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Viswanathan Mohan 2018 Transcript

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Freed:  This is Steve Freed with Diabetes in Control and we’re here at the American Diabetes Association, 78th Scientific Sessions. We have a special guest with us, he’s actually receiving a big award and we’ll get into that. But maybe we can start off with and, I guess, we can begin with your name, and that’s V. Mohan?

Mohan: Yes. I’m Dr. V. Mohan.

Freed:  And you actually came from India?

Mohan:  Yes.

Freed:  And my first question is do you — well, first of all, let’s talk a little bit about what you do and your practice and give us a little background

Mohan: I am one of those rare individuals who had the privilege of having a father who was the pioneer in diabetes in India. So, my father can be considered like the Joslin of the US. He started the first diabetic clinic in India in the year 1948, and so he’s often referred to as the Father of Diabetology. He worked in the government sector for about 25 years and then he had to leave early due to some political reasons. And then wanted to set up his own private diabetes center. And so, he invited me to do medicine, so that I can help him with his diabetes clinic. So, I had no idea of doing medicine at that time, and so since he — the circumstances were that I had to join my father, so I joined medicine and joined my father the same day, literally. And started working on diabetes right from my first year of medical school. I didn’t waste any time. So, I was doing my medical school and then in the afternoon, evening, worked with my father, and that went on. So, from the age of 18 I have been working on diabetes and spent the first 10 years as a student, and then working with my father. The next 10 years, I spent full-time with my father as a diabetologist. After 20 years, I left my father and said I wanted to start something on my own. And so, my father said, “If you’re smart enough, you’ll go out empty-handed. You’ll go out without any money and let’s see what you’ll do.” So, on that challenge, I came out with virtually nothing in the pocket or in the bank and started on my own in a small little clinic, which then grew and grew and grew because I’d already spent 20 years of my life — and I was 38 at that time — and so, I had already like, people already in their 50s, so it’s kind of a very precocious start. So then I started off and then we started branching out. And today I run a chain of 42 diabetes clinics. It’s probably the largest in the world. We have 430,000 registered diabetic patients across the country, so almost half a million patients within our own system. Ninety-three doctors work for me and we have 1,300 staff who work, so that’s just the clinics part. And then we have the research centers, which are in five locations including a six and a half acre campus with 40,000 sq. ft. built-ups, the largest in Asia. So, I have 25 scientists who work for me. I have 25 PhD students that are affiliated to the university. Four universities have affiliated us for taking on PhD students. Plus we run a series of courses; fellowship in diabetes, post-doctoral fellowship in diabetes, ophthalmology courses, podiatry courses, so that’s a whole academy that we run. And then we do a lot of charities. So, I run a number of charitable clinics, four in fact, where thousands of patients receive free diabetes clinic. It’s so happened that the history repeated itself and my daughter joined me when she was 18. She’s now here and she’s a diabetologist. She married a physician who’s also a diabetologist, so we have a third generation of diabetologists. She’s pretty well accomplished herself, so they have also traveled here to see me receive the award tomorrow.

Freed:  So, how many people came with you?

Mohan:  Two. From the family, I have two. But then from my centers, I have four more who have come. So, there are about seven of us. But then of course, the whole Indian continent and there are about a thousand people here from India, diabetologists. Almost every year today, the ADA, about a thousand people come and they all look up to me because I was a President of the Indian Diabetic Association. So, they’re all here and they’re all waiting to see me get the award tomorrow. (Laughs)

Freed:  That’s terrific. I don’t know what to say. (Laughs) Well, first of all I have to applaud you. What’s the award that you’re getting?

Mohan: So, this is the Dr. Harold Rifkin Award. So, Harold Rifkin was the former president of the ADA and one of — the man who wrote the Rifkin and Ellenberg textbook, which we all read when we were younger. So, in his name — in fact, he was the first recipient. In 1991, they gave the award to him, And then, of course a series of people have got it. The award — this is the only award, of all the awards given by the ADA, this is specifically given for international service to the cause of diabetes. So, I believe the criterion is that you should have worked in more than one country or at least your work should have benefited more than one country. To start with it was easy for me because I invited the ADA to India in 1988. And we had four ADA Meetings in India, that was the first time that ADA left America and came to another country, so that was a good start for me. Four consecutive years, we had the ADA presidents and speakers coming, jointly with the ADA, my institution and the ADA. And then we started working with the World Diabetes Foundation, this is based in Denmark. And so, they sent people from Africa, from Uganda, from Tanzania, from Rwanda, Nigeria, and also from many countries in Asia; Bhutan and Cambodia, Vietnam, Sri Lanka, Bangladesh. So, they all come to our center for training; doctors, nurses, podiatrists. So, this was on my CV that I’ve been training people from different countries. And of course within India we run the largest training programs. We have trained something like 20,000 physicians in India.

