>> GOOD AFTERNOON, I'M ELISEO
STABLE-PEREZ, DIRECTOR OF THE
NATIONAL INSTITUTE ON MINORITY
HEALTH AND HEALTH DISPARITIES.
I WANT TO THANK YOU FOR JOINING
US FOR OUR FIRST NIMHD
DIRECTOR'S SEMINAR SERIES FOR
2024.
HAPPY LEAP DAY AS WELL.
BLACK HISTORY MONTH DRAWS TO A
CLOSE THIS LEAP YEAR, I WANT US
TO TAKE A MOMENT TO RECOGNIZE
SCIENTIFIC PUBLIC HEALTH LEADERS
FROM THE BLACK AND AFRICAN
AMERICAN COMMUNITY IN OUR
COUNTRY'S HISTORY, FROM OUR
PAST, OUR PRESENT, AND HOPEFULLY
OUR FUTURE WHO MADE INDELIBLE
IMPACT ON OUR NATION AND INDEED
AROUND THE WORLD.
WE PAY TRIBUTE TO THE BLACK AND
AFRICAN AMERICAN TRAILBLAZERS IN
CLINICAL AND HEALTH SERVICES
RESEARCH WHO ARE COMMITTED TO
SHAPING A BETTER AND MORE
EQUITABLE FUTURE FOR UNDERSERVED
AND UNDERREPRESENTED
COMMUNITIES.
IN HONOR OF BLACK HISTORY MONTH
IT IS MY PLEASURE TO INTRODUCE
DR. KENRIK DURU, AN EXPERT IN
HEALTH DISPARITIES RESEARCH AS
TODAY'S GUEST LECTURER, KENRIK
WILL PRESENT ON DISPARITIES IN
DIABETES SCREENING AND
PREVENTION BY RACE AND
ETHNICITY.
DR. DURU IS A PRACTICING PRIMARY
CARE PHYSICIAN, PROFESSOR OF
MEDICINE AT THE UCLA MEDICAL
SCHOOL.
HE ACTUALLY WENT TO UCSF FOR HIS
DOCTOR OF MEDICINE DEGREE AND
WENT TO UCLA TO DO RESIDENCY AND
FELLOWSHIP, OBTAINED MASTER OF
SCIENCE IN HEALTH SERVICES FROM
UCLA SCHOOL OF PUBLIC HEALTH.
THAT IS WHERE I FIRST MET
KENRIK, AS AN INVESTIGATOR
SCHOLAR AWARDED A PILOT GRANT
THROUGH THE UCLA RESEARCH
CENTERS FOR MINORITY AGING
RESEARCH, COLLABORATORS OF OURS.
WE HAD ONE OF THOSE CENTERS AT
UCSF, AND THERE WAS ONE AT UCLA
AS WELL.
HIS RESEARCH INTERESTS INCLUDE
ENHANCING PHYSICAL ACTIVITY
AMONG OLDER ADULTS FROM RACIAL
AND ETHNIC MINORITY POPULATIONS,
DESIGNING INTERVENTIONS TO
REDUCE DISPARITIES IN MEDICATION
ADHERENCE, AND CLINICAL OUTCOMES
AMONG PATIENTS WITH DIABETES.
KENRIK LEADS RESEARCH ON HEALTH
CARE DISPARITIES, FOR BOTH
RACIAL AND ETHNIC MINORITY
POPULATIONS AND PEOPLE FROM
LOWER SOCIOECONOMIC STATUS.
STUDIES BARRIERS AND
FACILITATORS OF ADHERENCE TO
MEDICINES FOR CHRONIC CONDITIONS
OF WHICH HYPERTENSION AND
DIABETES ARE UP THERE.
HE HAS AN ENDURING COMMITMENT TO
MENTORING, WORKED WITH MANY
UNDERREPRESENTED SCHOLARS IN
MEDICINE.
HE IS THE PRINCIPAL INVESTIGATOR
ON SEVERAL NIH CAREER
DEVELOPMENT AND MENTORING
GRANTS.
HE HAS PUBLISHED MORE THAN 100
PEER REVIEWED PAPERS, RECEIVED
SEVERAL AWARDS INCLUDING
METROPOLITAN LIFE FOUNDATION
AWARD FOR ACADEMIC EXCELLENCE IN
MEDICINE, WILLIAM OSLER AWARD
FOR EXCELLENCE IN CLINICAL
TEACHING.
PLEASE JOIN ME IN GIVING A
VIRTUAL WELCOME TO OUR BLACK
HISTORY MONTH SPEAKER, DR.
KENRIK DURU.
>> THANK YOU FOR THE INVITATION.
WE MET EACH OTHER A WHILE AGO
BUT I ALWAYS APPRECIATED YOUR
THOUGHTS AND INSIGHTS ON MY WORK
AND CAREER.
IT'S AN HONOR TO BE HERE,
PARTICULARLY AS A BLACK MAN AND
BLACK PHYSICIAN-SCIENTIST
SPEAKING DURING BLACK HISTORY
MONTH IS PARTICULARLY SPECIAL.
I THINK WHAT I'LL BE TALKING
ABOUT IS RELEVANT TO THE WORK I
DO, BUT THEY IMPORTANT NOT ONLY
FOR BLACK PEOPLE IN THIS COUNTRY
AND AROUND THE WORLD BUT ALSO
PEOPLE FROM OTHER GROUPS OF
COLOR.
AND SO WITH THAT I WILL SHARE MY
SCREEN AND JUMP IN.
CAN YOU SEE MY SCREEN?
YES, OKAY, TERRIFIC.
ALL RIGHT.
SO TODAY'S TALK WILL BE ON
DISPARITIES IN DIABETES
SCREENING AND PREVENTION BY RACE
AND ETHNICITY.
I BELIEVE SOME SLIDES YOU WILL
KNOW AND SOME WILL BE NEW BUT
I'LL GIVE MY PERSPECTIVE ON THE
FIELD AND AT THE END TALK ABOUT
WHERE IT'S GOING, WHERE IT'S
NEEDS TO GO WHICH WILL HOPEFULLY
JUMP START A DISCUSSION.
THE FIRST IS DISPARITIES IN
DIABETES SCREENING AND
PREVENTION.
I'LL TALK ABOUT HISTORICAL
VIEWS, I'M GUESSING NOT ALL OF
YOU WILL KNOW THAT.
AND THEN TALK ABOUT DIABETES
PHYSIOLOGY, SUCH A COMPLEX
DISEASE.
SO WE'LL TALK ABOUT THE RELATIVE
ROLES OF GENETICS VERSUS SOCIAL
DETERMINANTS AND YOU'LL SEE
WHERE I COME OUT ON THAT DEBATE.
I'LL TALK A FAIR AMOUNT ABOUT
THE DIABETES PREVENTION PROGRAM,
THE LINCHPIN OF DIABETES
PREVENTION IN THIS COUNTRY.
I WANT TO MAKE SURE EVERYONE
KNOWS ABOUT THE RCT AND EFFORTS
TO TRANSLATE IT SUBSEQUENT.
I'LL TALK ABOUT DIABETES
SCREENING GUIDELINES, AND THEN
DISPARITIES IN DIABETES
SCREENING AND PREVENTION, AND
THEN AS NOTED SOME NEXT STEPS WE
CAN TAKE AS AS A SOCIETY AND A
HEALTH SYSTEM.
WE PROBABLY ALL KNOW DIABETES
PREVALENCE IS HIGH AND
INCREASING, AS YOU SEE ON THE
LEFT A CDC STATISTIC FROM A
COUPLE YEARS AGO.
WE BELIEVE 38 MILLION AMERICANS
HAVE DIABETES, AND 1 IN 5 DON'T
KNOW THIS.
ON THE RIGHT YOU'LL SEE A CURVE
THAT IS GOING UNCEASINGLY
UPWARD, WORLDWIDE ESTIMATES FROM
THE IDF ATLAS OF PATIENTS WITH
DIABETES, THESE NUMBERS ARE IN
THE MILLIONS.
AS YOU CAN SEE IN 2000 IT WAS
ESTIMATED THERE WERE 150 MILLION
PEOPLE ON EARTH WITH DIABETES.
THAT NUMBER DOUBLED AROUND 2010
TO 300.
IS GOING TO DOUBLE AGAIN TO 600
MILLION SOMETIME AFTER 2030.
WE'VE BEEN VERY UNSUCCESSFUL IN
BENDING THE CURVE WHICH
CONTINUES TO GO UPWARD EVERY
YEAR.
AND THIS IS A PROBLEM BECAUSE OF
THE NUMEROUS KNOWN COMPLICATIONS
OF DIABETES THAT WE SEE, AS
ELISEO MENTIONED I SEE PATIENTS
MUCH MORE AND SEE THESE THINGS
MUCH MORE THAN I WOULD LIKE.
ON THE LEFT ARE MICROVASCULAR
COMPLICATIONS, CHANGES IN SMALL
VESSELS SPECIFICALLY
CAPILLARIES.
THESE INCLUDE CHRONIC KIDNEY
DISEASE WHICH CAN LEAD TO
DIALYSIS, INCLUDING FOOT
PROBLEMS SUCH AS ULCERS AND
NEUROPATHY THAT CAN LEAD TO
AMPUTATIONS, AND EYE DAMAGE THAT
CAN LEAD TO BLINDNESS.
ON THE RIGHT ARE THE MACRO
VASCULAR COMPLICATIONS MEDIATED
THROUGH LARGE VESSELS INCLUDING
ARTERIES.
HEART ATTACK, MYOCARDIAL
INFARCTION, CHEST PAIN, CORONARY
HEART DISEASE, CONGESTIVE HEART
FAILURE, AND STOKE.
THESE ARE THE ONES WE LEARNED IN
MED SCHOOL BUT SOME ARE
EMERGING OVER TIME.
THERE ARE QUITE A FEW CANCERS
LINKED TO DIABETES BUT EVIDENCE
IS STRONGEST FOR THESE TWO.
WE BELIEVE DIABETES ACTUALLY
LEADS TO INCREASED RATES OF
PANCREATIC CANCER, AS WELL AS
HEPATOCELLULAR CANCER.
WE LEARNED QUICKLY IN 2020
DIABETES IS A RISK FACTOR FOR
SEVERE COVID-19 INFECTION, THE
KIND THAT PUTS YOU IN THE
HOSPITAL OR THE ICU OR LEADS TO
MORTALITY.
WE ALSO KNOW DIABETES IS A
PREDICTOR OF MAJOR DEPRESSION,
NOT SURPRISING.
DIABETES IS AN INDEPENDENT RISK
FACTOR FOR DEMENTIA,
PARTICULARLY VASCULAR DEMENTIA.
AND DIABETES IN AND OF ITSELF
CAUSES SKELETAL MUSCLE ATROPHY.
YOU'LL HEAR ABOUT THE MERITS OF
PREVENTION.
PEOPLE SAY IF THE PERSON IS 70
OR 75 THEY WON'T LIVE LONG
ENOUGH TO HAVE THOSE
COMPLICATIONS, DIALYSIS AND
RETINOPATHY BUT WILL DEVELOP
MUSCLE ATROPHY, YOU ARE NOT ABLE
TO LIFT THINGS, PULL THINGS, DO
THE THINGS YOU NEED TO DO, THIS
IS ONE CONTRIBUTOR TO LOSS OF
INDEPENDENCE.
SO I'M A BIG BELIEVER IN TRYING
TO PREVENT DIABETES THE BEST WE
CAN FROM CHILDHOOD THROUGH OLDER
ADULTHOOD.
SO, THIS IS EVIDENCE FROM 2019
JAMA PAPER.
WHATEVER NON-WHITE GROUP YOU
LOOK AT THEY HAVE HIGHER
PREVALENCE OF DIABETES.
THIS IS THE PREVALENCE IN THE
U.S., DIAGNOSED AND UNDIAGNOSED,
20+ YEARS AGE, VERTICAL BAR ON
THE FAR LEFT IS NON-HISPANIC
WHITES.
EVERY OTHER BAR ON THIS GRAPH IS
HIGHER THAN THAT FOR
NON-HISPANIC WHITES.
NON-HISPANIC BLACKS, MEXICAN
AMERICAN, PUERTO RICAN
AMERICANS, CUBAN, DOMINICAN,
CENTRAL AND SOUTH AMERICAN, AND
THREE COLUMNS ON THE RIGHT,
HIGHER THAN WHITES AMONG EAST
ASIAN INDIVIDUALS, SOUTH ASIAN
INDIVIDUALS, AND SOUTHEAST ASIAN
INDIVIDUALS.
AND THESE ARE COMPLICATIONS, THE
DATA IS OLD BUT THE POINTS ARE
THE MAIN THING THAT STILL HOLD.
THE SECOND COLUMN, THIS BY IS
THE WAY IS END STAGE RENAL
DISEASE DUE TO DIABETES, LEVEL
FOR WHITE PATIENTS, MUCH HIGHER
FOR AFRICAN AMERICAN, NATIVE
NATIVE AMERICAN AND ASIAN,
ACROSS THE BOARD.
AMPUTATIONS, THIS IS L.A., IF
YOU DIDN'T KNOW YOU CAN SEE THE
FREEWAYS ON THERE.
OME ONE PLACE HAS THIS MANY,
THAT WOULD BE LOS ANGELES.
ON THIS GRAPH, ON THIS MAP
RATHER, DARKER COLORS INDICATE
HIGHER RATE OF AMPUTATIONS.
AND ON THE SOUTH CENTRAL PART OF
THE SLIDE TOWARDS THE BOTTOM
THAT'S SOUTH CENTRAL LOS
ANGELES, WHICH IS PREDOMINANTLY
LATINO AND BLACK AREA.
YOU'LL SEE IN THE MIDDLE TOWARDS
THE NORTH IS SAN FERNANDO
VALLEY, PRIMARILY LATINO AREA,
AND THOSE AREAS HAVE REALLY HIGH
RATES OF AMPUTATIONS.
THE BIG WHITE AREA TO THE LEFT
IS PACIFIC OCEAN.
IF YOU LOOK AT COASTAL
COMMUNITIES, IT'S NOT LABELED
BUT CERTAINLY SANTA BARBARA,
MALIBU, PACIFIC PALISADES, SANTA
MONICA, MANHATTAN BEACH, RANCHO
PALOS VERDES WHERE AMPUTATIONS
ARE LOWEST, IT COULD BE
SUPERIMPOSED BY RACE/ETHNICITY,
IT'S ESSENTIALLY SHOWING THE
SAME THING.
JUST A SLIDE ON EYE DISEASE, I
MENTIONED THE MAIN TAKEHOME
POINT IS THE GREEN BARS FOR
HISPANIC LATINO PATIENTS, WHO
STARTING AT AGE 50 CERTAINLY
HAVE HIGHER RATES OF
RETINOPATHY THAN WHITE OR EVEN
BLACK PATIENTS.
DIABETES IS NOT ONLY MORE COMMON
AMONG PERSONS OF COLOR BUT THE
COMPLICATIONS ARE ALSO MORE
COMMON IN THIS GROUP.
SO I AM GENERATION X.
THIS IS FROM THE ROCKY AND
BULLWINKLE SHOW, THE WAYBACK
MACHINE.
THE DOG WITH THE BOW TIE IS
MR. PEABODY, THE BOY IS SHERMAN.
THEY USED TO GO BACK AND TAKE
KIDS BACK TO LEARN ABOUT
HISTORY.
I WATCHED THIS MANY A SATURDAY
MORNING.
