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1 It was the ­middle of winter, and I was sitting in a narrow classroom with an institutional linoleum floor, fluo­ rescent lights, and win­ dows overlooking a parking lot. Fifteen or so students, mostly men over the age of 40, sat uncomfortably at long ­tables facing a whiteboard, on which a nurse had drawn several figures illustrating insulin receptors. Having finished her explanation , she was erasing the figures. “Next, let’s talk about food,” she said in crisp, authoritative Japa­ nese. “Please turn to page 38 in your books.” We obediently flipped through the pages of our hospital-­issued textbooks­ until we came to a page with pictures of several dif­fer­ ent meals, accompanied by nutritional information. “Well, what are good foods?” A gaunt man in a work jumpsuit raised his hand. “Vegetables,” he said. “Rice!” said a ­woman in the back. “Japa­nese foods,” said another. “Konnyaku.” The nurse nodded in approval and launched into a practical explanation of healthy meal planning for the management of type 2 diabetes. She pointed to the photographed examples of appropriately balanced and portioned breakfasts, lunches, and dinners. ­Every meal pictured included a small bowl of rice. A ­little while ­later, the nurse prompted us for “danger” foods. “What should we be careful of?” she asked. “Fried foods.” “Western foods.” “Eating out.” “Beer and sake, ­things like that.” Anel­derlymantomyrightturnedandlookedatmeforlornly.Eventhough I was crammed uncomfortably ­behind a ­table like the other students, I wore my white lab coat and a hospital identification badge. “But it’s okay to drink a ­little sake, right?” he asked hopefully. * * * Introduction Two Countries, One Disease 2 Introduction rates of type 2 diabetes ­rose rapidly in Japan during the last years of the twentieth ­ century. By the early 2000s, nearly one in five Japa­ nese had impaired glucose tolerance, a precursor to diabetes (MHLW 2007). In a nationallyrepresentativesample ,morethan17­percentofmenandnearly10­percent of ­women over the age of thirty met standard diagnostic thresholds for type 2 diabetes in Japan (MHLW 2012). Prevalence increases with age: more than 22 ­ percent of men over sixty and more than 16 ­ percent of ­ women over seventy had hemoglobin A1c (HbA1c) levels over Japan’s 6.1 ­ percent threshold for diagnosing diabetes (MHLW 2010: 6). As Japan has grayed, its diabetes epidemic has grown. Most Americans are surprised to hear that type 2 diabetes is epidemic in Japan, a nation popularly associated with healthy food and small body mass. To be sure, age-­adjusted rates of diabetes are higher in the United States than inJapan.MorethanaquarterofAmericansoversixty-­fivehavediabetes(CDC 2011). But the U.S. population is younger than that of Japan, and rates for younger Americans and Japa­ nese are similar, particularly among males. Diabetes affects just 9 ­percent of all Americans over the age of eigh­teen (CDC 2012), a smaller proportion of the total adult population than are affected in Japan. By the 2000s, both countries faced serious and rapidly expanding epidemics. Japan experienced many of the same social and economic changes over the last ­ century that drove rising rates of diabetes in the United States: increased availability of cheap pro­ cessed foods, changing portion sizes, sedentary work and recreation patterns, reliance on motorized transportation, tobacco use, economic in­equality, and longer life spans. Moreover, as almost any type 2 diabetes patient in Japan is ­eager to point out, Japa­nese, along with many ­ people of Asian descent, may inherit greater risk for the condition as a result of physiological differences (Chan et al. 2009). When matched by age, body mass index (BMI), waist circumference, and diet, healthy individuals of Asian descent have higher postprandial glucose levels and lower insulin sensitivity (Dickinson et al. 2002). This higher risk for diabetes among ­people of Asian descent may be related to a tendency to deposit visceral fat and to a ge­ne­tic predisposition for a pancreatic beta-­cell abnormality that influences insulin re­ sis­ tance (Chan et al. 2009). Japan’s diabetes patients reflect this pattern, including large numbers of the “metabolically” but not conventionally obese: patients who have a normal BMI by conventional ranges, but increased abdominal adiposity. As its population aged, Japan’s policymakers worried that the diabetes epidemic , along with a host of other so-­called lifestyle diseases, could threaten Two Countries, One Disease 3 the soundness of the Japa­ nese health care system.1 Japan enjoys one of the most cost-­efficient health care systems in the world, but the specter of widespread chronic disease and an aging...


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