Freed:  How many pages is your CV?

Mohan:  How many pages? (Laughs) Well, I can tell you the number of publications because it is a world record. Well, it started out at 18. I mean, not many people get the advantage. So, currently my publication list is 1,150 publications, which is a world record by a practicing doctor in any field. So, (Laughs).

Freed:  I don’t know if you’ve heard of Aaron Vinik?

Mohan: Of course, a good friend of mine. Yeah.

Freed:  I remember I invited him to a CE Program to present and I asked for his CV before I got to know him.

Mohan:  Yes, that big. (Laughs) He has come to India several times.

Freed:  And so, when I introduced him at the program I got this accordion paper.

Mohan: (Laughs)

Freed:  I said I’m going to read —

Mohan:  Like a book.

Freed:  There’s a CV and I drop the thing.

Mohan: (Laughs) Yeah, he’s very, very good.

Freed:  A super guy.

Freed:  Anyways, let’s get back to India. I have a philosophy or at least the knowledge I believe that people that have darker skins whether you’re Italian, Indian, American-Indian, African-American, Japanese, whatever, people with darker skins have more diabetes in their history.

Mohan:  Yes.

Freed:  What do you say to that?

Mohan: I think that is true in some way, because even if you look at the US population, if you look at the prevalence of diabetes in the white population in the US and compare them with virtually any other population, whether it’s the Pima Indians or the Asians, or the Black population, or the Non-Hispanic whites, you compare them with any other population, they have the lowest, the white population. Lowest, and every other ethnic group has higher. In India, there are other causes and one of them is consanguinity. People tend to marry into their own families. This traditionally has been to keep the wealth within the family. So, it’s not unusual for a girl to marry her uncle for example. The mother’s brother would be the first choice for marriage and then would be the cousins, the first cousins, and then the second cousins, and very rarely outside that. So, for centuries this has been going on particularly in some communities. And so, what happens is when you have a diabetes gene, it gets multiplied over and over and over again, and therefore everybody in the family then has the gene, and that’s why you get diabetes.

But if you go back to the time when my father started his work and when I joined him in the year 1971, the prevalence of diabetes – and at that time we didn’t have a national study, that’s being done by my daughter now, the whole country is being studied — but in my father’s days, we used to just study a city. So, in my city, Chennai, which the fourth largest city in India, the prevalence of diabetes is 2% of the adult population [then]. Today, it is 24% of the population. So, one in four of all adults about 20 years in Chennai have diabetes. And if you go to age, let’s say 50 or 55 in Chennai or Delhi, or Mumbai, both 40% have diabetes and 35% have pre-diabetes, so 75% of the population has either diabetes or pre-diabetes at that age and only 25% are normal. Now, these are highly — very, very worrying statistics. And it means that if you take a country with 1.3 billion people and then you talk about such high prevalence rates of diabetes, you’re talking about almost a hundred million people with diabetes in India. Currently it’s about 73 million, but the projection is that it’ll soon reach a 100 million, maybe in the next five years or so.

Freed:  So, I can quote — because I’m here in the US, I can say there’s 30 million people here with diabetes, 25% don’t know they have it, 10% of those people have type 1 diabetes. And we have a 100 million approximately. It keeps going up. We started at 70 but now we’re up to a 100 million people most likely with pre-diabetes and 90% of those people–

Mohan:  Don’t know.

Freed:   –don’t know they have it yet. So, what are the numbers in India?

Mohan:  The percentages? So, in India it would be much worse. The undiagnosed will be much worse because we don’t have systematic screening as you have here. So, I would say half of the people don’t know that they have diabetes. Among the pre-diabetics, I would say about nobody knows because it’s totally asymptomatic and nobody screens at that age and there are no symptoms. So, the number of people with pre-diabetes in India is about 80 million now. So, we have 73 million people with diabetes and 80 million people with pre-diabetes. And of course it depends on the definition that you use. If you use the American definition which is 100 milligrams and above, 100-125, then it’ll probably be more than 100 million in India. We use  110, the WHO criteria which is slightly stricter, and even with that we have 80 milion people. So, you’re right about that and so half the people really don’t know that they have the disease.

Freed:  The type 2 diabetes at least here and I presume in India is a lifestyle driven disease.