SO WE'RE GOING TO DO THAT NOW,
GO IN THE WAYBACK MACHINE TO
THINK ABOUT DIABETES AND RACE,
130 YEARS AGO.
IN FACT WE'RE GOING TO 1898 AND
SEE WHAT THE SITUATION WAS.
THESE ARE THE VIEWS THAT WERE
OUT THERE THEN.
SO IN 1898, IT WAS NOTED THAT
DIABETES IS RARE IN THE COLORED
RACE, THOSE ARE PEOPLE THAT NOW
WE WOULD REFER TO AS BLACK OF
COURSE.
IN 1913 IT WAS NOTED DIABETES IS
2 1/2 TIMES AS COMMON AMONG JEWS
THAN NON-JEWS.
THINGS WERE CHANGING IN THIS
COUNTRY.
BY 1950s DISCOVERY WAS MADE
PIMA INDIANS HAVE THE HIGHEST
DIABETES RATE IN THE WORLD,
UNQUOTE.
IN 1980s, MEXICAN AMERICANS
ARE A DIABETIC RACE,
QUOTE/UNQUOTE.
YOU CAN SEE A LOT OF CHANGES
HERE FROM THE BEGINNING, THE END
RATHER, 19th CENTURY THROUGH
END OF 20th CENTURY.
AND JUST A NOTE WHILE WE'RE
TALKING ABOUT THIS, DISPARITIES
ARE NOT PRE-ORDAINED.
SO, THESE ARE SOME MORE QUOTES
REGARDING BLACK PEOPLE AND
DIABETES, APPARENTLY SOMEONE
TOOK MINUTES FROM THE 1904
AMERICAN MEDICAL ASSOCIATION
CONVENTION.
SOMEONE SAID I HAVE NEVER SEEN A
CASE OF DIABETES IN A COLORED
PATIENT AND I DO NOT KNOW OF
ANOTHER PRACTITIONER WHO HAS.
SOUNDS LIKE SOMEONE ELSE AGREED
WHOLEHEARTEDLY, A SENTIMENT
AMONG ATTENDEES IN 1904.
YOU MIGHT THINK MAYBE THAT'S
BECAUSE GIVEN THE JIM CROW
RACISM OF THE DAY PEOPLE WEREN'T
SEEING BLACK PATIENTS BUT THE
BOTTOM QUOTE, CHARLES BURNIE WAS
THE FIRST LICENSED BLACK
PHYSICIAN IN SOUTH CAROLINA, HE
GAVE THIS QUOTE IN 1910.
ANY PHYSICIAN IN PRACTICE WITH
COUNT ON THE END OF HIS FINGERS
THE NUMBER OF CASES OF DIABETES
HE HAS NOTED IN THE NEGRO RACE.
I THINK WE CAN ASSUME GIVEN
AGAIN THE SEGREGATION OF THE DAY
THAT ALL OF HIS PATIENTS, ALMOST
ALL OF HIS PATIENTS WERE BLACK,
HE SAW VERY FEW CASES OF
DIABETES.
THIS IS NOT SURPRISING.
UNFORTUNATELY IN THOSE DAYS, I
THINK BLACK PEOPLE TOOK JOBS
THAT NO ONE ELSE WOULD.
THERE WAS A LOT OF AGGRESSIVE
PHYSICAL LABOR FOR BOTH MEN AND
FOR WOMEN.
WE SAW VERY FEW BLACK PEOPLE
WORKING DESK JOBS.
ALSO I THINK FOOD WASN'T IN
ABUNDANCE, YOU COULDN'T EAT TO
EXCESS ACROSS THE POPULATION SO
NOT SURPRISING WE SAW LOWER
RATES AMONG BLACK INDIVIDUALS
130 YEARS AGO OF DIABETES.
DISPARITIES ARE NOT
PRE-ORDAINED.
BECAUSE WE MAY HAVE SEEN
SOMETHING ALL OUR LIFE AND YOU
ASSUME IT'S GOSPEL, IT ISN'T
ALWAYS THE CASE.
THINGS WEREN'T ALL THIS WAY.
MORE IMPORTANT, THEY MAY NOT
ALWAYS BE I THIS IF WE CAN FIND
THE RIGHT LEVERS TO PULL TO MAKE
CHANGES.
SO, ALSO INTERESTING, BY THE WAY
CITATION AT THE BOTTOM WHERE THE
QUOTES COME FROM, A FASCINATING
BOOK BY TUCHMAN, A HISTORY OF
RACE AND DISEASE.
ANYBODY INTERESTED SHOULD READ
THIS BOOK, ILLUMINATING TO PUT
OUR CURRENT WORK INTO CONTEXT.
THE BOOK NOTES THERE WAS A
THOUGHT 100+ YEARS AGO DIABETES
WAS A JEWISH DISEASE.
THAT WAS THE GROUP THAT WAS
THOUGHT TO HAVE THE HIGHEST
RATES OF DIABETES.
ALBERT EPSTEIN IN 1919 SAID WHEN
THE JEW IS THIRSTY HE HAS SUGAR
TESTED.
WHEN THE CHRISTIAN IS THIRSTY,
HE DRINKS.
VERY DIFFERENT IDEAS ABOUT WHO
HAS DIABETES.
PEOPLE MAY KNOW JOSLIN DIABETES
CENTER IS THE LARGEST IN THE
WORLDN BOSTON, NAMED AFTER
ELLIOTT JOSLIN, WHO STATED IN
1916 THE FREQUENCY WITH WHICH
DIABETES OCCURS IN THE JEWISH
RACE IS PROVERBIAL.
SO DIFFERENT PICTURE, IF YOU
DIALED BACK IN THE WAYBACK
MACHINE TO WHAT PEOPLE WERE
THINKING ABOUT DIABETES IN THE
BEGINNING OF THE 20th CENTURY,
JUST ANOTHER REMINDER SOMETIMES
WE MAKE ASSUMPTIONS THAT WE
SHOULDN'T, JUMPING TO
CONCLUSIONS.
I WILL SAY THESE ARE ALL
ANECDOTES.
THERE WASN'T GOOD NATIONAL DATA
UNTIL 1950s, ALL WE HAVE IS
ANECDOTES BUT SEEMS LIKE THINGS
WERE DIFFERENT IN TERMS OF MAYBE
WHO WAS MORE LIKELY TO HAVE
DIABETES THAN THEY DO TODAY.
AND THIS IS WHY.
THIS IS LOOKING AT THE BODY MASS
INDEX IN THIS COUNTRY, 19th
AND 20th CENTURY.
THIS GRAPH, THE DATA HERE IS
FROM 18-YEAR-OLD WHITE MEN, BUT
I THINK WE CAN SEE SIMILAR
TRENDS OR ASSUME SIMILAR TRENDS
IN WHITE WOMEN, AND IN BOTH MEN
AND WOMEN OF OTHER RACIAL/ETHNIC
GROUPS.
X-AXIS IS BIRTH COHORT, BORN IN
A GIVEN YEAR, Y-AXIS IS BMI.
YOU CAN SEE THE BMI ON AVERAGE
WAS BELOW 20, WEST POINT CADETS.
DATA FROM THE CITADEL, THAT
WOULD BE THE SECOND COLUMN, BMI
CLOSE TO 20, BARELY ABOVE ON
AVERAGE.
IN THE MIDDLE, INCREASE TO 22 ON
AVERAGE, GREATEST GENERATION.
U.S. DATA FOR WHITE 18-YEAR-OLD
MEN NATIONALLY AGAIN IT'S AROUND
THAT, IN THE 50s JUMPS UP TO
THE IN THE '80s CLOSE TO
OVERWEIGHT.
THE TRAJECTORY IS THE SAME,
MAYBE SHARPER AND HIGHER FOR
PEOPLE OF OTHER RACIAL AND
ETHNIC GROUPS.
WHAT HAS CHANGED, HISTORICAL
VIEWS WE'RE LEARNING ABOUT FROM
EARLY 20th CENTURY HAVE
CHANGED QUITE A BIT AS WE SIT
HERE TOGETHER IN 2024.
ALSO, FOR THOSE WHO DON'T STUDY
DIABETES IN GREAT DETAIL, JUST A
REMINDER DIABETES IS AN OVERALL
PHENOTYPE.
IF YOU CHECKED YOUR SUGAR ON AN
EMPTY STOMACH TWO DIFFERENT
MORNINGS AND GOT THAT READING OF
180, YOU WOULD HAVE DIABETES BY
DEFINITION.
BUT VERY LITTLE IDEA AS TO WHY,
WHAT'S GOING ON, UNDER THE HOOD
WITH YOU.
THERE COULD BE MANY PHYSIOLOGIC
PERTURBATIONS LEADING TO THE
ELEVATED BLOOD SUGAR.
THE TERM DIABETES MELLITUS IS A
COMBINATION OF GREEK AND LATIN
WORDS FOR SIPHON SPEED SWEET
MEANING YOUR URINE IS SWEET WITH
SUGAR, THAT'S HOW DIABETES WAS
DIAGNOSED FOR CENTURIES, WE KNOW
IT INCLUDES MANY PHENOTYPES AND
IT'S A SPECTRUM.
MANY OF US PROBABLY ARE USED TO
THINKING ABOUT DIABETES AS TYPE
1 VERSUS TYPE 2, THAT'S WHAT I
WAS TAUGHT IN MED SCHOOL.
BUT I THINK IN THIS 21ST CENTURY
AS WE GO IT'S GOING TO BE A
DIFFERENT PARADIGM.
WE'LL SLOWLY CHANGE.
I THINK WHERE WE'RE HEADED IS IN
BOLD THERE, WE'LL BE TALKING
ABOUT DIABETES WITH PREDOMINANT
BETA-CELL DYSFUNCTION, THAT
CREATE INSULIN, AND DIABETES
WITH PREDOMINANT INSULIN
RESISTANCE, WHERE CELLS AREN'T
ABLE TO UPTAKE INSULIN TO HAVE
INTENDED EFFECTS OF LOWERING
YOUR BLOOD SUGAR LEVEL.
THERE WILL BE A LOT OF
CONDITIONS IN BETWEEN.
SOME OF THOSE ARE BELOW,
SOMETHING CALLED MONOGENIC
DIABETES, MODY, WHICH IS RELATED
TO DIFFERENT LIVER AND PANCREAS
PERTURBATIONS THAT LEAD TO
ELEVATED BLOOD SUGAR.
THERE'S LATENT AUTOIMMUNE
DIABETES OF ADULTHOOD, SECRETING
LESS INSULIN, RATHER THAN THE
SUDDEN ONSET OF TYPE 1.
WE'RE MOVING INTO THE AREA OF
PRECISION MEDICINE, TERRIFIC
WHEN IT COMES TO DIABETES, TO
BETTER UNDERSTAND EACH
INDIVIDUAL, IDEALLY OFFER THEM
TREATMENT THEY NEED.
AND DIABETES PHYSIOLOGY IS
COMPLEX LIKE I NOTED, THAT 180,
THERE COULD BE MANY THINGS GOING
ON. I WOULDN'T FOCUS ON THE
TEXT.
THESE ARE ALL THE ORGANS AT
INTERPLAY WITH DIABETES.
BOTTOM LEFT IS INTESTINES, YOU
CAN SEE THERE'S THE BRAIN, THESE
ARE FAT CELLS, THIS IS THE
LIVER, THIS IS MUSCLE.
AND THIS IS THE PANCREAS.
AND REALLY YOU COULD HAVE ISSUES
WITH ANY OF THESE ORGANS,
MULTIPLE ORGANS, END UP WITH THE
SAME INSULIN RESISTANCE AT THE
BOTTOM WHICH LEADS TO DIABETES.
I THINK THE MAIN OTHER THING TO
NOTE AS YOU SEE AT THE TOP
THERE'S OBESITY, OBESITY
DIRECTLY AFFECTS ALL OF THESE
ORGANS.
AND THAT IS WHAT HAS CHANGED IN
OUR SOCIETY, THAT'S WHAT IS
DRIVING THESE MULTIPLE DIFFERENT
PHENOTYPES OF DIABETES IN THE
PATIENTS THAT WE SEE.
SO, IN MY BELIEF, GENETICS IS
NOT A MAJOR DRIVER OF DIABETES
DISPARITIES.
I THINK THERE'S A RECENT
"NATURE" STUDY FROM LAST MONTH
THAT LOOKED AT THE TYPE 2
DIABETES GLOBAL GENOMICS
INITIATIVE THAT HAD MORE THAN
2.5 MILLION PATIENTS, DIVERSE,
PEOPLE AROUND THE WORLD, 40%
NON-WHITE PARTICIPANTS.
THE AUTHORS CONDUCTED A GWAS
ANALYSIS, IF YOU DON'T KNOW
THAT'S A GENOME WIDE ASSOCIATION
STUDY.
THEY FOUND 127 SINGLE NUCLEOTIDE
POLYMORPHISMS, GENETIC
DIFFERENCES IN A POPULATION THAT
IN THIS CASE PREDICT DIABETES
AND 127 CONTINENT OF ORIGIN.
THIS WAS ONLY 10% OF TOTAL
NUMBER OF SNPs, HOWEVER WHEN
YOU ADJUST FOR BMI 103 WERE NO
LONGER SIGNIFICANT.
81%.
WE'RE TALKING ABOUT 20% OF 10%
NUMBER TIED TO RACE/ETHNICITY
WHICH IS 2.5%.
I DON'T THINK WE'RE GOING TO
FIND MUCH IF WE'RE TRYING TO
SOLVE THIS PROBLEM WITH
GENETICS.
IT MAY NOT BE THE ROAD TO GO FOR
DIABETES DISPARITIES.
THAT ROAD GOES RIGHT DOWN THE
LANES OF OBESITY AND SOCIAL
DETERMINANTS OF HEALTH.
I WANT TO STOP FOR A SECOND.
PEOPLE MAY HAVE HEARD OF OR
KNOWN FELICIA HILL BRIGGS, SHE
UNFORTUNATELY DIED LAST YEAR,
WAY TOO EARLY.
SHE WAS -- I HEARD HER SPEAK,
MOTIVATIONAL, INSPIRATIONAL, A
NATIONAL EXPERT ON SOCIAL
DETERMINANTS IN DIABETES.
FOR THOSE WITH AN INTEREST, TO
MY KNOWLEDGE THIS DIABETES CARE
PAPER SHE WROTE IN 2020 IS STILL
THE GOLD STANDARD FOR LOOKING AT
ALL THESE STUDIES.
AND THIS CAME UP EARLIER IN THE
MEET AND GREET, BUT ALL OF THESE
THINGS HAVE BEEN SHOWN TO LINK
TO HIGHER RATES OF DIABETES
AND/OR COMPLICATIONS.
WE SEE THIS AT THE INDIVIDUAL
LEVEL, LOWER INCOME, LOWER
LEVELS OF EDUCATION, LOWER
OCCUPATIONAL GRADE.
AT THE GEOGRAPHIC LEVEL PEOPLE
WHO LIVE IN CENSUS TRACTS ARE
LOWER HIGH SCHOOL GRADUATION
RATES, MORE SINGLE PARENT
HOUSEHOLDS.
WE SEE THIS WITH THE BUILT
ENVIRONMENT, IF THERE'S A HIGHER
LOCAL DENSITY OF FAST FOOD
RESTAURANTS, LOCAL RATES OF
DIABETES ARE HIGHER.
