Six years ago, Atsushi Nakanishi launched Triple W with nothing but the seed of an idea and an overwhelming passion to realize it. Today, the startup is the creator and seller of DFree — the world’s first wearable device for urinary incontinence.
The tiny, noninvasive device uses ultrasound to monitor the volume of urine in the user’s bladder in real time. When the bladder reaches its threshold, DFree sends an alert to the user’s smartphone to tell them it is time to go to the bathroom.
Nakanishi credits the ground-breaking product to a eureka moment in 2013. Due to uncontrollable diarrhea, he soiled himself in the street and, not long after, he learned that sales in Japan of adult diapers had surpassed that of baby diapers. Seeing both the need and demand for a product that lets people know when to use the bathroom, he “felt inspired” despite having zero medical background.
“In Japan, 78% of elderly people have urinary problems, such as frequent urination or loss of bladder control,” says Nakanishi. “I thought we could provide a solution for nursing homes and hospitals, and support rehabilitation and toilet care.”
DFree is one of thousands of products catering to the silver demographic that have entered the marketplace in recent years, prompting the world to look to Japan for solutions to the challenges presented by aging societies.
As home to the oldest population in the world with more than 28% of the country age 65 or older, Japan is ahead of the curve in the development of senior-related health care. And startups are among the organizations at the forefront of innovation in the sector, driven by both opportunity and a desire to do good.
Sendai-based TESS Co. develops, produces and distributes Cogy, a revolutionary wheelchair powered by the pedaling of the user, enabling them to maintain or even improve mobility. It is designed as an alternative to a walking stick or walking frame for those classified as pre-frail or frail, most of whom are older people.
“All of us will get weaker as we get older,” says Kenji Suzuki, founder and representative director. “People (with mobility issues or pain in their legs) need to keep moving. Our product can stop their symptoms from worsening and help them live a longer and healthier life.”
Cogy combines elements of a wheelchair and a bicycle, a concept that at first attracted skepticism and surprise. According to Suzuki, the medical profession was reluctant to get behind such a novel idea, while wheelchair and bicycle manufacturers rejected production, for reasons of capability and liability, respectively.
“It’s an innovative item but the basic technology is surprisingly simple — that’s why it’s difficult (to comprehend),” Suzuki says. “But Cogy shows us that by adapting existing things and technologies to the times, we can create miracles that no one has ever seen or experienced.”
Although both products have clear applications for older people, they are helping a much broader audience, too.
DFree has proven effective among people who have disabilities or are recovering from illness or injury. According to Nakanishi, one user with a brain injury resumed using the toilet after 18 months on diapers. Another, a 7-year-old boy with a disability, was able to undergo toilet training and transition to underwear.
Cogy, meanwhile, is also being used as a rehabilitation and training device at medical institutions and welfare facilities.
With some 180,000 medical institutions nationwide and a population of largely tech-savvy early adopters, Japan offers strong opportunities for the proliferation of such cutting-edge products via professional partnerships as well as direct sales to individuals.
Foreign-run, Tokyo-based startup Bisu Inc. is hoping its “home health lab” receives a warm welcome on entering the market next year. Designed to help anyone better understand their health condition, the technology centers around a urine and saliva analyzer characterized by microfluidic technology, novel design and intelligent software.
Unlike conventional urine test strips, which co-founder and CEO Daniel Maggs says have barely changed in almost 70 years, Bisu requires only a few drops of sample to be placed on the test stick, which is then inserted into a device and read in real-time. Users receive the results, along with custom advice on how to optimize their health and fitness, on their smart device within two minutes.
“People have long had limited, inaccurate or inefficient tools to understand the effect of their daily habits on their bodies,” says Maggs, adding that Bisu “marks a major step forward in the way people monitor their health.”
Although the first product line is focused on nutrition, such as the level of vitamins, minerals and water in the body, work is already under way to expand to oral, baby and even pet health. Long term, the idea is to provide a complete suite of tests for the whole family.
Rapid innovations in the field of microfluidics have opened up such opportunities, according to co-founder and CTO Wojciech Bula, who says startups can bring labs’ highly sophisticated technology to the mass market in the form of useful products.
“We can adapt — or even pivot — very fast, which gives us an advantage over larger companies,” he says.
Bisu has also been creative in the way it tackles challenges. Urine test strips, for example, are a regulated medical device, as they check for signs of disease, but Bisu uses only the portion that tests health, such as the user’s level of hydration, meaning it is not classed as a medical device. While large companies have tended to worry about regulations, Bisu Inc.’s detailed knowledge and agility has helped it to develop a successful prototype, Maggs says.
Another person who extols the capabilities of startups in the medtech sector is Katsunari Soma, director of AI Medical Service Inc., a startup dedicated to the early detection and classification of gastrointestinal cancer using artificial intelligence. Its technology is designed to support endoscopists by enabling them to more easily, quickly and accurately make a diagnosis.
“Startups have no pre-existing rules and no obligations,” he says, pointing to the fact that companies may be limited to making AI compatible with their own machines. AI Medical Service, however, is making AI that can be used with any endoscope worldwide.
