In part 2 of this Exclusive Interview, Dr. Jeffrey Mechanick talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston, MA about trans-cultural endocrinology in America and how doctors can take patient culture into account when planning individualized care.
Dr. Jeffrey Mechanick, MD, FACE, FACR, FACN, ECNU is the Clinical Professor of Medicine and Director of Metabolic Support in the Division of Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai, NY.
Transcript of this video segment:
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.