WE SEE THIS WITH SOCIAL CONTEXT,
IF THERE'S LOWER NEIGHBORHOOD
SOCIAL COHESION, THERE'S A STUDY
IN THE MEET AND GREET WE TALKED
ABOUT SHOWED THIS, WHEN YOU HAVE
LOWER COHESION YOU HAVE GREATER
RATES OF DIABETES.
FINALLY WE KNOW THERE'S PEOPLE
WHO REPORT MORE EXPOSURE TO
EVERYDAY RACISM, HIGH RATES OF
DIABETES, BUT I'LL NOTE THAT IS
MEDIATED THROUGH OBESITY WE
THINK BECAUSE ONCE YOU YOU A
JUST FOR BMI THE EXPOSURE IS
HIGHLY ATTENUATED.
WE'VE TALKED ABOUT HOW RACE AND
DIABETES WERE PERCEIVED IN THE
PAST.
ALSO KIND OF THE COMPLEXITY OF
DIABETES, AND WHY I THINK SOCIAL
DETERMINANTS ARE THE WAY WE HAVE
TO GO IF WE TRY TO GET A HANDLE
ON WHERE DIABETES DISPARITIES
ARE NOW.
I WANT TO TURN TO PREVENTION,
MAKE SURE PEOPLE ARE AWARE OF
THE DIABETES PREVENTION PROGRAM
WHICH IS REALLY THE MAIN THING
LIKE I NOTED THAT THIS COUNTRY
IS DOING TO PREVENT DIABETES IN
THE POPULATION.
SO IT SEEMS CRAZY RIGHT NOW BUT
PRIOR TO 1997, WE REALLY DIDN'T
HAVE GREAT DATA SHOWING YOU
COULD PREVENT DIABETES.
THERE WERE SOME PEOPLE WHO
THOUGHT IF YOU GAINED WEIGHT AND
BECAME OBESE IT WAS GOING TO BE
INEVITABLE, AND WE COULDN'T DO
MUCH AT THAT POINT.
BUT THERE WAS FIRST A STUDY IN
CHINA THAT SHOWED IF YOU
INSTITUTED LIFESTYLE CHANGE WITH
DIET AND EXERCISE YOU COULD LOSE
WEIGHT AND THEREFORE PREVENT
DIABETES.
WHICH, AGAIN, WAS TERRIFIC TO
SEE THAT IN A STUDY, NIH JUMPED
ON THIS WHICH IS GREAT AND
LAUNCHED A TRIAL CALLED THE
DIABETES PREVENTION PROGRAM, AN
RCT, PUBLISHED IN 2002, NEW
ENGLAND JOURNAL OF MEDICINE,
REALLY AN EARTHQUAKE TO THE
DIABETES PREVENTION SPACE.
I'LL TALK ABOUT THE STUDY ON A
FEW SLIDES SO YOU KNOW WHAT THEY
DID AND WHAT IT SHOWED.
THE DPT WAS AN RCT CONDUCTED AT
27 CENTERS ACROSS AMERICA.
TO BE ENROLLED THEY TOOK THE
PATIENTS AT HIGHEST RISK.
SO THERE'S DIFFERENT WAYS TO
MEASURE ABNORMAL GLUCOSE
REGULATION.
ONE IS IMPAIRED FASTING GLUCOSE.
IF YOU HAVE AN ELEVATED GLUCOSE
FIRST THING IN THE MORNING ON
EMPTY STOMACH THAT'S ONE SIGN,
YOU HAD TO HAVE THAT.
ALSO THERE'S SOMETHING CALLED
GLUCOSE TOLERANCE TEST.
IF ANY OF YOU HAVE BEEN PREGNANT
OR HAD A BABY YOU KNOW YOU HAVE
TO DRINK THAT SYRUPY SWEET
LIQUID AND HAVE BLOOD DRAWN OVER
TIME TO SEE HOW YOUR BODY
REGULATES THE LOAD.
WITH BOTH WERE THE PEOPLE
ENROLLED.
PEOPLE DESIGNING IT REALIZE
WHERE DIABETES DISPARITIES WERE
HEAD AND MADE HERCULEAN EFFORT
TO MAKE IT DIVERSE, 45%
NON-WHITE.
A COLLEAGUE TELLS ME AT THE TIME
IT WAS THE MOST DIVERSE TRIAL IN
THE HISTORY OF NIH.
AND NO ONE HAS CONTRADICTED ME
ON THAT YET.
AT THE TIME I THINK IT WAS
NUMBER ONE, MAYBE THERE WERE
SOME SINCE.
20% BLACK, 16% LATINO, 5%
AMERICAN INDIAN, 4% ASIAN.
THIS WAS THE INTERVENTION.
THERE WERE THREE ARMS REPORTED
IN THE NEW ENGLAND JOURNAL
PAPER, ONE WAS LIFESTYLE CHANGE.
ONE WAS MEDICATION MET FOR
METFORMIN AND PLACEBO ARM.
A FOURTH WAS A MEDICINE PULLED
OFF THE MARKET BECAUSE OF SIDE
EFFECTS, THAT WASN'T REPORTED,
WE DON'T PRESCRIBE THAT
CURRENTLY.
THE LIFESTYLE CHANGE, THE
ORIGINAL GOAL WAS LOSE 7% OF
BODY WEIGHT.
A NOTE IN BOLD IN THIS RCT WAS
DONE, 1:1 WITH LIFESTYLE COACH,
SO INTENSIVE INDIVIDUAL
ATTENTION, GOING OVER THE
CURRICULUM WHICH WAS DELIVERED
FIRST IN 16 WEEKS, WHICH
INCLUDED DIET, INFORMATION ON
DIETARY CHANGE, ON EXERCISE,
ALSO BEHAVIOR MODIFICATION.
THERE'S AN EFFORT TO WORK WITH
PEOPLE TO, FOR EXAMPLE, LEARN
HOW TO SAY NO IF YOU'RE AT AN
OFFICE PARTY AND THE TABLE IS
FULL OF CAKES AND COOKIES AND
CANDY, HOW DO YOU DECLINE?
MAYBE IF YOU FALL OFF THE WAGON,
CHANGE YOUR LIFESTYLE BACK, HOW
DO YOU GET BACK, REORIENT
YOURSELF, PREPARING PEOPLE TO
MAKE AND SUSTAIN LIFESTYLE
CHANGE.
THAT'S THE GOAL OF THE
CURRICULUM.
THEN THERE WERE AFTER THE 16
WEEKS, EIGHT MONTHLY BOOSTER
SESSIONS TO REINFORCE WHAT
PEOPLE LEARNED, TO SUPPORT THEM
IN MAKING THIS CHANGE.
SO OVERALL 12-MONTH YEAR-LONG
CURRICULUM.
WHAT WERE THE RESULTS?
THEY WERE GREAT.
THIS IS THE DPP RESULT, FAMOUS
GRAPH THAT WE KNOW WELL IN THIS
FIELD.
X-AXIS IS TIME, STUDY WENT
STOPPED PREMATURELY BEFORE FIVE
YEARS BECAUSE OF THE BENEFITS.
THE Y-AXIS IS CUMULATIVE
INCIDENCE OF DIABETES.
YOU CAN SEE RATE OF DIABETES WAS
HIGHEST IN THE PLACEBO ARM, BLUE
ARM.
PEOPLE TAKING METFORMIN
RANDOMIZED TO THAT ARM ARE LOWER
INCIDENCE.
PEOPLE RANDOMIZED TO LIFESTYLE
ARM HAD LOWEST INCIDENCE, 58%
REDUCTION AT AROUND FOUR YEARS.
AGAIN, HUGE STUDY, REALLY SHOOK
EVERYONE, THIS IS WHAT WE HAVE
TO DO.
NOW WE HAVE TO FIGURE OUT HOW TO
DO IT.
BUT I WANTED TO THEN SHOW ALSO
THAT ONE OF THE EXCITING THINGS
ABOUT IT WAS IT WORKED JUST AS
WELL AS IF NOT BETTER FOR
PERSONS OF COLOR WHICH MADE IT
EVEN MORE EXCITING.
THIS IS THE SUBGROUP I
MENTIONED, 58% OVERALL REDUCTION
INCIDENCE, BUT FOR WHITE
PATIENTS IT WAS 51%.
STILL GOOD BUT CERTAINLY BETTER
FOR OTHER GROUPS.
YOU SEE BLACK PATIENTS, 61%
REDUCTION IN INCIDENCE.
LATINO 66% REDUCTION.
AMERICAN INDIAN, 65%.
ASIAN AS HIGH AS 71%.
IN THE RCT THIS WORKED
TREMENDOUSLY, GREAT HOPE THIS
CAN REDUCE DISPARITIES IN
DIABETES PREVALENCE, AND THEN
DOWNSTREAM OF COURSE ALSO
DIABETES COMPLICATIONS.
SO VERY EXCITING.
WE'LL COME BACK TO WHAT HAS
ACTUALLY HAPPENED SINCE 2002 IN
THE REAL WORLD IN A FEW MINUTES.
I'LL SAY THIS.
THERE'S SOMETHING CALLED THE DPP
OUTCOME STUDY.
AND THIS BASICALLY AS YOU SEE ON
THE LEFT, ALL THE PARTICIPANTS,
88% CONSENTED TO BE FOLLOWED
OVER TIME.
RANDOMIZATION WAS BROKEN AND
THEY WERE OFFERED LIFESTYLE
CHANGE BECAUSE OF RESULTS I
MENTIONED.
AND MANY OF THEM TOOK IT UP, IT
WAS A CROSSOVER STUDY, WE
FOLLOWED REGARDLESS OF WHAT THEY
DID AFTERWARD.
STILL TIED TO THEIR INITIAL
RANDOMIZATION IN THE DPP.
SO ON THE RIGHT YOU CAN SEE THIS
IN GRAPHICAL FORM.
DPP IS ARROW ON THE LEFT.
RIGHT AROUND THAT 4-YEAR MARK
PEOPLE WERE SWITCHED AND
FOLLOWED OVER TIME.
AND WE NOW SEE EVEN AT 15 YEARS
LATER, BENEFITS STILL PERSIST.
YOU CAN STILL SEE WITH Y-AXIS
INCIDENCE WITH DIABETES, HIGHEST
AMONG PEOPLE IN THE ORIGINAL
PLACEBO ARM, REGARDLESS OF WHAT
THEY DID SINCE.
AND THEN YOU SEE METFORMIN
LIFESTYLE ARMS CONVERGING OVER
TIME BUT STILL MUCH BETTER THAN
PLACEBO.
SO EVEN THAT ONE YEAR OF DPP 15
YEARS AGO, WE STILL SEE
FOOTPRINT IN PEOPLE WITH
DIABETES RATES 15 YEARS DOWN THE
LINE, EVEN MORE EXCITEMENT ABOUT
WHAT THE POWER OF THIS
INTERVENTION WILL BE.
ALL RIGHT.
SO I WANTED TO BEFORE I TALK
ABOUT DISPARITIES, LIKE I NOTED,
HIT ON DIABETES SCREENING
GUIDELINES.
REALLY IT'S A TWO-PART APPROACH.
YOU WANT TO SCREEN PEOPLE.
ONCE THEY SCREEN POSITIVE,
PREVENT.
WE TALKED ABOUT PREVENTION.
WHAT'S THE STORY WITH SCREENING?
SO I THINK REALLY ANY CONDITION
IN ORDER FOR THERE TO BE A
JUSTIFIED SCREENING PROGRAM, IT
HAS TO MEET AT LEAST FOUR
CRITERIA.
THERE'S SOME OTHER ONES THAT
PEOPLE MAY BRING INTO THIS.
THE FIRST IS DISEASE SHOULD BE
AN IMPORTANT PUBLIC HEALTH
PROBLEM, AS WE TALKED ABOUT AT
THE BEGINNING, YES, DIABETES IS
AN IMPORTANT PUBLIC HEALTH
PROBLEM.
NUMBER TWO, THE DISEASE SHOULD
HAVE A DETECTABLE PRE-CLINICAL
PHASE, AND IT HAS THAT,
PREDIABETES, BEFORE YOU REACH
THE LEVELS DIAGNOSTIC AS
DIABETES.
NUMBER THREE, TREATMENT OF THE
DISEASE PRE-SYMPTOM SHOULD OFFER
A BENEFIT.
AND AS WE DISCUSSED, MAYBE IN
THE PAST THAT WASN'T ENTIRELY
CLEAR, BUT NOW WE KNOW IT DOES,
THAT'S THE DPP.
IF YOU TREAT THESE PEOPLE BEFORE
THEY REACH DIABETES, YOU CAN
ACTUALLY OFFER A BENEFIT IN
TERMS OF LOWER RATES OF DIABETES
DOWN THE LINE.
FOUR, THE SCREENING TEST SHOULD
BE ACCEPTABLE TO PATIENTS AND
PROVIDERS.
SO IT USED TO BE FOR EXAMPLE YOU
HAD TO HAVE A FASTING GLUCOSE
REQUIRING THE PERSON TO COME ON
EMPTY STOMACH IN THE MORNING AND
THAT COULD BE DIFFICULT.
OR GLUCOSE TOLERANCE TEST, WHICH
IS ALSO DIFFICULT, YOU HAVE TO
SIT FOR A COUPLE HOURS, MULTIPLE
STICKS.
NOW WE HAVE HEMOGLOBIN A1c
TESTING, SHOWN TO BE -- EVEN
ENDOCRINOLOGISTS ACCEPT THIS AS
A WAY TO GO, IN THE LAB OR
CLINIC.
MANY HAVE POINT OF CARE
MACHINES, YOU CAN COME IN, DO IT
RIGHT THERE IN THE CLINIC AND
GET YOUR TESTING AND A1C LEVEL.
GIVEN DIABETES MEETS ALL FOUR
CRITERIA, I THINK TO ME IT'S A
SLAM DUNK THAT WE SHOULD SCREEN
AND FORTUNATELY THE UNITED
STATES PREVENTIVE SERVICES TASK
FORCE AGREES.
THIS IS THE CURRENT ONE WE'RE
OPERATING UNDER NOW.
AS OF TODAY THERE ARE GUIDELINES
THAT ANYONE WHOO IS ASYMPTOMATIC
AGE 35 TO 70 WITH OVERWEIGHT OR
OBESITY SHOULD BE SCREENED FOR
PREDIABETES/TYPE 2 DIABETES.
NOTE AT THE BOTTOM, IN THE FINE
PRINT, OVERWEIGHT SHOULD BE
DEFINED AS BMI GREATER OR EQUAL
TO 25 BUT THERE'S DATA
SUGGESTING BMI GREATER THAN
EQUAL TO 23 SHOULD BE THE CUT
POINT FOR ASIAN AMERICAN
PERSONS, THIS IS BECAUSE OBESITY
RATES TEND TO BE LOWER AND RATES
OF DIABETES TEND TO BE AT
DIFFERENT SET POINTS, WE'LL TALK
ABOUT THAT LATER.
REGARDLESS, GUIDELINES CALL FOR
SCREENING FOR OVERWEIGHT.
MOST PEOPLE 25+.
THIS IS GENERALLY RECOMMENDED TO
BE DONE EVERY THREE YEARS, IF
YOU DON'T HAVE PREDIABETES.
IF YOU HAVE PREDIABETES SHOULD
BE ANNUAL.
THE POINT IS ONCE PEOPLE SCREEN
POSITIVE, THEY SHOULD --
CLINICIANS SHOULD OFFER OR REFER
PATIENTS WITH PREDIABETES TO
INTERVENTION, THE PREVENTION
PROGRAM OR METFORMIN.
WHY IS THIS A GRADE OF B, NOT A?
