often does not result in behavioral change,
so new and more effective methods of providing it must be devised. These might involve theuse of technology or group guidance in a workshop format. Recognizing the ingenuity of thoseserving in real-world guidance settings will be an important step in further promoting these efforts
to elevate health guidance quality. Outcome evaluations for health guidance will be introduced
when the fourth Specific Health Checkup Implementation Plan comes into effect in FY2024. Whilethese evaluations are still in their introductory stages and use simple and abstract indicators,
expectations are high for further progress in the future, including for the consideration of outcome
evaluation methods.
In addition to evaluations focusing on real-world health guidance settings, it will also be importantto reflect on the objectives of the specific health checkup and specific health guidance system andconduct regular evaluations of the system itself. Based on data, all health insurers have formulated
health project plans and health data plans starting in FY2015, and they are now conducting
evaluations of those plans that also cover specific health checkups and specific health guidance.
While the original objectives of these plans was to optimize the cost of care while maintaining andpromoting health, efforts to verify their effectiveness toward these goals on a nationwide basis
have been insufficient. In addition to evaluations at each insurer, expectations are high for an
evaluation of the system itself to be conducted and that data will be utilized to reinforce the healthcheckup system.
Ideal treatment structure for people living with obesity and related social support / measures

Recommendation 3 : Establish community healthcare provision and support systems that involve
collaboration among industry, Government, academia, and civil society and that are tailored
to individual challenges and needs to provide appropriate interventions to people who are
overweight or obese.
Challenges
As both a condition and as a disease, obesity can result in all varieties of complications, andearly detection and intervention are vital. However, the condition of obesity tends to be ignored
when no particular ailment is present, and the lack of widespread recognition toward obesity as adisease results in many cases in which people are not connected to medical examinations. While
it is important to avoid excessive medicalization, each related facility must cooperate so people
who require medical interventions can be guided to the right care, at the right times. Specifically,
there have been reports that obesity rates are higher the lower someone’s income is, and thatsome people living with obesity are receiving livelihood protection. Despite the need to reinforce
cooperation among local governments (namely, their welfare and medical departments) and healthinstitutions, there are almost no examples, guidelines, or consultation services for cooperation
among local governments, local health institutions, and facilities specializing in obesity treatment.

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Obesity is not only becoming more common among adults; it is also becoming more common
among children, and it is known that a certain percentage of people develop obesity as they transition
to adulthood. Therefore, early detection and intervention for obesity should also be strengthened
for children. Along with educating children on diet and exercise, children in need of support andinterventions should be managed through collaboration among government, school health offices,and health institutions. However, the number of municipalities engaged in initiatives for childhood
obesity is extremely limited, and efforts to raise awareness toward this issue have not progressed.
In 2023, the WHO compiled a report based on the concept of primary health care (PHC) titled,“Health service delivery framework for prevention and management of obesity.” 6 It calls for thecreation of systems that utilize community resources to help people recognize that obesity is acondition that requires intervention from schools, workplaces, and other parties in addition to
health facilities, and that allow people to access consultations and guidance on daily habits. It also
advocates for frameworks in which tools like self-management, community resources, community
healthcare, and advanced medical treatments are stratified and used appropriately according to
demand for medical interventions. Discussions in Japan have focused on interventions at healthinstitutions, but using appropriate medical and non-medical resources will be an effective point ofentry into the daily lives of people living with obesity.
Family doctors can provide a door to healthcare for people living with obesity that require medical
interventions after receiving support through community resources. Despite high expectations forfamily doctors to fulfill major roles in obesity control by providing interventions and, when necessary,referrals to advanced health institutions that specialize in obesity treatment, there has been a lackof progress in obesity control measures due to problems rooted in the healthcare system. First,
there is no reimbursement for providing medical treatment for obesity in the medical service feeschedule to incentivize family doctors to treat obesity. Items used to reimburse services provided
by family doctors are limited to specific diseases or patients and do not include obesity.7 People
living with obesity also require non-pharmacological therapies such as nutritional and exercise
guidance, but it is difficult for health institutions providing family doctor services to cover all ofthese bases because they do not always have dietitians and other specialists on staff.
There are times when people with obesity visit multiple departments in both community clinics
and core hospitals to treat various obesity-related health disorders and symptoms. It will benecessary for healthcare professionals in all departments including internal medicine, orthopedics,
psychiatry, psychosomatic medicine, and obstetrics and gynecology to recognize that obesity is adisease that requires medical intervention, to recognize the need to adopt treatment methods thatare specific to health impairments, and to collaborate with health facilities specializing in obesity
treatment. However, some have expressed the opinion that even health providers sometimes view
6. WHO. (2023) Health service delivery framework for prevention and management of obesity. https://www.who.int/publications/i/
item/9789240073234. Last retrieved on February 26, 2024.
7. Ministry of Health, Labour and Welfare, “Regarding the Partial Revision of Medical Reimbursement Calculation Methods (Ministryof Health, Labor and Welfare Notification No. 54, 2022);” “Items of Note Related to Partial Revision of Medical Reimbursement
Calculation Methods (Notice) Attachment 1 - Matters Related to the Medical Service Fee Schedule” 2022.3.4. https://www.mhlw.go.jp/
content/12404000/000984041.pdf. Last retrieved on February 22, 2024.

