Freed: This is Steve Freed and we are here for the American Association of Clinical Endocrinologists (AACE) 2018. We have a special guest with us, Dr. Jeffrey Mechanick, who is Clinical Professor of Medicine and Medical Director of the Kravis Center for Health at Mount Sinai Heart, Division of Endocrinology and Director of Metabolic Support with the Division of Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai in New York City. We are really glad to have you here and I understand you’re doing a presentation. Can you tell us the title of that presentation?
Mechanick: We are going to be speaking on transcultural endocrinology, and actually, this is going to be, not necessarily a first ever for AACE, because we have had some other transculturalization type activities at annual meetings in the past, but what is going to be different this time is that it is going to be a summary of activities that we did this past December 2017 for a program of Diabetes Care Across America. We went to three different cities in the U.S. and spoke about the different ways diabetes care can be fashioned based on different cultures and ethnicities.
Freed: That’s interesting. I know in the medical communities such as AMA and AACE, some of you guys come up with terminology that nobody knows what you’re talking about. So, can we start off by you telling us what ‘transcultural endocrinology’ is?
Mechanick: (Laughs) Right. So, we know what endocrinology is – it’s the study of hormones and the endocrine glands. The word ‘transcultural’ you could argue is a little bit of a made-up word but what it really describes is the process of taking evidence-based recommendations for a very specific medical problem, in this case, diabetes care, from a source population, a source culture with a certain distribution of races and ethnicities, and then, making it portable for a target population with perhaps a different culture, and within that culture, a different distribution of ethnicities and races. The problem is, is we didn’t really recognize this as having a significant impact on optimizing or providing diabetes care. However, now, we know that this is probably true. A lot of times, the realization of what we are doing for populations of patients is not quite what we would have liked with particular structured lifestyle changes, particular pharmacotherapy, even procedures like bariatric surgery because we’ve miscalculated the differences between the two cultures (the source culture for the recommendations and the target culture where we’re applying it). So, transcultural means going from one culture to another culture in the context of evidence-based recommendations.
Freed: Can you give us an example?
Mechanick: Sure. So, let’s say diabetes care – nutrition – how much carbohydrates should be in a healthy eating pattern for somebody with diabetes – it could be 55 percent. If you wanted low-carb it could be in a zone, it could be 40 percent. But, if you go to India where the staple is polished rice or glutinous rice, it might be as high as 60,70, or 80 percent. And in fact, the transculturalizaed recommendations are going to be between 60 and 70 percent rather than, 55/50 or there abouts percentage in a North American population, for instance. Furthermore, if you want to cut back on the glycemic index of that particular staple, what do you replace white rice with? Well, there are some concerns about the eating patterns that have gone from generation to generation as part of the culture. And also, socioeconomics – white rice is cheaper. Can average families afford the brown rice? Can they afford quinoa? Can they afford barley? Is it available in the food chain? What types of oils are going to be healthy as part of a cardiometabolic risk mitigation strategy – oils that are going to have more monounsaturated fatty acid, oils that in a polyphenol content in a diet that mimics the evidence-based Mediterranean-type diet. How do you export those recommendations that adopt Mediterranean diet eating patterns to areas of the world not accustomed to a Mediterranean eating pattern like India or Southeast Asia?
Freed: Continuing with the concept of diabetes, you talked about India, but more specifically, because the AACE organization – the endocrinology association – is primarily in the United states. If you look at your membership, you’ll see most are obviously from the U.S. How does it pertain to the U.S., where generally, unless you’re from a certain ethnic population, you’re not eating a lot of rice?