WE HAVEN'T SEEN MORTALITY
BENEFITS WITH DIABETES SCREENING
WE WOULD LIKE.
AND B IS ALSO A STRONGER,
COVERED BY INSURANCE, SOMETHING
WE SHOULD BE DOING.
I'LL TALK IN A MINUTE HOW WELL
WE ARE OR NOT DOING FOLLOWING
THIS RECOMMENDATION PARTICULARLY
AS IT COMES TO GROUPS OF
DIFFERENT RACE AND ETHNICITY.
I'LL TALK ABOUT THAT NOW.
SO, THIS IS THE PART OF THE TALK
ON DISPARITIES AND DIABETES
SCREENING AND PREVENTION.
THIS IS FROM 2017, USED TO BE
THE AGE WAS 45+, KNOW AS
MENTIONED IT WAS 35.
YOU USED TO HAVE SOME OTHER
CONDITION BESIDES OVERWEIGHT,
OFTEN HYPERTENSION.
PEOPLE OVER 45 WITH SOMETHING
LIKE HYPERTENSION, THESE WERE
THE SCREENING RATES REPORTED
THROUGH NHANES, SELF-REPORT.
AS YOU CAN SEE OVERALL WE'RE NOT
DOING TERRIFICALLY, 60% RANGE
MORE MOST GROUPS, BUT SURPRISING
FOR ASIAN PATIENTS, ASIAN
INDIVIDUALS, ONLY 51% SO
SIGNIFICANTLY LOWER FOR THIS
GROUP JUST NOT GETTING SCREENED
AT RATES OTHER GROUPS SHOULD.
YOU MAY SAY, WELL, MAYBE THIS IS
BECAUSE ASIAN PATIENTS MAY HAVE
LOWER BMI AND MAY NOT BE
TRIGGERING IN THE MIND OF THE
CLINICIAN THEY SHOULD BE
SCREENED.
WHEN YOU SUBSET THE PAPER AND
PEOPLE WITH BMI OF 30 AND ABOVE,
PRETTY CLEAR ALL THESE PEOPLE
HAVE OBESITY, YOU SEE THIS
DISPARITY PERSIST, YOU SEE
SCREENING RATES FOR WHITE,
BLACK, LATINO PATIENTS HIGHER
THAN WITHOUT THE SUBSET.
AGAIN THESE ARE PEOPLE AT HIGHER
RISK, WE ALL KNOW THAT, IN THE
70s, ASIAN PATIENTS STILL
STUCK AT 60%.
THIS IS AN UNDERSTUDIED AREA WE
NEED TO TALK MORE ABOUT.
FIRST THING IS TO REALLY LOOK AT
SUBGROUPS BECAUSE WE KNOW THAT
RATES, FOR EXAMPLE, OF DIABETES
ARE HIGHEST AMONG ASIAN PATIENTS
IN TERMS OF FILIPINO AMERICANS
AND SOUTH ASIAN INDIAN
AMERICANS, YOU WOULD
HYPOTHESIZE THOSE RATES WOULD BE
HIGHER, WE NEED TO FIGURE OUT
WHY.
THIS GOES BACK TO PHYSICIANS IN
THEIR MIND GET A SENSE OF WHO
HAS DIABETES.
USED TO BE JEWISH PEOPLE HAD
DIABETES.
BLACK PEOPLE DIDN'T.
AND THEN YOU SAW OVER TIME
INDIAN PEOPLE, PIMA INDIANS TEND
TO HAVE DIABETES, MEXICAN
AMERICANS HAVE DIABETES.
THERE MAY BE CLINICIAN BIAS,
LESS THINKING ASIAN PATIENTS DO,
REALLY AN IMPORTANT AREA FOR
WORK WE NEED TO DO IF WE'RE
TRYING TO GET THE SCREENING RATE
UP, FOR ASIAN PATIENTS TO
APPROXIMATE THOSE OF OTHER
GROUPS.
I WILL SAY ONE AREA WHERE PEOPLE
OF ASIAN DESCENT ARE SCREENED AT
HIGHEST RACE IS GESTATIONAL
DIABETES MELLITUS.
THE CONDITION DURING PREGNANCY
WHEN YOU GAIN WEIGHT AS YOU
SHOULD, AND SUGAR TENDS TO GO
UP, GDM, NOT AS HIGH AS TYPE 2
DIABETES BUT TO A POINT WHERE IT
BECOMES IMPORTANT TO MANAGE IT
FOR THE SAFETY OF BOTH THE MOM
AND THE BABY.
AND SO ON.
AND
AND SO THE OBs SCREEN AND
TREAT PEOPLE OFTEN WITH INSULIN
UNTIL THEY DELIVER.
THE KEY IS WHAT HAPPENS AFTER
THAT.
SO, PEOPLE TEND TO LOSE WEIGHT,
OF COURSE, BECAUSE THEY ARE NO
LONGER PREGNANT, OFTEN BLOOD
SUGAR GOES BACK TO NORMAL.
SOME PEOPLE FORGET ABOUT THIS
AND DON'T FOLLOW UP.
I TELL MY PATIENTS IT'S LIKE
HAVING A CHECK ENGINE LIGHT.
EVEN IF YOU CHECK ENGINE LIGHT
GOES OFF BECAUSE YOU LOST WEIGHT
THERE'S SOMETHING GOING ON UNDER
THE HOOD WE NEED TO PAY
ATTENTION TO, BECAUSE THIS IS
PROBABLY THE GROUP THE SINGLE
GREATEST RISK OF DEVELOPING
DIABETES OVER TIME.
BECAUSE OF THAT THERE ARE CLEAR
GUIDELINES WOMEN SHOULD COME
BACK FOR POSTPARTUM SCREENING
FOR DIABETES.
THEY ARE SUPPOSED TO SEE THEIR
OB AND 6 WEEKS, AND THEN IDEALLY
TRANSITION TO PCP TO FOLLOW
AFTER THAT.
SO THERE WAS RECENT
META-ANALYSIS IN THE JOURNAL OF
WOMEN'S HEALTH, 27 STUDIES
LOOKING AT SCREENING RATES
POSTPARTUM, AND FOUND ACTUALLY
WHITE AND BLACK PATIENTS HAVE
THE LOWEST RATES, ABYSMAL.
ONLY A THIRD ARE GETTING
SCREENING FOR DIABETES IN THAT
FOLLOW-UP PERIOD, EVEN THOUGH WE
KNOW THIS IS THE HIGHEST RISK
GROUP.
IT'S ABYSMAL FOR EVERYBODY, 50%
OR LOWER.
BUT THE POINT IS THAT AMONG GDM
PATIENTS WE HAVE SCREENING
DEFICIT AMONG WHITE AND BLACK
PATIENTS, OVERALL GENERAL
POPULATION IT TENDS TO BE AMONG
ASIAN PATIENTS SO DEPENDS IN
TERMS OF THE GROUP YOU'RE
LOOKING AT.
AND WE'LL TALK MORE ABOUT
THOUGHTS HOW TO IMPROVE
SCREENING RATES TOWARDS THE END.
SO I'VE BEEN MENTIONING EARLIER
THAT BECAUSE OF THE DPP TRIAL,
IT WAS JUMPED ON, AND THERE WAS
SOMETHING INSTITUTED CALLED
NATIONAL DIABETES PREVENTION
PROGRAM, NATIONAL DPP.
THIS WAS AUTHORIZED BY CONGRESS,
TOOK ABOUT 8 YEARS AFTER THAT
PAPER.
AUTHORIZED IN 2010, WITH REALLY
THE GOAL OF TRANSLATING THAT
PAPER TO REDUCE U.S. DIABETES
INCIDENCE.
TO BEND THE CURVE DECREASE NEW
CASES AND THEREFORE
COMPLICATIONS.
THE CDC WAS GIVEN THE MANDATE
AND DID A GREAT JOB.
THEY RECOGNIZE SUPPLIERS IN THE
COMMUNITY OFFERING DPP,
SUPPLIERS HAVE TO USE COMMON
CURRICULUM EVIDENCE-BASED, YOU
CAN MAKE SOME MODIFICATIONS BUT
YOU HAVE TO KEEP THE CORE OF IT.
THESE PROGRAMS ALSO HAVE TO
ACHIEVE ACCEPTABLE OUTCOMES.
THEY ALL HAVE TO SEND IN THE
RESULTS OF COHORTS IN TERMS OF
WEIGHT LOSS AND ACTIVITY CHANGE,
TO THE CDC.
AND IF NOT ACHIEVING ACCEPTABLE
RESULTS GET A PROBATION PERIOD
WHERE THE CDC WORKS WITH THEM,
IF NOT HITTING IT THEY LOSE
THEIR RECOGNITION BECAUSE
CORRECTED WANTS TO MAKE SURE YOU
CAN'T JUST PUT UP A SHINGLE AND
SAY YOU'RE DOING DPP AND NOT GET
RESULTS WE THINK YOU SHOULD.
THE ORIGINAL TRIAL LIKE I
REMEMBER WAS ONE ON ONE, AND IT
WAS REALIZED THAT WE JUST CAN'T
AFFORD ONE-ON-ONE SESSIONS FOR
AMERICA.
SO, THE CDC HAS AUTHORIZED GROUP
SESSIONS AS PART OF THIS.
AND THEY VARY A LOT.
THE AREA WE TEND TO STUDY I
THINK IN PERSON, THEY TEND TO BE
ONE LIFESTYLE COACH FOR MAYBE
SIX OR EIGHT PEOPLE.
BUT THERE ARE A LOT OF PRIVATE
COMPANIES IN THE MARKET NOW,
OFFERING VIRTUAL DPP WHICH HAS
BENEFITS BUT ALSO DOWN SIDES.
ONE OF WHICH IS SOME COMPANIES
HAVE 1:100 RATIOS ONLINE, SOME
ARE ASYNCHRONOUS, HARD TO REACH
THE COACH, GREAT DEBATE HOW
EFFECTIVE THESE ARE.
PART OF A FUNDED NETWORK LOOKING
AT NATIONAL DPP IN THE REAL
WORLD LOOKING AT ARE VIRTUAL
PROGRAM AS EFFECTS AS IN-PERSON
PROGRAMS? WHAT'S THE COST
EFFECTIVENESS, WHAT ARE BENEFITS
ON OTHER OUTCOMES?
BLOOD PRESSURE, FOR EXAMPLE,
LIPID CHANGE.
THIS KIND OF THING.
TO DO A COMPREHENSIVE EVALUATION
HOW THIS IS WORKING IN THE REAL
WORLD.
AND THE OTHER MODIFICATION IS
LIKE I MENTIONED YOU HAD TO HAVE
PREDIABETES IN THE RCT BUT HERE
AGAIN TO EXPAND IT YOU COULD
MAKE IT WITH THE QUALIFYING RISK
SCORE, IN THE U.S. ANYWAY, WHERE
IF YOU HAD ENOUGH RISK FACTORS,
FAMILY HISTORY, GESTATIONAL
DIABETES, HYPERTENSION, MALE
GENDER, YOU COULD GET IN AND
QUALIFY.
AND AS OF 2019, IT'S GONE UP
SINCE THEN, MORE THAN 300,000
PEOPLE PASSED THROUGH THE
PROGRAM.
IT'S STILL A LITTLE BIT OF DROP
IN THE BUCKET BUT I THINK WE'RE
TRYING OUR BEST TO IMPROVE IT.
WE HAVEN'T LOOKED ENOUGH AT HOW
WELL IT'S WORKING FOR DIFFERENT
RACIAL AND ETHNIC GROUPS, WHAT
I'LL BE TALKING ABOUT SHORTLY.
I THINK IT'S ONE THING TO HAVE
AN OVERALL EFFECT, ANOTHER THING
ALTOGETHER TO MAKE SURE WE'RE
REACHING PEOPLE OF COLOR,
PARTICULARLY BECAUSE AS WE SAW
IN THE RCT IN THE TIGHT
ENVIRONMENT, DOES THAT
TRANSLATE.
SO, THESE ARE THE RESULTS I
SHOWED BEFORE FROM THE RCT, AS
YOU REMEMBER JUST TERRIFIC.
EVEN BETTER FOR PERSONS OF
COLOR.
THESE ARE RESULTS FROM THE
TRANSLATION INTO THE REAL WORLD
THROUGH NATIONAL DPP.
SO, THIS WAS 2017.
I HAVEN'T SEEN UPDATED RESULTS
SINCE THEN BUT I DON'T THINK
IT'S CHANGED THAT MUCH.
SO A COUPLE THINGS TO NOTE.
ONE IS CDC IN THE TRANSLATION
KIND OF BACKED OFF THE WEIGHT
LOSS GOAL.
NOTHING IS EFFECTIVE AS RCT SO
REALIZED WE CAN SHOOT FOR 5%,
WHICH IS STILL VERY IMPORTANT
AND EFFECTIVE.
AS YOU CAN SEE WHEN YOU TAKE IT
TO THE REAL WORLD, BENEFITS FOR
PEOPLE OF COLOR VANISH.
YOU HAVE HIGHEST RATE OF WHITE
PATIENTS ACHIEVING WEIGHT LOSS
GOAL OF 43%, DROPS TO 27% BLACK
PATIENTS, 31% FOR LATINO
PATIENTS.
THIS IS NOT DIABETES INCIDENCE,
GOLD STANDARD BUT THESE ARE
CLOSELY LINKED, SURROGATE
OUTCOME CONCERNING TO MANY OF
US.
PART OF THE REASON WHY WE'RE NOT
SEEING THE WEIGHT LOSS IN BLACK
LATINO PATIENTS IS BECAUSE OF
LOWER PROGRAM RETENTION.
YOU MIGHT HAVE BEEN THINKING TO
YOUR SATISFY YEAR-LONG PROGRAM
IS A LOT TO COMMIT TO, ALL OF US
ARE BUSY, TO TALK ABOUT 16
WEEKS.
EIGHT MORE SESSIONS.
HOW MANY PEOPLE ACTUALLY STICK
WITH IT OVER TIME?
AND THE ANSWER IS MORE WHITE
PEOPLE THAN PEOPLE FROM OTHER
RACIAL/ETHNIC GROUPS.
RETENTION AT WEEK 18 IS 71% OF
WHITE PARTICIPANTS, DROPS TO 61%
FOR BLACK PARTICIPANTS, 53% FOR
LATINO PARTICIPANTS.
WE'LL TALK ABOUT THAT IN THE
NEXT SLIDE.
THIS IS FROM THE SAME 2017
DESCRIPTIVE EVALUATION OF THE
NATIONAL DPP, AND VERY CLEAR
STRONG DATA THAT THE MORE YOU
ATTEND, THE MORE YOU LOSE
WEIGHT.
SO, THE X-AXIS IS THE MEDIAN
PERCENT WEIGHT CHANGE.
CDC GOAL, I NOTED CDC GOAL IS
5%, WHICH IS THE BOLD VERTICAL
LINE IN THE MIDDLE.
AND ON THE Y-AXIS IS NUMBER OF
SESSIONS ATTENDED, ONE AT THE
TOP GOING DOWN, 29.
IF YOU ATTEND ONE SESSION YOU'RE
NOT DOING GREAT.
IF YOU GET TO FIVE THAT'S
BETTER.
NINE IS BETTER.
15 IS BETTER.
ONCE YOU HIT AROUND 19 SESSIONS,
YOU LOSE 5% OF WEIGHT.