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obesity as a condition rooted in personal responsibility and may lack awareness that obesity is
a disease that can be treated. On top of this, family doctors lack clear criteria to determine if apatient must be referred to a specialized obesity facility for consultation.

Voices from affected parties on this issue• “When I had my foot examined (by an orthopedic surgeon), I was told I could not undergo
surgery without dropping down to 90 kilograms. I thought it would be impossible on myown.”• “They wouldn’t do anything for me (at an orthopedic clinic). They just said something like,‘Come back if you can lose the weight.’ I thought ‘You’re kidding me,’ and went searchingfor options. That is how I arrived here (at the facility specializing in obesity treatment).”• “I didn’t want to visit a hospital because I was afraid the doctors would get mad at me.”Recommendation
After defining multi-disciplinary clinical practice guidelines for providing people withobesity with tailored interventions that fit their conditions (such as BMI, presence ofunderlying diseases, etc.), broadly distribute those guidelines and raise awarenessamong health professionals.
Efforts to disseminate obesity guidelines and criteria for referring patients to specialized obesity
treatment facilities among family doctors have not progressed sufficiently. As a result, family
doctors are unable to provide appropriate obesity diagnoses and interventions or refer patientsto specialists. Guidelines should clearly define referral criteria using numerical values for specificsymptoms that family doctors can use to refer patients to specialists if there is no improvement
after several months of an obesity management program. Those guidelines should be distributed
to and adopted by health institutions specializing in internal medicine and a wide range of
medical departments. While some steps have been taken to advance collaboration, it will also benecessary to collaborate with academic societies for fields that have close ties to obesity (suchas those for orthopedics and obstetrics and gynecology) to demonstrate how to best provide
treatment while engaging in multidisciplinary collaboration.
Establish systems to provide various interventions in communities and build industry,
Government, academia, and civil society networks that form a foundation for healthcarecollaboration to ensure people with obesity receive the support they need in a timely
manner.
Effective methods of treating obesity such as nutrition therapy, exercise therapy, behavioral
therapy, and pharmacological therapy are not being adequately provided in communities. Thisis leading to cases in which people are unable to continue the treatment they need in theircommunities during or after their treatment at specialized obesity facilities, so it will be necessary
to establish an environment in which effective treatments can be provided in communities.
Specifically, where medical resources are limited, it would be ideal if integrated and seamless
community support systems could be established with collaboration with exercise therapy