Since its establishment in 2017, the business has collaborated with more than 100 hospitals in Japan to receive videos and photos of procedures carried out on patients suspected of having gastrointestinal cancer. Staff used the diagnoses to mark lesions in the resources as malignant or benign. Once trained in indicators of cancer, the AI learned to classify the percentage likelihood of a lesion being cancer.
The first product, scheduled for performance assessment testing this summer, focuses on classification of cancer in the stomach.
It is a ground-breaking step, according to Soma, as work in the field to date centers around diagnosing cancer in the colon via the rectum. “There is no product on the market that is compatible with (access via) the stomach,” which is more complex, he explains.
In the long term, the startup aims to make AI that is capable of detecting conditions throughout the whole gastrointestinal tract.
CEO Tomohiro Tada, who has performed more than 20,000 endoscopies, wants to eradicate cases of missed cancer caused by the inherent difficulty of finding small lesions in the patients’ inflamed gastric lining, which is exacerbated by the heavy workload of specialists, particularly in places with few of them.
“The technology is designed to help nonexpert physicians find cancer like expert physicians do,” Soma says.
In March, an AI Medical Service experiment with SoftBank Corp. found that 5G transfers of video endoscopies are clearer than that of 4G, which would allow doctors to make diagnoses remotely. No outcomes will be pursued — as hospitals in Japan do not allow medical devices to be connected to networks — but the results offer hope; network connections may be the future if telemedicine becomes more important, Soma says.
Another startup using AI to help avoid physician burnout is Ubie Inc. Its medical questionnaires ascertain and record patients’ symptoms, which are analyzed by AI and automatically generated into a medically appropriate record.
Founded by medic Yoshinori Abe and software engineer Kota Kubo in 2017, the startup aims to guide people to the right health care at the right time, thereby allowing earlier detection and management of conditions.
Some 800,000 individuals in Japan are using the business-to-consumer app to check their symptoms and find out about appropriate care options. In the business-to-business market, more than 350 medical facilities across 46 prefectures are using the cloud-based software as a “smart examination tool.”
Naoto Shimazu, CEO of Ubie’s Singapore office (the other country where Ubie operates), says physicians report greater work efficiency from using the tool.
“Better workflows mean improved health outcomes,” Shimazu says. Clinics can even refer patients with more complicated cases to hospitals using the software, while patients can better manage their medical history.
In recognition of the technology’s capability to “reform the work styles of doctors” through innovation of the doctor–patient interview process, Ubie was awarded the 2020 Japan Service Award sponsored by the Japan Productivity Center.
Acutely aware of Japan’s aging society, Ubie has also future-proofed its service with a user-friendly, intuitive interface suitable for all. It is also expanding its questionnaire to assess more conditions common among older people.
“With more senior patients in Japan, all products should be universal — readily available and usable for patients of any age,” Shimazu says.
People may be living longer but it doesn’t mean they are doing so healthily. In 2019, longevity was more than six years longer than in 2000, but on average only five of those years were lived in good health, according to the World Health Organization. And heart disease is the No. 1 cause of the number of lost healthy life years.
Heartseed Inc. is one Japanese startup working to tackle heart failure, a condition where the heart does not pump at the optimum level. It has developed a next-generation cardiac regenerative therapy that works via re-muscularization of the heart wall using cardiomyocyte spheroids. These balls of cells are injected using a specially developed needle with a smooth tip to avoid bleeding. As they connect with their new surrounding cells, they become stronger, forming microtissue and new blood vessels that boost the heart’s pumping power.
In March, the biotech startup obtained approval for a clinical trial this summer, which would mark the first long-term engrafting of cardiomyocyte spheroids in humans.
Heartseed’s work is groundbreaking due to its self-developed “purification” process, whereby residual induced pluripotent stem cells and noncardiomyocytes are eliminated, and only cardiomyocyte cells remain.
“Everyone has long known the importance of removing iPS cells because of the risk of tumor formation. How to do it is a different thing,” says COO Kikuo Yasui, adding that founding scientist and CEO Keiichi Fukuda spent 10 years researching and perfecting “purification.”
Yasui describes the trial as a “big milestone” for both the startup and Fukuda, who has been researching heart failure for 20 years. Fukuda, he says, is so passionate about changing cardiovascular treatment with regenerative medicine that he established the startup with the determination to avoid any de-prioritization of work that can occur in a large company.
There have been other advantages to being a startup, too.
“Our therapy is totally new so not all regulations are decided. Big companies tend to wait until regulations are established, until the path becomes clear. The role of startups is to move into uncertainty and create something new,” Yasui says.
Despite working in a contrasting specialization, Triple W’s Nakanishi agrees that innovation and new product development is at the core of startups. Still, that alone does not guarantee success.
“Highly novel products take a long time to gain adoption,” he says. “Large companies are not very adept at creating innovative products but they have the know-how and sales power to gain adoption.”
He advocates the formation of an ecosystem of startups, large corporations and government to help drive innovative products into the market.
As the world’s second-largest market for both medtech and health care, as well as a historic global innovation center for the industry, Japan is certainly capable of big things as it grapples with the challenges posed by its aging society.
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