WE KNOW IF YOU'RE NOT RETAINING
IN THE PROGRAM AND DROPPING OUT
EARLIER YOU'RE LOSING NO WEIGHT,
OR 1% OR 1 1/2%, NOT HITTING
GOALS WE'D LIKE.
OUR TEAM DID INTERVIEWS TO
FIGURE OUT WHY BLACK AND LATINO
PATIENTS ARE LEAVING EARLY AND
NOT LOSING WEIGHT.
COMES DOWN TO SOCIAL
DETERMINANTS.
PEOPLE HAD HOW LONGER JOBS THEY
COULDN'T MISS.
PEOPLE ON SALARY JOBS, IT'S
EASIER TO CARVE OUT TIME TO GET
TO THE PROGRAM, EITHER IN PERSON
OR ONLINE.
IF YOU WORK HOURLY YOU JUST
CAN'T DO THAT, CAN'T TELL YOUR
BOSS I NEED TO TAKE A BREAK
DURING THE DAY TO JOIN THE DPP.
ANOTHER BIG ISSUE IS
TRANSPORTATION AMONG BLACK AND
LATINO PATIENTS.
IT MAY BE HARDER TO GET TO THE
DPP, BECAUSE THE DPP IS NOT
NECESSARILY IN NEIGHBORHOODS
WHERE THEY LIVE.
IF YOU HAVE TO CATCH A COUPLE
BUSES AND TRANSFER YOU MIGHT DO
THAT AT SESSION 1, AND BY
SESSION 6 YOUR MOTIVATION WANES
AND YOU STOP JOINING, STOP
ATTENDING.
THERE ARE OTHER REASONS WE FOUND
AS WELL BUT REALLY IT COMES DOWN
TO SOCIAL REASONS.
I THINK THAT IS WHERE WE NEED TO
TACKLE THIS, AND I'LL TALK ABOUT
SOME THINGS WE'RE DOING, SOME
THINGS SHOWN TO WORK TO
ESSENTIALLY KEEP BLACK AND
LATINO PATIENTS IN THE PROGRAM
FOR LONGER TO HELP THEM HIT THAT
5% WEIGHT LOSS TARGET OR AT
LEAST LOSE MORE WEIGHT AND
THEREFORE MAKE THIS MORE
EQUITABLE AS A NATIONAL PROGRAM.
BY THE WAY, U.S. IS NOT THE ONLY
COUNTRY IN THIS SPACE.
THE U.K. INSTITUTED WHAT THEY
HOPE IS A NATIONWIDE DIABETES
PREVENTION PROGRAM THERE.
OF COURSE, SAME OBESITY PROBLEM
WE HAVE HERE IS THERE IN THE
U.K.
A FEW DIFFERENCES.
ONE IS IT'S MODELED ON THE U.S.
DPP, BUT 18 SESSIONS ARE A LOT,
18+, THEY LIMIT TO 13 SESSIONS
OVER NINE MONTHS.
SO FEWER SESSIONS, SHORTER
PERIOD OF TIME.
NATIONWIDE ROLLOUT IN 2016, AND
SO THE FIRST EVALUATION PAPER
THAT I SAW CAME OUT ON THE LAST
MONTH OR TWO.
JUST TO NOTE THAT IT'S EASIER TO
ANALYZE THIS ONE BECAUSE
ENROLLMENT WAS STRICTLY LIMITED
TO PATIENTS WITH PREDIABETES, NO
RISK SCORES, SUCH THAT THERE'S A
CUTOFF.
IF YOUR LEVEL IS ABOVE A CERTAIN
A1c YOU GET IN, IF IT'S RIGHT
BELOW YOU DON'T GET IN.
AND THOSE TWO GROUPS DON'T
DIFFER IN MUCH BESIDES SLIGHT
A1c VARIATION.
YOU CAN USE REGRESSION
DISCONTINUITY DESIGN,
EXPERIMENTAL APPROACH TO
EVALUATE THE PROGRAM.
THAT IS WHAT THE INVESTIGATORS
DID.
AND THEY HAVE A VERY LONG PAPER
LOOKING AT OVERALL WEIGHT LOSS,
IF YOU DIG DEEP IN SUPPLEMENTARY
MATERIAL THIS IS WHAT YOU FIND,
WAY BACK IN THE SUPPLEMENTAL
TAPES, BREAK DOWN IN WEIGHT LOSS
BY RACE AND ETHNICITY.
SO YOU CAN SEE IN THE U.K. WHAT
THEY FOUND WAS WEIGHT LOSS IS
GREATEST AMONG WHITE
INDIVIDUALS, ACTUALLY PRETTY
GOOD AMONG BLACK INDIVIDUALS IN
THE U.K.
AND REALLY ABYSMAL AMONG PEOPLE
OF ASIAN DESCENT.
IF YOU KNOW THE U.K. WELL THIS
IS NOT SURPRISING BECAUSE THERE,
SOME ASIAN GROUPS FACE MORE
ADVERSE DETERMINANTS THAN BLACK
INDIVIDUALS, PEOPLE PARTICULARLY
WITH ORIGIN IN BANGLADESH AND
PAKISTAN.
ALL THESE PARTICIPATION NUMBERS,
WEIGHT LOSS NUMBERS, COME DOWN
TO SOCIAL DETERMINANTS AND WHAT
THESE GROUPS FACE IN TERMS OF
ADVERSE CONDITIONS IN THEIR
ENVIRONMENTS, BE IT IN THE U.S.
OR IN THE U.K.
ALL RIGHT.
THIS IS THE LAST SECTION.
AND LET ME LOOK AT THE TIME.
I'LL FINISH UP CERTAINLY BY
12:00 AND LOOKING FORWARD TO
DISCUSSION.
HOW CAN WE REDUCE DISPARITIES IN
DIABETES SCREENING AND
PREVENTION?
ONE THING TO CONSIDER RACE-BASED
BMI CUTOFF FOR DIABETES
SCREENING.
WE KNOW SCREENING RATES ARE
LOWER FOR ASIAN AMERICANS.
THIS IS A STUDY FROM 2022 USING
NHANES DATA LOOKING BY WEIGHT.
ON THE LEFT IS NORMAL WEIGHT.
SECOND WITH OVERWEIGHT.
FOCUS ON THOSE.
WITHIN EACH THERE'S FIVE BARS,
LEFT TO RIGHT WHITE AMERICANS,
ASIAN AMERICAN, BLACK AMERICAN,
MEXICAN AMERICAN, OTHER HISPANIC
AMERICAN.
WHAT THE RED BAR IS TRYING TO
SHOW IF YOU LOOK AT THE
OVERWEIGHT CLUSTER, SECOND ONE,
THAT RATE OF DIABETES AMONG
WHITE INDIVIDUALS OVERWEIGHT IS
ACTUALLY LESS IF YOU GO TO THE
LEFT, LESS THAN ASIAN, BLACK,
MEXICAN AMERICAN INDIVIDUALS
NORMAL WEIGHT.
SO THOSE PEOPLE NORMAL WEIGHT
ARE REALLY HAVING HIGHER RATES
OF DIABETES THAN WHITE PATIENTS
IN THE OVERWEIGHT.
AND SO THERE'S A PUSH, AT LEAST
A PAPER AND DISCUSSION THEY
SUGGESTED THAT WE CHANGE THE
THRESHOLDS FOR DIABETES
SCREENING.
LIKE I MENTIONED EARLIER RIGHT
NOW IT'S AT 25+ FOR ALL.
CONSIDER 23+ FOR ASIANS BUT
RECOMMENDATIONS IN THIS PAPER
TALK ABOUT LEAVING THAT CURRENT
25+ BMI CUTOFF FOR WHITE
INDIVIDUALS, DROPPING TO 20+ FOR
ASIAN INDIVIDUALS, AS LOW AS
18.5 FOR BLACK AND LATINO
INDIVIDUALS.
I THINK THIS IS WHAT THEY ARE
ADVOCATING.
I THINK ANY RACE-BASED CUTOFFS,
DEFINITELY THERE'S PROS AND
CONS, AND IT'S CONTROVERSIAL.
PROS, , MAY MAXIMIZE
EFFECTIVENESS AND LEAD TO
GREATER HEALTH EQUITY.
CONS, HOPEFULLY I'VE CONVINCED
YOU THAT RACE CERTAINLY IN
DIABETES BIOLOGIC CONSTRUCT IS
NOT THERE.
THESE DISPARITIES ARE NOT
BIOLOGIC.
THEY ARE ALL SOCIAL.
IF YOU DO RACE-BASED CUTOFFS
THERE'S A FEAR IT WILL CEMENT IN
THE MINDS OF PATIENTS AND
PROVIDERS THAT THERE IS A
BIOLOGIC CONSTRUCT AND WE WANT
TO AVOID THAT.
PRACTICALLY SPEAKING WHAT TO DO
ABOUT MULTI-RACIAL INDIVIDUALS,
YOU KNOW, DO YOU SAY HOW WHITE
ARE YOU, ARE YOU BLACK,
HISPANIC, HOW DO WE PICK A
THRESHOLD?
WHICH I THINK IS GOING TO BE
VERY DIFFICULT, ONE HANDICAP TO
THIS APPROACH BUT BEING
CONSIDERED.
WHEN THE UPDATED GUIDELINES ARE
PUT OUT WE'LL SEE IF THEY GO
DOWN THIS ROUTE OR NOT.
TO BE DETERMINED.
SO ANOTHER THING ON THE
DISPARITIES IN THE PREVENTION
SIDE IS TRYING TO GET PEOPLE TO
STICK WITH THE DPP LONGER.
WE HAVE THE EVIDENCE NOW THAT
DIFFERENT IMPLEMENTATION
STRATEGIES, IMPLEMENTATION CAN
BOOST DPP RETENTION.
THESE ARE SOME THINGS TO GET
PEOPLE TO STAY.
FIRST IS MOTIVATIONAL SESSION
ZERO BEFORE THE FIRST SESSION,
BRINGING PEOPLE TOGETHER TO TAKE
MORE TIME TO TALK ABOUT THE
EVIDENCE BEHIND THE PROGRAM,
WHAT I TALKED ABOUT TODAY, THE
EXPECTATIONS WHICH AREN'T THAT
GREAT, BASICALLY SHOWING UP
WHICH IS KEY BUT AFTER THAT IT'S
JUST TALKING ABOUT YOUR DIET OR
EXERCISE.
IT SHOULDN'T BE OVERWHELMING, WE
HOPE, AND I THINK THE THING IS
TO CONVINCE PEOPLE.
THEY HAVE SUCCESSFUL PATIENTS
COME TO SESSION ZERO WHO SAY I
WAS JUST LIKE YOU AND I WASN'T
SURE THIS WOULD WORK FOR ME BUT
I DID THE PROGRAM AND I LOST THE
WEIGHT, I FEEL BETTER, SLEEP
BETTER, MOVE BETTER, AND YOU'VE
SEEN -- WE'VE SEEN WITH THIS
KIND OF SESSION ZERO YOU CAN
KEEP PEOPLE IN FOR UP TO 100
DAYS LONGER SO REALLY A BIG
DEAL, SOMETHING THAT SHOULD
BECOME STANDARD OF CARE.
IF YOU ATTEND DPP WITH A PARTNER
THAT KEEPS YOU IN FOR 35 DAYS
LONGER, WE THINK IT'S THE
ACCOUNTABILITY TO THAT PERSON
THAT KEEPS YOU IN.
IF THERE'S A DIRECT REFERRAL
FROM YOUR PROVIDER OR YOUR
DOCTOR THAT KEEPS YOU UP TO 34
DAYS, A LOT OF PEOPLE GET IN
THROUGH A HEALTH PLAN.
HEALTH PLAN FLAGS SUGAR, SENDS
THEM A LETTER, CALL THIS NUMBER
FOR THE DPP.
IF THE DOCTOR EXPLAIN WHY YOU
SHOULD DO IT AND WHY THEY
SUPPORT IT, THAT KEEPS PEOPLE
IN, LIKE I NOTED, FOR 34 DAYS
LONGER.
I MENTIONED THE CURRICULUM IS
EVIDENCE BASED, BUT THERE ARE
OPPORTUNITIES TO TAILOR, BASED
ON GENDER 30 DAYS LONGER AND
GIVING PEOPLE SWAG, TOTE BAGS
AND THIS AND THAT, CAN ALSO KEEP
PEOPLE IN FOR 28 DAYS LONGER.
PROGRAMS ARE MORE AND MORE
STARTING TO DO THESE THINGS AS
WELL AS OTHERS TO PUSH
RETENTION.
THE PROBLEM IS SOME PROGRAMS
SERVING PATIENTS OF COLOR HAVE
LESS RESOURCES, MORE DIFFICULT
TO DO THIS BUT THIS IS WHERE WE
NEED TO DO TO IMPROVE RETENTION
AND THERE BY MAKE DIABETES
PREVENTION WORK THE WAY IT CAN
FROM THE DPP RCT.
SO, ANOTHER APPROACH IS SUGAR
SWEETENED BEVERAGE TAXES.
MANY OF YOU HAVE FIGURED OUT
SUGAR SWEETENED BEVERAGE INTAKE
IS ASSOCIATED, ONE STUDY OF MANY
ON THIS SLIDE, STUDY OF 50,000
BLACK WOMEN WHO DID NOT HAVE
DIABETES, THEY FOLLOWED THEM AND
WOMEN WHO DRANK TWO OR MORE
SODAS OF DAY, RISK OF 1.2 HIGHER
FOR DEVELOPING DIABETES.
WOMEN WHO DRANK 2 OR MORE
SERVINGS OF KOOL-AID OR JUICE
BESIDES ORANGE OR GRAPEFRUIT
JUICE HAD RELATIVE RISK OF 1.3
FOR INCIDENT DIABETES.
THESE BEVERAGES, ALL OVER THE
PLACE, LEAD TO DIABETES.
IF YOU RAISE TAXES ON THEM,
ANALOGOUS TO CIGARETTES, WHAT
HAPPENS?
THIS WAS PUBLISHED LAST MONTH
FROM UCSF, FIVE CITIES, BOTTOM
LEFT, INSTITUTED SUGAR-SWEETENED
BEVERAGE TAXES, PHILADELPHIA,
BOULDER, SAN FRANCISCO, OAKLAND,
SEATTLE.
IF YOU CAN GO TO THE RIGHT
ESSENTIALLY THE GRAYISH-BLUE
CIRCLE IS THE PRICE CHANGE.
IT'S IN A PERCENTAGE.
IF YOU LOOK CITY WITH THE
HIGHEST TAX, PHILADELPHIA, THEY
PUT TAXES OF 60% OF THE BASE
PRICE ON THESE BEVERAGES, IT
WENT DOWN TO SEATTLE, MORE IN
THAT LIKE 16-17% RANGE.
I THINK THE KEY THING TO NOTE IS
MY COLLEAGUES HAVE SHOWN
ELEGANTLY THAT WHEN THE TAX IS
HIGHER, THE VOLUME CHANGED IN
ORANGE SQUARE, IT'S GREATER, YOU
HAVE GREATER REDUCTION IN VOLUME
SOLD BASED ON HIGHER TAX.
A NICE STEP-WISE PATTERN THERE
WHERE PHILADELPHIA SOLD LESS OF
THIS AFTER THE TAX THAN FOR
EXAMPLE IN SEATTLE WHERE TAX WAS
SMALLER.
I'LL SAY MY COLLEAGUES WENT
DOING PRESS RELEASES WITH THIS
WORK, THERE'S BEEN TREMENDOUS
PUSHBACK FROM THE
SUGAR-SWEETENED BEVERAGE
COMPANIES.