20facilities, local psychologists, and nutrition care stations or other personnel or facilities that can
provide nutritional guidance.
Within the current framework, the pharmaceutical for treating obesity can only be prescribed withinsurance coverage if prescribed by facilities, physicians, and treatment periods that meet certain
requirements described in its Optimal Clinical Use Guidelines.8 Many family doctors who do notmeet those requirements are currently unable to prescribe this medication. Along with steps toencourage the appropriate use of obesity drugs, it will be necessary to also consider how toensure access to them in communities in the future.
The key to connecting people with obesity to these treatments as early as possible will bereaching out to them via the administrative institutions, industrial health providers, educational
institutions, and dental institutions that are related to their daily lives so they can receive early
consultations with their family doctors, who serve as the gateway to healthcare. It will also
be important to strengthen collaborative networks across community organizations such as
municipal governments, health institutions and medical associations, and schools. Using the latest
technology will be useful when doing so.
Online medical consultations are one effective option for supporting patients in areas withoutobesity treatment facilities or specialists who can provide nutritional guidance. They allow boththe nearby health facility and the remote one to confirm the patient’s condition and confirm thedirection of treatment. They include the Doctor to Patient with Doctor (D to P with D) format, inwhich patients consult a specialist online with their doctor present, as well as Doctor to Patientwith Nurse (D to P with N) format, in which patients consult a specialist online with a nurse
present. Outpatient nutritional guidance is also being provided online. The effective use of digital
devices can improve access to healthcare for people with obesity, so regional systems to support
this must be established.
In terms of the healthcare provision system, an item that should be examined is the utilization offamily doctors and related facilities. An overview of the resources available for obesity treatment—such as the number of educational and training facilities in each academic society and the numberof certified specialists—should be taken to determine whether there is a balance with the numberof people who need treatment for obesity. Another item to confirm will be how many family
doctors and other medical staff have completed a certain degree of training or education and cancontribute to providing treatment.
As part of measures for lifestyle disease control, design incentives that will encourage
family doctors to take part in obesity treatment.
Financial incentives for those who treat obesity or make referrals to specialized health institutions
must be established and steps must be taken to encourage proactive involvement from family

8. Optimal Clinical Use Guidelines for Semaglutide (Genetic Recombination). Ministry of Health, Labour and Welfare, 2023.11.
https://www.pmda.go.jp/files/000265450.pdf. Last retrieved on February 22, 2024.

21

doctors, specialized institutions, and other such parties. When establishing incentives for obesity
treatment, steps should be taken to set outcome indicators for interventions, to establish apremium for providing guidance to people with obesity that is not part of existing medical
service premiums, and to consider long-term interventions for obesity as an upstream disease.
Incentivizing family doctors to treat obesity will motivate them to take part in obesity treatment andlead to effective use of the family doctor function. Ultimately, enabling family doctors to provide
appropriate early detection and intervention in obesity treatment will enhance the overall efficiencyof healthcare and help lower the cost of healthcare in the future.
Ideal treatment structure for people living with obesity and related social support / measures

Recommendation 4 : Establish healthcare provision systems and pursue nationwide equity somultidisciplinary interventions can be delivered to people with severe obesity.
Challenges
Currently, 82 health institutions nationwide are certified by the JASSO as hospitals specializing in
the treatment of obesity (as of January 1, 2024).9 Of Japan’s 47 prefectures, 16 prefectures havezero certified hospitals. Examining the number of facilities providing bariatric surgery, an effective
treatment for people with severe obesity that provides weight loss and enhances metabolism,
there are only 27 integrated obesity treatment centers certified by the Japanese Society for theTreatment of Obesity (JASTO) (as of February 1, 2023).10 As a result, there are a certain number ofpeople who, depending on where they live, do not have access to a specialized hospital.
Furthermore, policy support to encourage people to undergo internal therapy at health institutions
is insufficient. For example, despite the fact that visceral fat area (VFA) measurements andformula diets11 are important parts of examination and treatment, they are not covered by healthinsurance. As people who need VFA measurements or formula diets must pay for them entirely
out-of-pocket, they can become significant financial burdens. Even though a new, highly-effective
therapeutic for obesity is now available and in high demand, treatment is more effective whencombined with dieting, exercise, and other non-pharmacological therapies, so support measures
to promote non-pharmacological therapies must be further strengthened.
Furthermore, along people living with severe obesity, some also experience associated physicaland mental disorders or socioeconomic challenges. These require patients to visit multiple
departments, which can cause ongoing treatment to feel like a burden and hinder adherence. This
9. Japan Society for the Study of Obesity (JASSO). “List of Certified Hospitals Specializing in the Treatment of Obesity.” http://www.jasso.
or.jp/data/data/pdf/hplist.pdf. Last retrieved on February 15, 2024.
10. Japanese Society for Treatment of Obesity (JSTO). “List of Certified Facilities for Bariatric Surgery (Weight Loss and Metabolic
Enhancement Surgery).” surgery)”http://plaza.umin.ne.jp/~jsto/gekashisetsu/file/shisetsuichiran20230201.pdf. Last retrieved on March 8,
2024.
11. Formula diets: Adjusted, low-calorie diets that contain protein, vitamins, minerals, and trace elements. They are considered effective infacilitating low-calorie diet (LCD) therapy while helping people maintain necessary levels of intake for protein and other nutrients. JASSO.
Guidelines for the Management of Obesity Disease 2022. http://www.jasso.or.jp/contents/magazine/journal.html. Last retrieved on
February 22, 2024.