Mechanick: This is actually a really good question because originally, the whole transcultural project started with a global footprint, going from country to country where it’s sort of intuitively obvious that you’re dealing with different populations. A lot of times, these countries were relying on the U.S. or Canadian or European evidence-based guidelines but they were hardly portable over to these other countries in Africa or the Persian Gulf or Southeast Asia. But now let’s look within our own boarders in the US; this has been the specific focus of AACE this past year or so. So, what we do is we go from city to city and we look at these different cities and we look at the composition of the populations – how diverse that particular city is. In this particular program, in fact, we spent careful attention to the needs of Native Americans, the needs of Latinos, and the needs of African Americans across all socioeconomic strata, even looking at subpopulations within those ethnicities. So, for instance, within Latin America you have different Latin American countries such as the Caribbean. Within African American populations you also have the Caribbean, and you have those who came from Africa directly … there’s so much detail that needs to be considered and really the follow-up point to your question is: How does this translate to the N of One care? A single healthcare professional, a physician, a clinical endocrinologist dealing with that one patient who comes in, in front of them who’s an Asian-Indian or a Southeast Asian or somebody from Ecuador who has their own culture – how do you adapt your evidence-based recommendations, whether it’s from the AACE algorithm or some other algorithm, to that particular patient? In this precision medicine model, it’s not just the transcultural component, there’s also the physical world-built environment component, and also the genetics, the epigenetics, genomics, epigenomics. If you look at the biological correlates for instance, and we’ll take Asian Indians because that was your example, they could have sarcopenic obesity. The cutoff for BMI for normal weight to overweight instead of 24.9 it might be 22.9 – 22.9-24.9 is overweight and 25 and over is obese. However, they could actually have a BMI that is in the normal range but have almost an obesity phenotype because of the sarcopenia – because of the decreased muscle mass and because of the culture of not having as much progressive resistance training. In addition, beta cell mass is decreased and that might be something that is inherited, maybe transgenerational. With decreased beta cell mass, you may see more postprandial hyperglycemia in Asian Indians than fasting hyperglycemia which you might see in Caucasians or the aggregated population in the U.S., from which, a lot of these trials were based. And then the last point is – as we talk about Asian Indians – are our clinical trials whether they are on diabetes interventions, focusing on glycemic control, or the new paradigm of cardiovascular outcome trials, how much representation is there in Asian Indians or for Latinos or African Americans? They’ve been disenfranchised essentially from inclusion in those clinical trials so how on earth are we able to reliably extrapolate information from those trials for your N of One precision care to your patient in front of you.
Freed: We’re getting a little bit off track. I know that there have only been a couple of studies where they look at a particular drug for a particular race and obviously that is very important. We know that if metformin doesn’t work for African Americans why are we prescribing it? How does this all get into play?
Mechanick: Well, right now we don’t have enough data to actually answer the question for the ideal cocktail, the ideal algorithm, the ideal way to structure lifestyle for the different ethnicities and the different cultures. There are a lot of variables. But let’s stipulate that, that uncertainty and that incompleteness exists – how is that actionable? It’s actionable now through education and research. So, AACE is now endeavoring to build-up this educational arm, to start training our clinical endocrinologists, having more activities like that lecture forthcoming, so that we’re aware of these transcultural problems – aware of the shortcomings of generalizing from these studies. From a research standpoint, also, a lot of the principle investigators when they design these studies are going to need to capture a more representative population in their studies and also make these studies robust enough so that any post hoc analysis to look at a particular subset is going to be powered sufficiently.
Freed: If you look at the bigger picture, obviously, you have to deal with the American Diabetes Association (ADA) because that is where the protocols stem from, especially for type 2 patients – 90 percent do not go to endocrinologists, they go to family practitioners and internists. How do you get the information? What is the process for what you have today and moving it over so that it hits the general population, and mostly, the family practitioners because that is really where it starts.
Mechanick: Well the first part is how do we deal with the sister societies? A lot of the transcultural program predated incorporating it in AACE activates. When we set up this global network, of colleagues and thought leaders who were experts in diabetes care, the majority were really members of the American Diabetes Association. So, they’re already situated there in the ADA. ADA, Endocrine Society, EASD (European Association for the Study of Diabetes), and IDF (International Diabetes Federation), already have representation of experts in the transculturalization process, it’s just a matter of it bubbling up internally within those societies so it becomes a priority. As far as primary care goes, you’re absolutely right, and one of AACE’s objectives is to work more closely with the primary care community and it’s not just for the transculturalization; it’s really for the larger picture of optimizing diabetes care and obesity for the general population. There are not enough endocrinologists to be able to do it so we need to work hand in hand with primary care.