COKE IN ATLANTA, THEY RUN
ATLANTA, THERE'S A COKE MUSEUM,
PEPSI IS A BEHEMOTH, IT WILL BE
A LONG PUSH BUT I THINK WE'LL
GET THERE WHERE WE CAN GET THEM
TO MAKE MORE HEALTHY BEVERAGES
AND TAX THE ONES WE KNOW ARE
LEADING TO DIABETES WHICH IS
GOING TO ADD POPULATION LEVEL BE
VERY IMPORTANT I THINK.
THIS IS THE LAST SLIDE AND I'LL
MOVE TO A SUMMARY AND LOOKING
FORWARD TO DISCUSSION ABOUT
ANYTHING THAT I'VE MENTIONED SO
FAR.
IF ANY OF YOU HAVE BEEN TO
CHICAGO IN THE PAST, OR FROM
THERE, YOU KNOW THIS BUILDING ON
THE RIGHT ONE OF THE ROBERT
TAYLOR HOMES.
I TRAINED THERE.
THESE USED TO BE UP AND DOWN THE
DAN RYAN FREEWAY IN SOUTH
CHICAGO FOR MILES, THERE'S LIKE
15 OF THEM.
THEY WERE KNOCKED DOWN, TENANTS
HAD THE CHANCE TO MOVE AND THEY
WERE RANDOMIZED IN INNOVATIVE
STUDY, MOVING TO OPPORTUNITY,
THAT YOU'VE HEARD OF.
ALSO WAS INSTITUTED IN
BALTIMORE, NEW YORK, LOS
ANGELES, BOSTON.
WOMEN WITH CHILDREN RANDOMIZED
TO SECTION 8 HOUSING VOUCHERS.
WHEN I TALK WITH MED STUDENTS
PEOPLE SAY THIS IS UN ETHICAL,
HOW CAN YOU RANDOMIZE PEOPLE TO
HIGH POVERTY AREAS?
WHEN YOU READ THE PAPERS A LOT
OF THE RESIDENTS REALLY DID NOT
WANT TO GO TO LOW POVERTY AREAS
BECAUSE HONESTLY THOSE ARE
MOSTLY WHITE AREAS, IN CHICAGO,
PEOPLE WERE NERVOUS ABOUT THAT,
REALLY WANTED TO STAY AROUND
THEIR NETWORKS AND PLACES THEY
KNEW.
SO IT WAS A MIXED BAG IN TERMS
OF WHAT PEOPLE WANTED SO DONE I
THINK UNDER EQUIPOISE.
STUDY WAS DONE, AFTER 10-15
YEARS THEY WERE FOLLOWED, AMONG
FAMILIES RANDOMIZED TO LOW
POVERTY AREA REDUCTION IN
DIABETES INCIDENCE OF 22% AND
OBESITY INCIDENCE OF 13%.
THIS GOES TO SAY WHEN YOU HAVE,
YOU KNOW, BUILT ENVIRONMENT WITH
LESS FAST FOOD, YOU HAVE MORE
NEIGHBORHOOD SOCIAL COHESION,
BASICALLY ALL THESE THINGS, CAN
YOU PREVENT DIABETES, PREVENT
OBESITY AND DIABETES.
THAT OF COURSE NUMBER ONE WE
NEED MORE STUDIES LIKE THIS.
THIS IS FROM 2007, I'M JUST
HAPPY TO SEE MORE AND MORE
FUNDING OPPORTUNITIES FROM NIH
LOOKING AT WORKING WITH
COMMUNITIES, FOR EXAMPLE, TO TRY
TO GET MOTHER LANDLORDS TO TAKE
SECTION 8 HOUSING VOUCHERS AND
DO THE THINGS WE NEED TO DO, TO
CHANGE DETERMINANTS, AGAIN TO
HAVE THESE IMPORTANT EFFECTS ON
DIABETES AND BLEATS OBESITY, AN
IMPORTANT FIELD, WE CAN LOOK
BACK IN 10 TO 15 YEARS MOVING IN
THIS DIRECTION, AND WE'RE MAKING
A DIFFERENCE.
I'LL SUMMARIZE AND HAPPY TO TAKE
QUESTIONS.
FIRST BULLET, DISPARITIES IN
DIABETES CHANGED OVER THE LAST
CENTURY, 130 YEARS AGO PEOPLE
SAID THEY DIDN'T SEE BLACK
PEOPLE WITH DIABETES, MAINLY A
JEWISH DISEASE.
HARD TO KNOW WITH DATA BUT
THINGS ARE VERY DIFFERENT NOW.
DISPARITIES LIKE I SAID WEREN'T
ALWAYS THAT WAY, WE CAN CHANGE
THEY ARE NOT ALWAYS THIS WAY FOR
FUTURE GENERATIONS.
SOCIAL DETERMINANTS PLAY A
GREATER ROLE THAN GENETICS.
THE PREVENTION PROGRAM WAS
EFFECTIVE BUT LOST IN
TRANSLATION THOSE BENEFITS,
PARTICULARLY FOR MINORITY GROUPS
THAT PROMISED IN 2002 NOT
REALIZED UP TO NOW.
AND TALKING ABOUT SCREENING,
DISPARITIES OUT THERE
PARTICULARLY ASIAN PATIENTS,
THEN AS WELL AS BLACK AND WHITE
PATIENTS AFTER GDM, WE NEED MORE
WORK TO UNDERSTAND IN MY MIND
WHY EVERYBODY NEEDS TO BE
SCREENED POSTPARTUM BUT WHY WE
AREN'T SCREENING ASIAN PATIENTS
GIVEN THEY HAVE DIABETES AT
HIGHER RATES THAN WHITE
PATIENTS.
AND THEN WHAT TO DO, WE TALKED
ABOUT RACE-SPECIFIC THRESHOLD
FOR SCREENING, BEING CONSIDERED,
TRYING TO FIGURE OUT HOW TO KEEP
PEOPLE IN THE DPP, AND THEN
PUBLIC POLICIES, MANY I COULD
HAVE TALKED ABOUT BUT THINGS
THAT CAN IMPROVE DIETARY
QUALITY, NEIGHBORHOOD LEVEL
DETERMINANTS WHERE OUR PATIENTS
LIVE AND WORK AND PLAY TO MAKE
DIFFERENCES WE CAN HAVE A
DIFFERENT DISPARITIES PICTURE IN
25 YEARS THAN WE DO TODAY.
SO WITH THAT, I WILL STOP AND
HAPPY TO TAKE QUESTIONS THAT
HAVE BEEN PUT IN THE CHAT.
>> THANK YOU FOR THE TERRIFIC
OVERVIEW.
I LOVE THE HISTORY.
FOR THE DIVERSE AUDIENCE, A GOOD
EXPLANATION OF CLINICAL SPECTRUM
OF WHAT DIABETES IS ABOUT,
DIFFERENT POINTS.
I WONDER IF YOU COULD GIVE US
JUST A COUPLE MINUTES OF SENSE
OF WHAT YOU'RE WORKING ON WITH
RELATIONSHIP TO THIS IN YOUR OWN
RESEARCH, EITHER IN THE
COMMUNITY ENGAGEMENT PART OR
STRUCTURAL PART, SO --
>> YEAH, SURE.
AS YOU SIGH, I -- SEE, I
MENTIONED IN PASSING THE WORK WE
DO.
ESSENTIALLY A LOT OF SHARED
DECISION MAKING WORK IN DIABETES
PREVENTION.
SO WE WORK CLOSELY WITH
PHARMACISTS.
SO IT'S IN THE HEALTH SYSTEM.
I'M TRYING TO CONNECT WITH FOLKS
WHO DO MORE.
REALLY WORKING WITH PATIENTS TO
MAKE A DECISION WHAT DIABETES
PREVENTION OPTION IS THE BEST
FOR THEM.
WHETHER IT BE LIFESTYLE CHANGE
OR METFORMIN, PUTTING THAT INTO
PRACTICE.
IN OUR STUDIES, I ALSO WORK WITH
A COLLEAGUE, WE OVERSEE DPPs
AT ALL TEN UNIVERSITY OF
CALIFORNIA SITES.
THERE'S A BIG EFFORT IN U.C. FOR
BOTH PATIENTS, EMPLOYEES,
FACULTY, STAFF, TO SEE IF WE CAN
GET UNIVERSITY COMMUNITIES, IN
CALIFORNIA AS YOU KNOW THEY ARE
VERY DIVERSE, UCLA WE DO A LOT
OF WORK WITH DIETARY CAFETERIA
WORKERS, THEY HAVE HAD TIME OFF
TO PARTICIPATE IN THIS.
WE'RE TRACKING TO SEE ARE THEY
LOSING WEIGHT AT THE SAME RATE
WE'D LIKE TO SEE.
IF WE SEE THAT, THAT'S MORE
EVIDENCE THAT OTHER
INSTITUTIONS, FOR EXAMPLE, GIVE
THEIR DIVERSE WORK FORCES TIME
OFF TO PARTICIPATE SO THEY CAN
THEN -- WE CAN GET MORE
EQUITABLE TRANSLATION.
ALSO WORK WITH HEALTH PLAN, TO
TRY TO -- THEY DO WORK ON
HIGH-COST PATIENTS, WE'RE
FOCUSING ON GROUP WITH DIABETES
TO EVALUATE CASE MANAGEMENT
PROGRAMS TO CONNECT PEOPLE TO
SERVICES, CAN WE IMPROVE
DIABETES OUTCOMES AND CAN WE DO
THAT ALSO FOR PEOPLE OF
DIFFERENT RACIAL/ETHNIC GROUPS.
A FEW THINGS.
YOU GOT TO WRITE GRANTS,
DIFFERENT SPACES, DIFFERENT
COLLEAGUES, SO EXCITING BUT
THOSE ARE SOME THINGS I'M
WORKING ON RIGHT NOW AS WE
SPEAK.
>> THANK YOU.
AND MAYBE IF SOMEONE COULD STOP
SCREEN SHARING AND WE COULD SEE
EACH OTHER BETTER.
SO, A COUPLE COMMENTS.
ONE, YOU MAKE A STRONG CASE OF
YOUR OWN PERSPECTIVE THAT THE
DIABETES EPIDEMIC IS PARALLEL
TO THE BREATHES EPIDEMIC,
INCREASE IN BMI.
YOU SHOWED THE NUMBERS.
BMI HAS BEEN GOING UP.
WHEN YOU LOOK AT THE RATE OF
DEVELOPMENT OF EACH OF THESE
CONDITIONS, THEY ARE NOT QUITE
THE SAME.
SO THERE ARE CLEARLY OTHER
FACTORS THAT GO INTO THIS.
THERE ARE SOME PEOPLE WHO ARE
HIGH BMI AND DON'T GET DIABETES.
WE FOCUS ON ASIAN AMERICANS WHO
ESPECIALLY SOUTH ASIANS WHO ARE
NOT ABOVE A CERTAIN LEVEL AND
YET DEVELOP DIABETES.
SO WHAT DO YOU THINK ELSE IS
GOING ON HERE IN TERMS OF THIS?
>> YEAH, THAT'S A GREAT
QUESTION.
I'LL SAY THIS.
AS YOU KNOW, ELISEO, BMI IS
DEFINITELY NOT A PERFECT METRIC.
IT'S WHAT WE MEASURE.
WE'RE LEARNING MORE ABOUT BODY
COMPOSITION, THAT IS THE DRIVING
FACTOR.
I WISH WE HAD CTs AND MRIs,
COULD GO BACK IN TIME AND GET
BODY COMPOSITION STUDIES IN
1898, 1920, 1950.
I KNOW WHERE YOU'RE GOING.
SO MUCH IS VISCERAL FAT.
WE BELIEVE THAT CHANGES IN
VISCERAL FAT IS WHAT IS HONESTLY
DRIVING THIS, WHEN YOU DIG INTO
THE OBESITY.
GREATER VISCERAL FAT AND NOT AS
HIGH BMI, IT'S NOT 1:1
CORRELATED BUT VISCERAL FAT,
ANYONE WHO CAN FIGURE OUT HOW
THAT WORKS EXACTLY IS GETTING A
NOBEL PRIZE.
IT'S CLEAR, WHEN YOU DO GASTRIC
BYPASS SURGERY PEOPLE LOSE
VISCERAL FAT, DIABETES IS
QUOTE/UNQUOTE REVERSED.
EVEN IF THEY HAVE FAT STILL IN
THEIR ARMS AND LEGS, THE
VISCERAL GUT FAT IS WHAT IS
DRIVING SO MUCH OF THIS.
SO I THINK TO YOUR POINT, THAT'S
ACTUALLY A BETTER PREDICTOR THAN
BMI, SOME STUDIES SHOW CHANGE IN
THAT OVER THE LAST 150 YEARS, IF
WE COULD MEASURE IT, IS MORE
CLOSELY LINKED TO WHAT WE'VE
BEEN TALKING ABOUT TODAY.
>> THANK YOU.
NO, IT WOULD BE A GOOD THING
BECAUSE THERE'S ALSO, AS I'M
SURE YOU KNOW, AS A PHYSICIAN, A
LOT OF INDIVIDUALS IN THE
COMMUNITY WHO SORT OF RESENT THE
LABEL OF OBESITY, CALLING IT A
DISEASE, AND CLINICIANS DO TEND
TO -- WE DO TEND TO WANT TO
CATEGORIZE, YOUR BMI IS ABOVE A
CERTAIN POINT, AND PEOPLE --
THERE'S DIFFERENT CULTURAL SORT
OF PERCEPTIONS OF THAT, SO IT'S
NOT SUCH A SORT OF STRAIGHTFORD
-- STRAIGHTFORWARD ALL THE TIME.
METFORMIN WORKS, RELATIVELY FEW
SIDE EFFECTS, IT'S EASY, SEVERE
SIDE EFFECTS ARE RARE BUT WE
ALWAYS WORRY ABOUT THEM.
I THINK NON-ELDERLY PARTICIPANTS
WORKED AS WELL AS LIFESTYLE.
WHAT ARE YOUR THOUGHTS ON THAT?
>> YES, I PROMISE I DIDN'T GIVE
YOU THESE QUESTIONS AHEAD OF
TIME.
I DIDN'T FEED YOU THIS.
YES, TWO THINGS.
ONE IS ACTUALLY I DIDN'T TALK
ABOUT THIS, YOU CAN ONLY TALK
ABOUT SO MUCH, IN WOMEN IN DPP
WITH GESTATIONAL DIABETES
METFORMIN WORKED AS WELL.
GOING BACK TO MY WORK WE'RE
DOING SHARED DECISION MAKING,
REALLY GETTING AT THAT AS IS
LIFESTYLE CHANGE RIGHT FOR YOU?
OR IS METFORMIN RIGHT FOR YOU?
OR CAN YOU DO BOTH?
JUST BECAUSE BOTH WEREN'T
OFFERED DOESN'T MEAN YOU CAN'T
DO IT.
OUR TEAM REALLY HAS PUSHED THIS
ISSUE HARD, AROUND ANNALS PAPER,
FIVE YEARS AGO, SHOWING
NATIONWIDE USE OF METFORMIN IS
VERY LOW IN THESE PATIENTS,
WE'VE BEEN TRYING TO PUSH IT BUT
PUSHBACK BECAUSE IT'S NOT FDA
APPROVED, PEOPLE DON'T LIKE
THAT.
B, SOMEONE IN CDC TOLD ME THESE
PEOPLE WILL EAT THEIR WAY OUT OF
A PILL SO THEREFORE WE THINK
THIS IS NOT GOING TO BE THE
ANSWER.