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means people with severe obesity need multidisciplinary treatment and holistic support. Obesity
treatment coordinators play an essential role in providing these by making arrangements withvarious departments and providing patient consultations to serve as hubs for seamless support.
Also, preventing rebound and nutritional disorders after bariatric surgery and providing mental
health care requires lifelong care from multidisciplinary teams. However, the lack of a premiumfor obesity treatment coordinators in the medical service fee schedule means their services are
generally covered by the health facility, so the first step will be to raise awareness toward theimportance of obesity treatment coordinators and team treatment.

Voices from affected parties on this issue• “The people here (at the hospital specializing in obesity treatment) are kinder. The fact
they listened to me put my mind at ease and I could see a path ahead, so I am grateful.”• “The fact they arrange this and that across departments made me feel very secure.”• “Talking to the obesity treatment coordinator before talking to the doctor helped put mymind at ease from the start.”
Voices from physicians involved in treating obesity regarding this issue• “Things go smoothly thanks to the obesity treatment coordinators being here (to serveas consultation partners when patients have problems and to facilitate communication
between patients and multiple departments and health professionals).”

Recommendation
Strengthen systems for collaboration across multiple departments and professions toprovide a foundation for the provision of multidisciplinary treatment.
In the Guidelines for the Management of Obesity Disease 2022, the primary treatment for obesity
is a combination of nutritional, exercise, and behavioral therapy that is based on a firm grasp of
the patient’s personality and that aims to improve lifestyle habits. An essential element in providing
this will be team treatment that is based on multidisciplinary cooperation. As severe obesity isoften accompanied by mental disorders, treating it will also require collaboration with psychiatry
and psychosomatic medicine. To implement these forms of multidisciplinary team treatment
which involves multi-professional collaboration, many integrated obesity treatment centers are
hosting conferences and other events to reinforce collaboration and provide comprehensive
treatment. However, activities like holding conferences or providing some of the aforementioned
internal medicine or non-pharmacological therapies are not being adequately evaluated byexisting systems. While a new therapeutic drug for obesity was recently launched, it was used in
combination with non-pharmacological therapies during clinical trials. To maintain the effectivenessseen in clinical trials, it will be necessary to promote multidisciplinary and multi-professional
collaboration and reinforce the system for the provision of non-pharmacological therapies bymultidisciplinary teams.

23

Establish specialized, holistic obesity treatment systems at integrated centers forobesity treatment and design incentives for achieving this.
An essential element in providing continuous, holistic treatment to people with severe obesity will
be health professionals like obesity treatment coordinators who serve as consultation partners
for patients, manage arrangements with multiple departments and health professionals, andaccompany patients in their treatment. In the short term, the functions of obesity treatment
coordinators should be supplemented by multiple disciplines to create environments in which
treatment stays centered on patients. In the long term, premiums for the activities of obesity
treatment coordinators and multidisciplinary team treatment must be introduced to the medical
service fee schedule so broad, long-term support can be provided to patients both within
hospitals and in communities through local collaboration.

The roles of obesity treatment coordinators
In addition to pharmacological therapy and surgery, obesity treatments include continuous
nutritional and exercise therapy, as well as behavioral therapy that supports these. Even if
someone plans to have surgery in the future, obesity treatment requires long-term therapies
like nutritional and exercise therapy. Furthermore, because people have their appetites
suppressed during the treatment process, they may begin to experience psychologicalstress. Other characteristics of people with obesity can include social and economic
challenges, mental disorders, and intellectual disabilities. This means treatment requiresconsistent, long-term support involving multiple professions such as internists, nurses,
national registered dietitians, physical therapists, pharmacists, psychiatrists, psychosomatic
physicians, and clinical psychologists.
Against this backdrop, one hospital providing weight loss and metabolic enhancement
surgery has appointed obesity treatment coordinators to support ongoing multidisciplinary
treatment. They are engaged in a wide range of activities for obesity treatment, including
nutritional and exercise therapy as well as emotional support. They also manage
appointments and provide counseling on topics like daily life. Obesity treatment coordinators
have received positive feedback from physicians in several departments as well as frompeople living with obesity.
However, the personnel costs for obesity treatment coordinators are borne by the hospital
because their services are not currently eligible for reimbursement in the medical service
fee schedule. There are many issues rooted in the fact that the position does not have anofficial certification or is an established profession. These include the difficulty of contacting
the government with the intent to support patients’ daily lives, such as through employment
support, or when coordinating with outside parties to foster cooperation in the community.