Mohan:  Yes.

Freed:  And so, how do you account for so many people in India? I know there’s a lot of rice obviously and carbohydrates is probably king.

Mohan: Yeah.

Freed:  I saw a short of diabetes in India and all they showed was people going into these bakeries and eating all these carbohydrates. It doesn’t take a genius to figure out why there’s so much. But the cost is about 300 — if you include all the cost, missing work and everything, the cost here is about $350 billion for just the 25 million. I can’t imagine what the cost is in India.

Mohan:  Let’s get back to the causes. So, I mentioned that in 1970s when I was very much there, I was already in medical school at that time and we had 2% of diabetes. And today if we have 24% diabetes, now that’s in a period of 40, 50 years time that this has happened. And what I very simply say is that the genes didn’t change in 40 years. My genes didn’t change in 40 years. The population’s genes didn’t change in 40 years. What changed was the lifestyle. So, two things happened, one was that people of course got a little richer and more affluent because they could afford more. And the first thing they do is to eat more. And what would they eat in India? They would eat rice, in South India. In North India, they would eat wheat which is pretty much the same. Refined wheat and refined rice. And rice, we have shown extensively in our study, and tomorrow in the debate I’m going to show all these data, that it’s the carbohydrate which is one of the major drivers of the diabetes epidemic. So, you may say, “Well, they’re not taking carbohydrates in 1970s,” they were taking carbohydrate but that rice was a little different. What the rice they used to take then was a hand pounded rice, it was brown rice. So, the husk was still there. They had not polished it as much as — the rice mills came to India in the late 70s, so until then there were no rice mills. So, in a local — the corner store would just pound the rice and give it to you and that’s it, and then you cook it. That’s actually healthier. When the rice mills came, they started polishing the rice more and more and more, and so it got whiter and whiter and whiter, and people like that, “Oh, really white nice rice,” but that’s pure starch. It’s pure carbohydrate. Everything else is gone. The B complex is gone. The protein is gone. The fiber is gone. Everything is gone, so that’s one big change.

The other thing which happened was that although they would eat the rice at that time, they did a lot of physical activity. So, they were working in the fields and they’re mostly agriculturers plowing the fields and working the whole day. Now, even in the rural areas where the agriculture is, they’re sitting on tractors. They can easily get a loan. And so, they’re sitting on tractors, so the physical activity is gone. In the urban areas, people didn’t have cars or scooters or motorbikes. They would walk to work or they would walk to a bus stand and then walk from there. There was a lot of walking involved. Now, anybody can get a motorbike or a scooter, and so the physical activity has kind of gone down. The quantity of rice and the carbohydrates have gone up; along with that when all the McDonald’s come in and all the fast foods come in, then a lot of junk food also goes in, so the fat intake also goes up, the calories go up, the sugar goes up. So, when you start drinking your Coca Cola or your Pepsi and all the sweetened drinks, the beverages, then your sugar intake also goes up. So, you already have a huge carbohydrate load, on top of that you have your sugar, and then, now we’re really asking for trouble because we already have the genes, ’71 the genes were there. But my father used to say that when the Indians migrate, they go to the UK or the US, they get diabetes. They don’t get it in India. Last year we did a study where we compared the Indians living here with the Indians in India. And it’s actually higher there now, because people here have started looking out at themselves. They’ve started exercising, they are more literate, they’re more educated, and so on. And that’s not happened in India. They’re still worrying about the communicable diseases. Nobody is thinking about diabetes and so they’re putting on more weight. The education levels are just catching up. So, we have a bigger problem in India now there than the Indians living here.

Freed:  Do you find that the medications that are available here and very expensive are available in India, like the SGLT2s, GLP-1s?

Mohan: We have them all. One of the things which is good is that the prices are not the same.

Freed:  Right.

Mohan:  So, they have a country-wise pricing. So, anything which costs, let’s say, $3 or $4 here would probably be half a dollar there. Okay. So, it’s about eight times cheaper. It’s still expensive by Indian standards because the Indians also earn that much less. We don’t earn in dollars. We earn in Rupees. So, it’s still — if you calculate the purchasing power parity, the PPP, it’s still expensive but at least it’s not as expensive as here. Insulin is also much less expensive. And then what happens is that of course we can’t get the SGLT2s and the GLPs, we cannot get the generics. But the others, the moment that they go off patent then the Indian companies make them. And the Indian pharmaceutical industry is very strong, very, very strong. So, the moment they go off patent, they’ll make the drug five cents and then everybody can afford it.

