I started to study health problems in dairy farming in the Kitakami mountain district during the latter half of the1970's. Fields were located mostly in steep slopes and pastures were limited in area. In this district a survey of dairy farmers, time budget was carried out by the direct time-study method. And the energy consumption of farmers for their dairy farming activities was measured using the Douglas bag method. Working hours were prolonged because grass grew thick from early May to late October (the busy farming season). In this season, many farmers worked 13-14 hours per day. Grass harvesting that was done on the steep slope consumed a lot of energy. There was a close correlation between gradient and energy consumption for mowing. Various other kinds of agriculture were researched in Iwate Prefecture. And we pointed out some problems in each study. In recent years, the most serious problem in farm work is a high rate of accident occurence. About 400 farmers died in accidents every year for the past 40 years, and there is not a sign to decrease at all. This is the big problem that the Japanese Association of Rural Medicine should wrestle with.
The title of this lecture, ‘What should we discuss from now?’ is taken from the first paragraph in the introduction of “General Theory of Farmers' Arts” written by Miyazawa Kenji. It can be said the life of Miyazawa was marked by “failure and resurrection.” He suffered his setback five times in his life, and was not able to recover from the last frustration until he closed his life at the age of 37. From the fact that the manuscript fee was received only once throughout his whole life, it could be difficult to say that his life ‘in this world’ was successful. However, thousands of people have been touched by his awkward, but earnest, way of life, and it will give many suggestions to the prospect of JARM.
Two years and six months have passed since the national health care system “Tokutei Kensin and Tokutei Hoken Sidoh”, which is a metabolic syndrome-specific health check up and counseling system, was enforced on April in 2008. It is high time for us to review it and make a proposal for a future improvement of the system. We would like to discuss the present problems and how we can increase the efficiency of the system in the workshop. Tokutei Hoken Sidoh, which is six month counseling and instruction for health-promoting lifestyle behavior, has significant effects not only on an improvement of lifestyle, i.e., physical activity and energy intake, but also on the reduction in body weight, waist circumference and blood pressure. Particularly, initial counseling and instruction after health check-up has a great importance for realization of future risks of cardiovascular diseases, and motivation for reducing abdominal obesity and other risk factors. However, the effects are lost in time after the accomplishment of the six-month program. Therefore, how to maintain the motivation and actual lifestyle change should be sought. At present, the cost effectiveness of Tokutei Hoken Sidoh appears to be low, because we tend to expend a lot of time in counseling. To increase efficiency, standardized group counseling would be needed. In addition, the stratification of individuals may be necessary for attending group counseling, because there are large differences in realization and motivation among subjects regarding metabolic syndrome.
Health education provided by a group of professionals from different disciplines, so-called “team medical care”, is considered essential for the treatment of diabetes. When each specialized professional educates diabetic patients on how to manage their condition, patient-centered medical care is realized, and it becomes possible to provide appropriate support to individual patients. The treatment of obesity is somewhat similar to that of diabetes. Diet therapy and exercise are the basic therapies, and diabetes in many obese patients can simply be improved by weight loss. Metabolic syndrome has been reported to be associated with visceral fat-type obesity. In order to prevent the development of atherosclerotic occlusive diseases due to weight loss, individual counseling after each medical checkup is provided by public health nurses or registered dietitians. Behavior modification is necessary to improve lifestyle. Helpful education and advice by various professionals help patients to modify their behavior, and thus patient-centered medical care can be achieved. Recently, for the treatment of diabetes, new oral hypoglycemic agents and insulin preparations as well as incretin preparations have become available, indicating that diabetes treatment strategies are increasing. This has allowed better glycemic control in diabetes than was possible before. Nonetheless, diet therapy and exercise remain the basic treatment methods, and they should not be made light of.