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Ideal treatment structure for people living with obesity and related social support / measures

Recommendation 5 : Generate evidence on the effectiveness of measures for controlling obesityand other chronic diseases to advance obesity policy and create better and more equitable
healthcare provision systems.
Challenges
A sufficient amount of surveys and data reflecting the voices of the general public and patientsand on real-world circumstances regarding obesity has yet to be collected and more discussions
on these topics must be held. These circumstances make it difficult to obtain a comprehensive,
accurate grasp on the status of obesity in Japan or to mount effective countermeasures. Genetic
predisposition is a major factor for obesity and childhood obesity has become a serious issue
worldwide. There are close links between childhood obesity and the development of lifestylediseases in adulthood, 12 so providing personalized interventions will require collecting andconsolidating lifetime data in the future.
In Japan, the main sources from which health data is collected are regular health checkups
such as those conducted in accordance with the Industrial Safety and Health Act or specifichealth examinations, and medical claims data from examinations and treatments at healthinstitutions. However, there are issues related to fragmentation among each type of data and thecharacteristics of obesity as a disease hinder efforts to leverage this data in obesity research andto grasp real-world circumstances for obesity.
Challenges that have been pointed out from the perspective of data fragmentation include the factthat users cannot be tracked when changing insurers due to each health service being provided
by a different party, and the lack of a disease registry. Another issue is the fact that medical claims
data and health checkup data cannot be matched. From the perspective of the characteristics
of obesity as a disease, issues that have been identified include the inability to register “obesity
disease” in medical claims due to low recognition of obesity as a disease, and the difficulty ofevaluating obesity treatments and interventions because it is a chronic condition.
While PHRs are also a useful form of data for obesity research, utilization rates for PHRs are low
and they face similar issues related to data fragmentation and data reliability.
Despite the need to launch new studies, this area also faces a number of obstacles including
the workloads associated with data entry in real-world care settings, the need for long-term
patient follow-up, the difficulty of detecting obesity disease due to its characteristics as a chronic
condition, and a lack of funding. In addition, there is little financial support to further research using
a disease registry for obesity.

12. Childhood Obesity Prevention — Focusing on Population-Level Interventions and Equity N Engl J Med. 2024 Feb 22;390(8):681-683.
doi: 10.1056/NEJMp2313666. Epub 2024 Feb 17.

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Recommendation
Generate evidence on the effectiveness of measures for obesity and lifestyle disease
control, and how treating obesity reduces societal costs.
In the short term, developing effective policies and effective provision systems for obesity
treatment will require generating evidence and data through the research currently being
conducted. As one example of action in this area, the Japan Obesity Research Based onelectronIc healTh record (J-ORBIT) has called on many health institutions to gather informationin electronic medical records and is constructing a database of people with obesity. Conducting
existing studies by mobilizing many health institutions rather than one academic society or healthinstitution will let us better understand real-world conditions of obesity, which will in turn help
us investigate more effective obesity treatments. There are also societal costs associated withobesity. These include economic burdens such as medical expenses or the cost of long-termcare as well as the loss of opportunities to work. Generating evidence that providing treatment forobesity can contribute to optimizing national healthcare expenditures by reducing health harms
and controlling societal costs will be a necessary element in advancing obesity policy.
Gather and compile data for the entire life course to build a centralized data
infrastructure to advance research on measures for obesity and chronic diseases.
Obesity and other lifestyle diseases share common risk factors and can be related to each other,so life course data from birth to adulthood should be collected and consolidated to establish
a centralized data infrastructure. Over the long term, it is desirable that various forms of data(such as academic society registries, medical claims data, and health checkup data) are linked
and that data collection, input, and analysis is streamlined from the prediagnostic stages using
PHRs, wearable devices, and AI. In collaboration with the Government, science and technology
should be utilized to establish an information platform using a new, cross-disease model. Such aframework is likely to contribute to addressing obesity as well as improving public health.
measures aimed at preventing obesity or its progression
Ideal treatment structure for people living with obesity and related social support / measures