>> RIGHT.
I WOULD COUNTER THAT.
>> I AGREE.
>> A COUPLE OTHER QUESTIONS THAT
WE'RE GETTING IN.
HERE'S FIRST ONE, DO YOU THINK
THE ISSUE WITH ASIANS HAS TO DO
WITH APPEARANCE, THEY MIGHT
CARRY MOST OF THE WEIGHT IN
ABDOMEN, WE TOUCHED THAT,
TRUNCAL OBESITY.
>> NO OTHER THOUGHTS, I GUESS
I'M JUST STILL -- I DON'T THINK
WE KNOW WHY PEOPLE AREN'T
GETTING SCREENED.
MAYBE PARTIALLY DUE TO
DIFFERENCES IN APPEARANCE.
EVEN IF BMI ABOVE 30, RATES ARE
STILL LOWER.
PART HAS TO DO WITH HONESTLY
BIAS ON THE PART OF CLINICIANS
AND OTHERS, MAY NOT BE THINKING
THIS, MAY NOT BE DOING SCREENING
TESTS WE SHOULD, KNOWING
PREVALENCE RATE FOR THESE
PATIENTS.
>> OVER THE YEARS, I HAVEN'T
PRACTICED IN ALMOST NINE YEARS,
BUT WHY NOT SCREEN EVERYBODY
ABOVE A CERTAIN AGE?
YOU'RE GETTING DOWN TO -- NOW
IT'S LIKE 70% OF THE POPULATION,
OVERWEIGHT OR OBESE, BMI ABOVE
25.
LOWER FOR SOME GROUPS.
SO, I THINK IN THE CONTEXT OF
WHAT PEOPLE GET, UNNECESSARY
TESTS ANYWAY, ADDING A1c TO
YOUR BLOOD DRAW SEEMS BENIGN TO
ME AND DOES PROVIDE SOME USEFUL
INFORMATION TO THE PATIENT'S
FUTURE.
NOW, HERE'S ANOTHER QUESTION,
GIVEN WHAT YOU KNOW, YOUR
RESEARCH AND EXTENSIVE EXPERTISE
IN THE CARE OF PATIENTS WITH
DIABETES, WHAT WOULD BE ON YOUR
CLINICIAN'S WISH LIST OF
COMPONENTS OF AN ELECTRONIC
MEDICAL RECORD SYSTEM THAT MAY
MITIGATE THE SOCIAL REASONS THAT
ARE BARRIERS TO ENHANCED
SUSTAINABILITY OF PARTICIPATION
IN THE DPP AND BALANCES,
EFFICIENTLY WITH PHYSICIAN, LONG
QUESTION, EVIDENCE-BASED
CLINICAL DECISION SUPPORT,
INCORPORATION PATIENT SHARED
DECISION TO FACILITATE DIABETES
POPULATION HEALTH SCREENING,
LIFESTYLE AND TREATMENT
COMPLIANCE TO PREVENT SECONDARY
DIABETIC COMPLICATIONS IN RACIAL
AND ETHNIC MINORITIES.
>> THAT WAS LONG.
I'LL TRY MY BEST TO ANSWER THIS.
WE TOUCHED ON THIS IN THE MEET
AND GREET EARLIER.
EHR AS WE KNOW IT IS BUILT FOR
BILLING, THAT'S WHAT IT IS.
YOU CAN'T GET OUT OF THERE
UNLESS YOU DO A BILLING, YOU
FILE A CHARGE.
IT'S NOT ORIENTED TOWARDS
ADDRESSING SOCIAL DETERMINANTS
OF HEALTH.
PART OF THE PROBLEM IS WE PUT
MODULES IN BUT NOBODY FILLS THEM
OUT.
WHEN YOU GO LOOK AT IT, IT'S
EMPTY.
IT'S NOT VERY HELPFUL.
I'D LOVE TO SEE SOMETHING THAT
JUST POPS UP ON THE SCREEN THAT
TELLS MORE ABOUT THE PATIENT.
EVEN SOCIAL DETERMINANTS BUT
ALSO WHO THEY ARE AS A PERSON.
WHAT TV SHOWS THEY LIKE, THESE
KIND OF THINGS, YOU GET TO KNOW
AND BUILD TRUST, GET TO KNOW WHO
THEY ARE.
PATIENTS DON'T HAVE CONTINUITY.
DOCTOR DOESN'T KNOW THEM.
THEY DON'T TRUST THEM, THEY ARE
NOT WILLING TO DO THE DPP THEN
OR DO THINGS THAT ARE HEALTHY
FOR THEM.
I'D LOVE TO SEE THAT IN THE EHR,
A SEPARATE BOX, THIS IS THE
PATIENT'S PERSONALITY BOX.
I THINK THAT WOULD BE USEFUL IN
BUILDING A TRUST AND I'M
ACTUALLY WORKING WITH A SCHOLAR,
ELISEO, WHO HAS THAT SAME IDEA.
I CAN'T CLAIM TOTAL OWNERSHIP OF
THAT.
BUT I DO THINK THAT'S THE KIND
OF THING THAT WOULD BE HELPFUL
TO ADD, ONE THING AT LEAST.
>> THAT'S GREAT.
AND ONE OF THE THINGS I WOULD
HAVE SAID WHEN I WAS SEEING
PATIENTS IS, YOU KNOW, WHAT YOU
JUST DESCRIBED, I DON'T KNOW
ABOUT TV SHOWS, BUT IN GENERAL
GET TO KNOW THE PATIENT, THE
MOST IMPORTANT PART OF WHAT WE
DO INITIALLY AS OPPOSED TO, YOU
KNOW, THE SYMPTOMS AND REVIEW OF
SYSTEMS AND ALL THE THE OTHER
STUFF WE'RE PROGRAMMED TO DO ALL
THE TIME.
ANOTHER QUESTION, WHAT ARE SOME
INNOVATIVE PRACTICES YOU HAVE
OBSERVED THAT HAVE HELPED
ATTENUATE DISPARITIES ACROSS THE
DIVERSE ASIAN SUBGROUPS WHICH
YOU DISCUSSED IN NHANES DATA,
CONSIDERING PATIENTS VALUES,
CULTURE, INTERSECTIONAL AND
SDOH, AND DR. HILL BRIGG'S WORK
YOU DISCUSSED ACROSS THE LIFE
COURSE.
>> IT'S GREAT TO WORK WITH
YOUNGER FOLKS WITH EXCITING
IDEAS, YOU SUPPORT THEM, BUT
THERE'S A NURSE AT UCLA WHO IS
INTERESTED IN FILIPINO AMERICANS
WITH DIABETES, HE'S DOING WORK
IN THIS GROUP.
I THINK HIS BELIEF IS, AND WE'RE
TESTING THIS, THERE'S SOMETHING
CALLED A COLONIAL MENTALITY THAT
MANY FILIPINO AMERICANS HAVE,
LOSS OF SELF-ESTEEM AND
SELF-WORTH, FILIPINO TERMS
DESIGNATE THIS.
SKIN COLOR AND ACCULTURATION ARE
BIG DRIVERS OF BEHAVIOR WITHIN
MANY GROUPS, AND SO I THINK
TRYING TO WORK WITH FILIPINO
PATIENTS AND STAFF TO GET A
SENSE OF WHAT THEIR BELIEFS ARE
AND PERCEPTIONS ABOUT DIABETES
TIED TO OTHER FILIPINOS TO
BECOME AWARE OF THESE THINGS AND
MAKE THE CHANGES TO IMPROVE
THEIR CARE.
SO MUCH ALONG WITH SOCIAL IS
VERY CULTURAL.
I THINK I HAVE TO PLEAD
IGNORANCE, I DON'T HAVE CULTURAL
COMPETENCE TO DO THIS WORK
MYSELF BUT I'M GLAD TO BE
PARTNERING WITH THIS INDIVIDUAL
WHO DOES.
THOSE THE THINGS WE NEED TO SEE,
IF WE'RE GOING TO TACKLE THIS
IT'S SOCIAL AND DEFINITELY THE
CULTURAL AS WELL AS BUILT
ENVIRONMENT IN TERMS OF DRIVING
THESE DISPARITIES.
>> RIGHT.
THANK YOU.
I KNOW IN CALIFORNIA WE ALWAYS
SAW A LOT OF FILIPINO PATIENTS,
SO I THINK YOU SEE LESS IN THIS
AREA, OR OUTSIDE OF REALLY
CALIFORNIA, A COUPLE OTHER
REGIONS.
I WOULD ALSO, YOU KNOW, WE CALL
ASIANS A VERY HETEROGENEOUS
GROUP, IN REALITY SOUTH ASIANS
ARE REALLY DIFFERENT.
THEY DON'T SHARE MUCH OF THE
EAST ASIAN CULTURE OR HISTORY OR
BACKGROUND OR HERITAGE.
AND THERE HAVE BEEN NOW A NUMBER
OF STUDIES SHOWING THAT SOUTH
ASIAN POPULATION IS HIGHER RISK
OF DIABETES AND CARDIOVASCULAR
DISEASE, YET DESPITE NOT HAVING
AS MUCH OBESITY IN BEING AT
LEAST A SIGNIFICANT NUMBER BEING
VEGETARIAN, SO YOU GET THIS SORT
OF REVERSE PARADOX, YOU DO WORSE
EVEN THOUGH YOU'RE NOT SUPPOSED
TO, AND THIS IS WHERE SOME OF
THE INTEREST IN BOTH METABOLIC
DIFFERENCES OF FAT AND DIFFERENT
MEDIATORS THAT COULD LEAD TO
THIS DIFFERENCE, DIFFERENT
RECEPTORS, THERE'S BEEN A TON OF
WORK ON GENETICS, I'LL LOOK UP
THE PAPER YOU MENTIONED.
FRANCIS COLLINS'S LAB WAS
WORKING ON GENETICS OF EFFECT TO
DIABETES, THE INSULIN RESISTANCE
SPECTRUM OF DIABETES.
WHICH IS GOOD.
ANOTHER QUESTION, DPP
INTERVENTION RESULTS LOOK GREAT
IN ALL THREE ARMS, OKAY?
WHAT HAPPENS ONCE RESEARCH
PROJECT ENDS IN MINORITY
POPULATION, DO WE NEED LONGER
FOLLOW-UPS? YOU SHOWED THE DATA
OF THE FOLLOW-UP STUDY WHERE YOU
CONTINUE TO SEE INCREASED RATES
OF DIABETES, STILL SEPARATION
GAINED.
SO IT WAS ENCOURAGING THAT
WHATEVER WAS DONE IN THOSE THREE
TO FIVE YEARS OF BEING IN THE
STUDY IMPACTED PEOPLE OVER 20
YEARS OF FOLLOW-UP?
>> 18 YEARS OR THEREABOUTS.
>> 18, OKAY.
DO WE NEED LONGER FOLLOW-UPS?
A LOT OF GUIDELINES FROM TASK
FORCE, SCREENING RATES HAVE NOT
IMPROVED, INCLUDING PREGNANCY.
CAN YOU SPEAK TO THE STUDY THAT
INDICATE THAT CHILDREN IN
FAMILIES IN A HAVE MANY FRESH
FRUITS CONSUMED MORE SUGAR, TWO
TO THREE ORANGES EQUALS ONE
GLASS OF JUICE, SHOULD
GUIDELINES CHANGE?
TWO-PART QUESTION.
FOLLOW-UP AND HOW DOES THAT
MAYBE -- HAVE WE SEEN ANY
IMPROVEMENT OR DECREASE IN GAPS?
>> IN TERMS OF THE FOLLOW-UP,
I'LL SAY THAT PEOPLE TEND TO
REGAIN WEIGHT, SO THEY LOSE
WEIGHT, WE KNOW THEY REGAIN
WEIGHT BUT THE POINT YOU JUST
SAID WHICH I TRIED TO MAKE IS TO
ME IT'S GETTING PEOPLE TO STICK
WITH THE PROGRAM FOR NINE MONTHS
OR TWELVE MONTHS.
IF YOU DO THAT EVEN 18 YEARS
LATER THAT BENEFIT, METABOLIC
MEMORY, IT'S STILL GOING TO BE
THERE.
THE RISK IS STILL LOWER.
SO, I THINK WE KNOW THAT IF
PEOPLE LEAVE THIS PROGRAM, IF
YOU GO BACK THREE, FOUR, FIVE
YEARS, MAY GAIN WEIGHT, MAY NOT
BE DOING LIFESTYLE, IDEALLY THEY
WOULD BE BUT THE KEY IS DO THE
INTERVENTION THE WAY YOU'RE
SUPPOSED TO IN THAT FIRST YEAR.
IN TERMS OF KIDS, I'M NOT A
PEDIATRICIAN.
MY KNOWLEDGE OF HEALTH IN KIDS
IS LIMITED TO MY OWN THREE KIDS,
WHEN I GO TO THE DOCTOR.
BUT I WILL SAY FOR MY PATIENTS,
JUST MY BELIEF, I THINK WE FOCUS
ON FRUIT AS AN ISSUE.
PATIENTS SAY CAN I EAT THIS
FRUIT OR THAT FRUIT, I DON'T
THINK IT'S A GOOD IDEA AND SUCH
BUT SO MUCH IS ULTRA PROCESSED
FOOD.
AN ARTICLE I READ BETWEEN
TODAY'S SESSIONS ABOUT BIG NEW
STUDY IF YOU LOOK AT THE
WASHINGTON POST TODAY ULTRA
PROCESSED FOODS, WHAT THOSE ARE
DOING, HOT DOGS, CHIPS, THESE
ARE THE THINGS.
THE ORANGES AND FRUIT TO ME ARE
FINE.
I TELL PEOPLE THAT'S GREAT.
KNOCK YOURSELF OUT.
WE HAVE TO TALK MORE ABOUT ULTRA
PROCESSED FOODS BASICALLY JUST
FATS AND CARBS AND SUBSTITUTES.
ATTITUDE.
THAT'S WHERE THE PROBLEM IS
GOING, WE NEED TO WORK ON THAT.
>> YEAH, ONE OF THE QUALITY OF
THE FOODS, NOT JUST QUANTITY,
YOU CAN'T LOSE WEIGHT UNLESS YOU
EAT LESS, RIGHT?
THAT'S AN ABSOLUTE.
NO EXERCISE IS GOING TO BE
SUFFICIENT.
AND THE QUALITY OF WHAT YOU EAT,
CAN BE SATISFYING, FULFILLING,
NUTRITION WITHOUT JUST BEING A
LOT OF EMPTY CALORIES.
ULTRA PROCESSED FOOD IS WORST
CULPRIT BUT MANY TIMES LEAST
EXPENSIVE AND EASIEST.
WE HAVE TO KEEP WORKING.
THERE'S A LOT OF STRUCTURAL
FACTORINGS THAT CONTRIBUTE TO
THIS.
AND SOME OF THAT IS BASED ON
FOOD INDUSTRY, BASED ON
NEIGHBORHOODS, AND BASED ON
ECONOMIC RESOURCES THAT FAMILIES
HAVE.
>> ONE THING ABOUT THE COOKING,
I HAVE TO SAY THE OTHER THING
THAT'S CHANGED, ALONG WITH
WEIGHT IS COOKING.
I THINK PEOPLE HONESTLY HAVE
FORGOTTEN HOW TO COOK, IN BROAD
TERMS.
IT'S NOT SO EASY.