Freed: What is the focus on the transcultural drivers in Type 2 diabetes?
Mechanick: Well, there are many transcultural drivers in Type 2 diabetes. Let’s go through some of the main ones. Nutrition would be one, and I would prefer that to be viewed as eating patterns. So, there is no good or bad food; it’s really the eating pattern that determines our risk for various chronic diseases. Those eating patterns change from one culture to another. It’s very important to understand that. It’s not even the food that are on the table – it’s also the timing of eating – we’re learning a lot about the chronobiology of obesity care and diabetes care; consuming most of the food earlier in the day, not eating so much right before you go to sleep, not night grazing. So, a lot of that finds its roots in cultural dictates. So, nutrition is one. Number two would be physical activity. There are many parts of the world where it is sort of ingrained in the culture not to sweat in public. There are many parts of the world where it is so hot that people do not want to go outside or as in the Islamic faith, [are required] to be covered. These things make it more difficult to go outside and exercise in the warmer climates. A lot of those cultural dictates find their way when we look at our American population in this diverse mosaic of an American population. So, as a physician you have to be prepared to discuss this. The sarcopenia – talking about progressive resistance training to build-up muscle mass, to add protein supplements perhaps to supplement a vegan diet or a vegetarian diet that you might find in an Asian-Indian family or an Asian-Indian culture for instance here. The socioeconomics, the belief system, the attitudes toward doctors and relating to doctors, dieticians, and the paramedical, and attitudes toward stress – a lot of populations come in from other countries where there is a huge amount of stress. There is actually an allostatic stress model for diabetes where you’re revving up all of that stress and the cortical input to the limbic system, counterregulatory hormones, cortisol, adrenaline, and however you cobble together all of the pieces of this, but stress is a huge factor and being able to come up with nonpharmacologic, nonsurgical ways to manage stress – that’s lifestyle medicine. So, meditation, various forms of dances, various forms of other physical activities are all part of the ways that we can transculturalize lifestyle medicine in order to better manage chronic disease such as diabetes.
Freed: When you sit down with a patient, you only have so much time. You have to put emphasis on something. Certainly medications. In looking at physical activity and nutrition, I always like to ask the question: Give me a percentage of the importance; is it 80 percent nutrition, or is it 50-50?
Mechanick: The best answer to that question is we do not know, but, we do not know for a good reason. The reason is, is lifestyle medicine has really received short shrift when we look at the whole portfolio of interventions for chronic disease. Hopefully that is something that will change and we’ll be able to answer that, and put together the right prescription and cocktail. But let me just fast-forward a little bit to tactics and implementation and time constraints and the world we live in. What we really need are well-equipped centers and practices to help manage chronic disease. Now you can find this in the AACE chronic care models for diabetes and obesity where not only do you have patient activation as an initial process but also, a prepared practice as an initial process. So, for instance, in this center that we have developed at Mount Sinai, we actually have a gym right there where the doctor’s office is. We have exercise physiologists, we have the nutritionists, we have the certified diabetes educator, and it’s all there with various economic models so that patients cannot only afford it but also, it’s available and we have evidence-based protocols to really pull all this together as seamless as possible. I would assert that this type of multidisciplinary approach to structured lifestyle, not mutually exclusive with the pharmacotherapy, and not mutually exclusive with procedures or various surgeries. This is all part of the toolkit that we have to manage chronic disease. This is all about chronic disease; it’s not about the acute DKA (diabetic ketoacidosis) episode or amputation of a foot or the acute MI (myocardial infarction). This is about prevention – preventing those complications and preventing the serious morbidity, the impact of quality-adjusted life years (QALYs), disability adjusted life years (DALYs) – all the metrics we have for chronic care. That is what is making our general population unhealthy – that’s what’s compromising the wellness and this is where we need to refocus our attention.
Freed: So, you mention you have an activity center at Mount Sinai. Do you find that the medical professionals use that facility?