Recommendation 6 : Break away from the tendency to favor certain body shapes and sizes andthe concept of personal responsibility for obesity, foster understanding of obesity as a medical
condition, and eliminate stigma that prevents timely and appropriate medical interventions.
Challenges
The terms “obesity” and “metabolic syndrome” have come into wide use in modern society.
However, not everybody understands the definitions of these terms in a medical context,
and broader recognition for both terms tends to only focus on body image. On top of this,understanding toward body diversity in society is inadequate, and people have a persistenttendency to view obesity in a negative light. Additionally, despite the fact that it is widely known
that lifestyle factors can result in obesity, there is insufficient understanding toward the fact that26

genetic factors and SDH can also influence obesity. As a result, people tend to view obesity asa matter of personal responsibility. Such an environment results in greater social and individual
stigma toward obesity and hinders public health interventions.

Voices from affected parties on this issue• “At first, I didn’t even consider visiting a hospital because I did not understand thatobesity is a disease.”• “When I visited a hospital for an examination, they just told me to come back after I lost
weight, without any support in doing so.”Recommendation
Leave attitudes that are centered on personal responsibility in the past and raiseawareness that obesity is impacted by genetic factors and social determinants of health(SDH) in addition to lifestyle habits.
Removing the stigma attached to obesity both as a condition and as a disease will require longterm education and awareness raising, including during school education. The tendency of
the general public and even health professionals tend to view obesity as a matter of personal
responsibility heightens stigma inside and outside of health facilities, impeding efforts to provide
early and appropriate health consultations and interventions. This awareness must be built toward
the fact that genetic factors and SDH can cause overweight and obesity and that such factors
can make it difficult for individuals to overcome obesity by improving daily habits on their own.
Distinguish obesity as a disease that requires medical attention from other forms ofobesity or metabolic syndrome and spread accurate definitions and recognition.
One factor that prevents people from receiving specialized medical treatment for overweight andobesity is the lack of understanding toward the differences between obesity as a condition andas a disease. We should distinguish between obesity as a condition, where treatment focuses ona non-pharmacological approach using exercise, nutritional, and cognitive-behavioral therapies;
and obesity as a disease, which requires the active consideration of pharmacological and surgicaltreatments. Steps should also be taken to make it widely known that obesity as a disease requires
interventions that are more based on medicine.
Foster acceptance of different body shapes and sizes and eliminate social stigma andself-stigma for people living with obesity.
Certain factors may hinder obesity treatment and encourage the off-label use of obesity drugs forweight loss. These include the tendency for obesity to be perceived in a negative light in Japaneseculture or the tendency for people to favor only certain body images. Thus, steps should also betaken to strengthen awareness of body diversity.