YOU HAVE TO BALANCE, I'M
COOKING, I NEED THESE
INGREDIENTS, HAVE TO BUY THEM, I
DON'T BUY TOO MUCH SO IT GOES
BAD OR TOO LITTLE SO I CAN'T
FINISH THE MEAL, GET BACK,
FIGURE OUT HOW TO COOK IT, STORE
IT, ALL THAT.
FOR A LOT OF PEOPLE IT'S NOT
EVEN JUST -- IT'S THE TIME,
PRICE, THE MENTAL THOUGHT ABOUT
COOKING.
YOU CAN'T JUST PUT RAN DO --
RANDOM STUFF IN YOUR CART.
A CHEF, HOW DO WE TEACH PEOPLE
ALL THE STEPS IN PREPARING,
BUDGETING, COOKING, AT UCLA WE
HAVE A TEST KITCHEN.
NOT ME BUT OTHER COLLEAGUES ARE
WORKING ON THOSE VERY ISSUES.
PART OF THE PROBLEM IS WE JUST
DON'T COOK ENOUGH.
IF WE WERE TO COOK MORE AT HOME
I THINK THESE THINGS WOULD ALSO
IMPROVE.
THAT'S ANOTHER AREA OF ACTIVE
WORK.
>> ABSOLUTELY.
AND LINKED TO THAT, YOU KNOW,
POSTDOCTORAL FELLOW IN MY LAB,
NUTRITIONIST, Ph.D., SORT OF
THE ROLE OF TRADITIONAL FOODS.
FOR EXAMPLE, IN THE LATINO --
MOST LATINO COUNTRIES, NOT ALL,
HAVING MORE PULSES OR LEGUMES OR
BEANS ARE TRADITION, PEOPLE IN
THIS COUNTRY WHEN THEY BECOME
EITHER MORE ACCULTURATED, LESS
ORIENTED LATINO CULTURE, THEY
ABANDON THAT, CONSUME MUCH LESS
OF THAT.
SIMILAR KIND OF PATTERNS CAN BE
FOUND FOR OTHER IMMIGRANT
POPULATIONS.
MEXICO HAS NOW THE HIGHEST
OBESITY RATE IN THE WORLD.
IT PASSED THE UNITED STATES.
AND OF COURSE THEY ALSO HAVE THE
HIGHEST RATE OF DIABETES IN THE
WORLD.
AND THEY HAVE DONE SOME MORE
INTERVENTIONS ON THE STRUCTURAL
SIDE WITH SUGAR-SWEETENED
BEVERAGES AND TAXES.
BUT THIS IS A GLOBAL PROBLEM,
IT'S JUST NOT A HIGH INCOME
COUNTRY PROBLEM ONLY.
NEXT QUESTION, IS THERE ANY
MOVEMENT IN THE FIELD TO FOCUS
ON CHANGING CLUSTERED LIFESTYLE
BEHAVIORS WHICH PLACE
INDIVIDUALS AT RISK FOR
DIABETES?
NOT SURE WHAT IS MEANT BY
CLUSTERED LIFESTYLE BEHAVIORS
BUT MAYBE YOU DO?
>> NO, I'M NOT SURE IF THAT
MEANS ACTIVITY AND DIET TOGETHER
MAYBE, LIKE WORSE DIET AND LESS
ACTIVITY.
>> CAN WE GET CLARIFICATION?
THAT WILL HELP.
WHILE WE WAIT, EXCELLENT
PRESENTATION, CONGRATULATIONS TO
DR. DURU, HAS THE INFLUENCE OF
AFFORDABILITY ON HEALTH CARE
FOOD CHOICES BEEN STUDIED IN
RELEVANCE TO DPP?
ALSO ARE THERE CORRELATIVE
STUDIES IN PATIENTS WHO ARE
REFRACTORY TO METFORMIN AND/OR
OTHER THERAPIES?
>> YES, THERE HAS BEEN A LOT OF
ATTENTION PAID TO THE DPP, WHAT
PEOPLE ARE ABLE TO EAT.
IF YOU HAVE ALL THESE SESSIONS
ABOUT COOKING FOOD AND PEOPLE
CAN'T AFFORD TO BUY FOOD YOU'RE
TALKING ABOUT, OR THE FOOD
YOU'RE TALKING ABOUT IS NOT WHAT
THEY LIKE TO EAT IT'S GOING TO
BE A PROBLEM.
I'LL JUST SAY THE BIGGEST
PROBLEM, A LOT OF INDIVIDUALS,
SPOUSE DOESN'T WANT TO EAT THE
FOOD THEY EAT, OR THE KIDS DON'T
WANT TO EAT THE FOOD.
IT'S HARD TO COOK TWO MEALS
EVERY DAY, ONE FOR THEMSELVES
HEALTHY AND ONE FOR THE KIDS
YELLING BECAUSE THEY WANT HOT
DOGS AND FRENCH FRIES.
THAT'S ALSO PART OF IT WITHIN
YOUR OWN HOUSEHOLD TRYING TO
FIGURE OUT HOW TO DO THIS.
THERE WAS ANOTHER PART OF THE
QUESTION, I JUST FORGOT IT.
>> CORRELATIVE STUDIES IN
PATIENTS REFRACTORY TO
METFORMIN.
>> THAT'S RIGHT.
WELL, REFRACTORY TO METFORMIN,
IT'S HARD TO KNOW WHAT THAT
MEANS.
A LOT OF PEOPLE CAN'T TOLERATE
METFORMIN.
SOME PEOPLE CAN'T BECAUSE OF
NAUSEA, VOMITING, G.I. SIDE
EFFECTS THAT ARE TRANSIENT BUT
SOME PEOPLE NEVER TAKE IT AGAIN
AFTER THEY EXPERIENCE THOSE.
PEOPLE WHO MAKE METFORMIN AND
DON'T ACHIEVE THE GOAL THEY
WANT, WITH METFORMIN IT'S A
MEDICATION FOR DIABETES ANYWAY,
THE FIRST LINE.
IF YOU START IT AND THEY
PROGRESS TO DIABETES YOU WOULD
ADD SOMETHING ELSE ON TOP OF IT.
THERE ARE MULTIPLE NIH STUDIES
THAT GIVE GUIDELINES OF WHAT TO
DO.
I THINK NO ONE HAS TALKED ABOUT
YET OZEMPIC.
>> NEXT QUESTION.
DO YOU THINK THAT WILL AFFECT
TRAJECTORY OF DIABETES
DISPARITIES?
>> THIS IS GOING TO BE A BIG
ISSUE BECAUSE, YOU KNOW, THE
MEDICATIONS ARE EXPENSIVE AND
NOT ALWAYS COVERED, IF THEY ARE
COVERED IT'S A LOT OF HOOPS TO
JUMP THROUGH AND MANY PATIENTS
OF COLOR MAY BE IN SETTINGS
WHERE THEY DON'T GET THOSE,
PROVIDERS WON'T DO THAT.
I'LL GIVE L.A. COUNTY CREDIT
BECAUSE THEY HAVE MADE THE BOLD
STEP ANYONE WITH DIABETES IN
L.A. COUNTY SAFETY NET SYSTEMS
CAN GET OZEMPIC COVERED.
WE'RE GOING TO SEE IF THIS MAKES
A DIFFERENCE IN REDUCING WEIGHT
AND DIABETES ACROSS THE SAFETY
NET HEALTH SYSTEM.
THE HOPE IS THOSE STUDIES,
HOPEFULLY IF THERE IS A BENEFIT,
CAN LEAD THE WAY TO GREATER USE
BUT IN THE SHORT TERM I'M VERY
WORRIED WE'LL SEE WORSENING OF
DISPARITIES IF WE DON'T DO
SOMETHING BECAUSE WEIGHT LOSS
PEOPLE SEE IT'S GOING TO AFFECT
DIABETES INCIDENCE.
IT'S NOT REALLY APPROVED FOR
PREDIABETES YET.
MAY BE.
WE'LL SEE.
A LOT OF PEOPLE AT RISK ARE
CLAMORING TO GET IT, AND WE
BELIEVE THE RISK OF DIABETES
WILL BE LESS.
ANY NEW TECHNOLOGY OR MED THAT'S
EXPENSIVE, IT'S A REAL CHALLENGE
TO FIGURE OUT HOW TO ALLOW
EQUITABLE ACCESS AND USE, WE'RE
STILL WORKING ON THAT.
>> RIGHT.
I'M NOT AS TUNED IN TO THE
CLINICAL NUANCES HERE BUT I
PERSONALLY AM SKEPTICAL ABOUT
THESE NEW RAGE DRUGS.
BUT YOU NEVER KNOW.
WE'LL SEE IF SOME WILL PAN OUT.
THE FACT THAT THEY ARE SO
EXPENSIVE MAKES IT LIKELY THEY
WILL WORSEN DISPARITIES MORE
LIKELY THAN IMPROVE THEM BUT
IT'S STILL A DRUG THAT PEOPLE
HAVE TO TAKE SO ADHERENCE IS A
BIG ISSUE.
AND I THINK A LOT OF PEOPLE
STILL ARE LOOKING FOR A MAGIC
BULLET, AND IN FACT WE KNOW WE
HAVE BEHAVIORAL INTERVENTIONS
THAT WORK, IN FACT IF YOU WANT
TO GET MORE INVASIVE BARIATRIC
SURGERY HAS CLEAR BENEFITS, DONE
WITH MUCH LESS ADVERSE EFFECTS
NOWADAYS.
I THINK WE'LL THROW IN DO YOU
THINK SCREENING, I THOUGHT IT
WAS ROUTINE ALL WOMEN WOULD BE
SCREENED EARLY IN PREGNANCY,
WHAT USUALLY HAPPENS 12 TO 16
WEEKS, RIGHT?
>> YEAH.
>> 18 OR SOMETHING LIKE THAT?
>> LATER, THAT'S RIGHT.
>> AND MANAGING GDM WOULD HELP
REDUCE INCIDENCE OF TYPE 2 IN
RACIAL MINORITIES?
>> WELL, I'LL SAY EVERY OB I
KNOW, THEY ARE SERIOUS ABOUT
THIS FOR GOOD REASON.
THEY TAKE IT PERSONALLY THEY
HAVE TO PROTECT THIS MOTHER AND
THE BABY.
AND ANYONE THAT GOES TO PRENATAL
CARE GETS THIS.
SOME WOMAN ARE NOT CONNECT WITH
THE CARE, AREN'T SCREENED,
COMPLICATED DELIVERY BECAUSE
IT'S NOT CONTROLLED.
FETUS GETS LARGE BECAUSE OF
CIRCULATING SUGAR, PROBLEMS WITH
SHOULDER DISLOCATION AT BIRTH
AND WORSE COMPLICATIONS.
IF YOU GO TO PRENATAL CARE
YOU'LL GET THIS TEST, THEY WILL
MAKE SURE YOU GET IT.
I THINK IN TERMS OF PREVENTING
DIABETES, THE PROBLEM I'VE SEEN,
IT'S HARD TO INSTITUTE LIFESTYLE
CHANGE YOU WOULD LIKE AT THIS OF
THAT POINT.
FOCUS IS NOT NECESSARILY ON
LOSING WEIGHT, NOT THE WAY IT
SHOULD BE ON LOSING WEIGHT, BUT
IN ORDER TO PREVENT DIABETES
OVER LONGER TERM YOU HAVE TO
TALK ABOUT LOSING WEIGHT.
THAT'S NOT WHAT THEY FOCUS ON
FOR GOOD REASON.
I DON'T KNOW THAT MORE SCREENING
AND TREATMENT DURING PREGNANCY
WILL DO THINGS TO AFFECT TYPE 2
DIABETES BUT THE HOPE IS THERE'S
A LINK, YOU GO TO POST PART UM
SCREENING, GET CONNECTED WITH
PCP AND THEY PICK UP THE CHAIN
AND MOVE FORWARD ARE
TRANSITIONING TO WEIGHT LOSS
INTERVENTION FROM PREGNANCY
INTERVENTION.
SO WE HAVE TO DO A BETTER JOB
CONNECTING PEOPLE THROUGH THAT
PASSING THE BATON.
>> TO PUT NUMBERS ON IT, IF YOU
KNOW THEM, PREDIABETES THE
NUMBER I REMEMBER IS 50% DEVELOP
DIABETES WITHIN TEN YEARS OR SO,
I DON'T KNOW IF IT'S STILL
CONSIDERED THAT HIGH OR IF IT'S
EVEN LOWER.
IS GESTATIONAL DIABETES IN THE
SAME BALL PARK OR HIGHER?
>> THAT'S THE ONE THAT'S IN THE
BALL PARK.
I'LL SAY THAT WE HAVE ANOTHER
COLLEAGUE AT TUFTS, A MODEL FROM
DPP THAT THERE'S NOT ONE RISK
FOR EVERYBODY.
THERE ARE 11 VARIABLES THAT
PREDICT YOUR RISK OF DIABETES,
A1c AND BMI ARE CHIEF BUT EVEN
CHOLESTEROL AND AGE AND RACE,
THOSE ARE THINGS, WE THINK
EVERYONE HAS THEIR OWN RISK, IF
YOU HAVE GDM YOU'RE AT THE
HIGHEST LEVEL OF TRANSITION
RATE.
>> GOOD TO KNOW.
WELL, WE'VE RUN OUT OF TIME.
THERE ARE QUESTIONS ABOUT THE
ROLE OF POLITICAL DETERMINANTS
BUT I THINK WE CAN DO THAT
OFFLINE.
AND THEN A QUESTION ON THE
RACE-BASED VERSUS RACE-NEUTRAL
CUT OFF, I THINK YOU'VE TALKED
ABOUT THIS BUT YOU WEREN'T SURE
WHAT THAT TASK FORCE WAS GOING
TO COME OUT ON.
>> THAT'S RIGHT.
>> AND GIVE YOU MY VIEWS, THEY
SHOULD SCREEN EVERYBODY ABOVE A
CERTAIN AGE AND NOT BOTHER WITH
BMI OR RACE.
BUT ANY LAST COMMENTS ON IT?
>> NO.
I DON'T KNOW THAT -- LET'S WAIT
AND SEE WHAT THE TASK FORCE
SAYS.
>> AREN'T YOU ON THE TASK FORCE?
>> NO, NO, I HAVE NOT YET BEEN.
MAYBE ONE DAY I'LL BE HONORED
ENOUGH TO JOIN.
BUT NOT AS YET.
>> OKAY.
>> AS EVERYONE HERE KNOWS, THE
RACE-BASED THING, THERE'S A LOT
OF MOVEMENT, WE'LL SEE WHERE IT
ENDS UP.
I WANT TO MAKE SURE WE DO THINGS
THAT REDUCE DISPARITIES.
IF THEY DO, I'M FOR THEM.
BUT IT'S A COMPLICATED THING TO
SORT OUT.
>> KENRIK, THANK YOU FOR THE
TIME YOU SPENT WITH US, BOTH
EARLIER WITH MEET AND GREET AND
THIS AFTERNOON, IN THIS TALK.
IT WAS TIMELY TIME TO GO OVER A
LOT OF ISSUES WITH DIABETES, AND
PARTICULARLY FOR OUR AUDIENCE.
AND SO, AGAIN, THANK YOU FOR
YOUR WONDERFUL TALK.
>> PERFECT, THANKS TO ALL OF YOU
FOR YOUR ATTENTION.
HAVE A WONDERFUL AFTERNOON,
WONDERFUL WEEKEND.
>> TAKE CARE.
BYE-BYE.
[END OF PROGRAM]