Mechanick: So, one of our aspirations would be to have this scale up so that it would be more widely available for the professional staff and for the ancillary staff in the hospital. But more and more, a lot of them are being referred in or self-referring in for medical care. So, it’s available a la carte – you can come in and have the exercise physiologists see you or the nutritionists or you can have the whole package with a cardiologist and endocrinologist see you, etc. But it’s within the context of preventive care. If we had a healthcare system that fully reimbursed and fully supported an infrastructure where for every American, we had access to qualified and experience exercise physiology, physical activity, the built-in environment with running trails, stairs to encourage people to take those instead of elevators, healthy food buffets at medical conferences and work, and if in schools we got rid of the candy machines – a lot of this has been done. Much of this was pioneered and amplified but our former first lady [Michelle Obama]. A lot of this has been advanced and supported by many government agencies and by many aspects of industry of the healthcare environment but here’s the question, why don’t we see more of it? Now one of the answers is an emerging concept that arose from our 2014 obesity consensus conference, that, in general, Americans place little value on obesity care, diabetes care, chronic care – being healthy. We’re more consumed with other aspects of life like money and materialistic goods. I realize this is a big statement and we as doctors need to sort of dig ourselves out of this pigeonhole of just worrying about people when they get very, very sick and they’re in the hospital which consumes a lot of money from the healthcare system. Instead, we should be trying to understand the behavioral medicine component, the socioeconomic component, the motivations, and the ways to really make a dent in primordial, primary, and secondary prevention to decrease the prevalence of chronic illness.
Freed: Do you feel that financial incentives would be a big boost to motivating people?
Mechanick: So, that’s behavioral economics and there’s two sides to the coin there. At face value, many people would say that behavioral economics works – you add a taxation to those that have kiosks for barbeque and hotdogs on the streets of New York City and you subsidize the fruit stands that are selling apples. There are problems with that. First of all, there is a little bit of a game theory involved because what about the fruit store that is on the street that is going out of business? Also, we know from studies, scientifically, that when the money runs out, people revert back to their old habits. There is no legacy effect, essentially, with behavioral economics.
Freed: What were the overall summit findings and the conclusions?
Mechanick: Well, there were several findings from our Diabetes Care Across America. First of all, we need to change the way clinical investigation is done – we need to have more of an active recruiting strategy for Latinos, African-American, and Asian-American populations to be more representative so that the findings can be more generalizable. Second, there is an issue of trust. Many of the minorities, many of these cultures and ethnicities, have lack of trust in their
physician. What we have learned is, and there was a study presented at the American College of Cardiology with provision of care by the barber shops and the pharmacists working with the barbers, that agents in the community, either in a community facility or a church – if medical care in some fashion, can be discussed, not necessarily dispensed comparable to what you would find in a doctor’s office, but could be a place where people could go where they would trust the messenger. That would be another issue. Other issues would be changing the eating patterns, recognizing the eating patterns, the language barrier, and taking care of food deserts. So, when we were in Houston, we learned about food deserts for the lower socioeconomic class, who did not even have access to the healthy foods even in the franchised, large stores where food was made available for purchase – they were not able to find fresh fruit and vegetables. A lot of times there was spoilage. [We can] teach the children – work on the children so when the children come home, they can educate the parents and the grandparents who are all living together. In short, we learned a lot. We’re actually now in the process of putting all this information together, curating the information and developing a position paper on transcultural diabetes care by AACE.
Freed: So, if there are a couple of points you want the medical professionals to walk away with, with a true understanding, what would those points be?
Mechanick: I think, firstly, to recognize that there are differences – people are different, drugs work differently, and that lifestyle needs to apply differently. How can this be done in only a 15-minute visit? Listen. Establish that rapport, recognize some space issues – some people like you to be close, others require that space. Be respectful of the cultural aspects for that particular patient. Once you establish that rapport and that connection, the message is going to be much better heard. Number two would be to read. Read about the differences that exist in the literature. If you see a study that is coming out that is in India and would be more applicable to your patients who are from India, than for your patients from Mexico, for instance. Lastly, stay tuned. A lot of this is really in its infancy and I wish I had more science to be able to convey, but that is one of the aims of this program.
Freed: Well, I don’t want to take any more of your time. Enjoy the rest of your stay here and it was a pleasure seeing you again.
Mechanick: Great, thanks Steve.