27

6. Issues related to off-label use of diabetes and obesity
drugs called GLP-1 agonists
Obesity treatment is closely related to issues in the area of weight loss. Drugs called Glucagon-Like
Peptide-1 Receptor Agonists, or GLP-1 agonists, are approved for production and marketing forthe treatment of type 2 diabetes. A new obesity drug with similar ingredients and mechanisms waslaunched in Japan in February 2024. It is highly effective and has attracted interest in Japan andoverseas as a drug that will provide more options for the treatment of obesity.
However, advertisements and other materials that can be seen as recommending GLP-1 agonists as“medication for weight loss” for the purpose of beauty or dieting have appeared online. GLP-1 agonists
are for treating diabetes, but there have been reports of off-label use for aesthetic purposes amongpeople who obtained them through personal importation or through prescriptions at certain healthinstitutions.
As of March 2024, the time of writing, when someone with obesity is eligible for treatment with GLP-1
agonists in Japan, they can only be prescribed by physicians and facilities that meet certain requirements.
Some are concerned that the free access to care for those who cover medical examinations by out-ofpocket payments will lead to the spread of off-label use of obesity drugs, as seen in the case of diabetes
drugs, and that this may increase side effects and health hazards associated with their use. Healthdamage caused by adverse reactions to GLP-1 agonists used for weight loss are not covered by theAdverse Drug Reaction Relief System, and notices on their appropriate use are being issued frequently
by the MHLW, academic societies, and pharmaceutical companies.
Preventing off-label use requires preventing physicians from making prescriptions, but because
physicians have the protected right to prescribe and there are no regulations or penalties in place,
we must ultimately rely on the conscience of physicians. While encouraging drug wholesalers not
to sell to health institutions that provide off-label prescriptions, it may also become necessary toconsider measures like strengthening physicians’ training programs or establishing certification andregistration systems. Multi-stakeholder collaboration with academic societies, medical associations,the government, and the private sector will also be necessary to provide information on the appropriate
use of these drugs and to strengthen communication on the risk of side effects.
In 2023, there was an increase in demand for diabetes drugs including GLP-1 agonists that resulted
in temporary shortages in domestic supplies. Many respondents to the “Emergency Survey on Drug
Shortages” conducted by the Japan Medical Association in August and September 2023 reported thatmultiple diabetes drugs were difficult to obtain or prescribe, so problems related to the stable supply of
drugs are also present.
As we can see, supply shortages have also emerged, so in the future, it will be necessary to consider
a framework that will prevent off-label use and ensure that a stable supply of drugs can be provided tothe people living with diabetes and obesity who truly need them.

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7. Acknowledgments
When compiling these recommendations, we crystallized issues from interviews with local
governments, experts, and affected parties as well as from discussions with our Advisory Board
participants, all of whom are listed below. We express our deepest gratitude for their cooperation.
Please note that these recommendations were compiled by HGPI in its capacity as an independent
health policy think tank and should not be taken to represent the opinions of any local government
representative, advisory board member, or related party, or of any organization to which they areaffiliated. This report is copyright 2024 Health and Global Policy Institute.

Local governments, experts, and people living with obesity who lent theircooperation in our interviews(Titles omitted; in Japanese syllabary order for each group)
Health and Welfare Policy Division, Department of Health and Welfare, Saga Prefecture
Health Education Division, Department of Education, Fukushima Prefecture
Health Promotion Division, Health and Welfare Department, Miyagi Prefecture
Health Promotion Division, Department of Children’s Health, Kushiro City, Hokkaido
Four people living with obesity

Advisory board members (titles omitted; in Japanese syllabary order)
Takeshi Imaoka(Associate vice President, Medical, Diabetes Products and Clinical Pharmacology
Medical, Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K)

Tomonori Okamura(Professor, Department of Preventive Medicine and Public Health, School of
Medicine, Keio University)

Yuko Oguma(Associate Professor, Sports Medicine Research Center, Graduate School of HealthManagement, Keio University)

Tetsuya Kakuma(Professor, Health Sciences Course, Department of Fundamental Nursing Sciences,
School of Nursing, Faculty of Medicine, Oita University)

Iwao Kurose
Atsuhito Saik

(Executive Director, Japan Medical Association)(Professor, Division of Diabetes, Metabolism and Endocrinology, Department ofInternal Medicine, Graduate School of Medicine, Toho University)

Tomotaka Shingaki(Sr.Advisor-Medical, Diabetes products and clinical Pharmacology Medical,
Japan Drug Development and Medical Affairs)

Hiroshi Sugii(Vice chair/ Member of the board, AVP CMRQ Development Region Japan, CMRQ
Development Division, Novo Nordisk Pharma Ltd.)

Sayaka Tsuji
Ichiro Tatsuno(Obesity Treatment Coordinator, Toho University Medical Center Sakura Hospital)(Chairman, Japanese Society for Treatment of Obesity/ President, Chiba Prefectural
University of Health Sciences)

Koutaro Yokote(President, Japan Society for the Study of Obesity/ Director General, Chiba University
Hospital)29

About Health and Global Policy InstituteHealth and Global Policy Institute (HGPI) is a non-profit, independent, non-partisan health policy thinktank established in 2004. In its capacity as a neutral think-tank, HGPI involves stakeholders from wideranging fields of expertise to provide policy options to the public to successfully create citizen-focusedhealthcare policies. Looking to the future, HGPI produces novel ideas and values from a standpointthat offers a wide perspective. It aims to realize a healthy and fair society while holding fast to its
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