Freed:  But even today an American can go online and order drugs from India.

Mohan: Yes, you can. In fact, your Metformin comes from there. Fifty percent of all your Metformin is generally —

Freed:  But Metformin is only a $3 drug. So, imagine you could buy at Walgreens for free. But the expensive drugs–

Mohan:  SGLT2.

Freed:  Because even I for myself I go online to overseas pharmacies that I can trust.

Mohan: To Canada.

Freed:  And when it comes, I can see that it’s made in India.

Mohan:  Yeah. Oh, it’s made in India. (Laughs) Okay. You know, the pharmaceutical industry is very strong there. Yeah.

Freed:  So, I know that you’re obviously when you see so many carbohydrates, you’re in the bout with diabetes. You put the two together, it doesn’t take a genius to figure it out. So, what do you teach your other doctors in how to train people, and what do you teach them? Soon, as you say low carb people get all upset, so.

Mohan: So, we can’t tell people to go off carbs completely because then that will be completely different from what they eat.

Freed:  Right.

Mohan:  So, we teach them the plate concept. So, we tell them, “Okay. This is your plate. Half your plate, you’ll fill with vegetables, veggies, okay, which is very good for you. It’s going to give you vitamins, minerals, and all that stuff from a very low calories. So, whatever green leafy vegetables you like and that gives you B12 and so on. Quarter of the plate, you take some protein.” There are a lot of vegetarians in India, so you have to the lentils and the beans, and the dals, and stuff like that. If they do eat meat and so on, then we say, “Okay. You can have fish. You can have chicken. You can have red meat, cut down. But then take — the rest, you can have eggs and so on,” so the protein part. And then you have a quarter of plate, there you take your rice. Now, normally the way they eat in India is to take the plate, the first thing to go is the rice, and we call it the mountain of rice. And then around that, a little bit of the side dishes. So, the whole thing is going to come from carbohydrate. So, we teach people this way of eating. And so, they are happy they get their rice but then they have so much of other things to fill up and so they don’t feel hungry. And then, we tell them they can have yogurt and buttermilk and stuff like that, to low calorie soups and stuff. So, we make it interesting for them. And then, the other thing we tell them is of course physical activity. We teach them half an hour, minimum exercise everyday, 150 minutes a week, and then slowly build it up. The more, the better. So, that’s the other thing that we do. And then, of course the medicines part and the monitoring part. And so, we kind of  split that into education modules.

Freed:  I’m sure you monitor A1Cs–

Mohan: Yup.

Freed:  –for your patient base.

Mohan:  Yes, of course.

Freed:  What is your average A1C?

Mohan: Not very good. I think the clinic average is about eight, so it’s not very good. The average — of course there would be a significant number of people below 7 and below 6.5. But as the clinic gets more famous, what happens is that the worst cases will come to us. Physicians would treat them and then when they really get lost, they can’t do anything, go there now. (Laughs) So, we’ll get people with 14 and 15 A1C. And so, getting them down to seven is going to be a big dream. So, if we get them to nine first and then eight, then slowly inching down to seven. So, a large number of people do get to it. And now, we even the Libre and the continuous glucose monitoring, and so on. So, we teach people where their peaks are and how to control those. So, precision — we actually inaugurated the department precision diabetes a year ago. So, with that I think now the personalized treatment is getting better and better.

Freed:  Well, I’d certainly give you a lot of credit dealing with people with type 2 diabetes. It can be very difficult.

Mohan:  It is.

Freed:  And especially for the older person, getting them to change their lifestyle is almost impossible.

Mohan: Yes.

Freed:  But when you can talk to them and show them what’s going to happen and improve your quality of life–

Mohan:  True.

Freed:  –that you can enjoy life as you get older.

Mohan: That’s right.

Freed:  Some doctors have the philosophy, “Well, she’s 88 years, an 8 A1C is enough.” I don’t believe that. If she lives to 150,  she’s going to be miserable for 50 years. Everybody is entitled to normal blood sugars.

Mohan: So, we use the approach of the best A1C possible in that given patient without serious risk of hypoglycemia. So, we don’t set a target at all. They can reach 6.5, that’s good. They can reach six, that’s good. But if they can’t get below 8 without their life being all upside down and all the time they’re worried, they can’t go to sleep, they’re wondering whether they’ll wake in the morning, and they’re throwing a fit and they already have heart trouble, then we tell them, “Ease up. Now, this is enough. Let’s settle for something, 7.5, 8.” So, I guess we totally individualize. I don’t think age is a criteria at all. I agree with you.