David: 0:16

Hello, welcome to Diabetes Technology Report. I'm David Klonoff. I'm an endocrinologist at Sutter Health in San Mateo, california. We have a very special guest today, who's approximately 12 time hours away from where I am, and my colleague, interviewer Dr David Kerr, will introduce him.

David Kerr: 0:37

Thanks, david, and hello everyone. I'm David Kerr, again speaking to you from Santa Barbara, california. It is a real pleasure today we have the doctor who is the face of diabetes in a particular part of the world in India. Dr Mohan, welcome. It's a real honour to have you on board. I'm always interested how people end up spending their life being involved in diabetes and diabetes technology, so can you just give me a brief thumbnail of how you've ended up being a superstar in diabetes technology?

V. Mohan: 1:13

Thank you both the Davids, for having me on the show. Mine is a very peculiar story which probably very few people would have had the opportunity to even tell the story. So I wanted to be. I never wanted to be a doctor in the first place, I wanted to be a poet, a writer, which explains why I write so much. And my father, my late father, was like the Jocelyn of India, professor Vishwanathan, and he started the first diabetic clinic in India, actually in my city, in Chennai. Halfway through his career he had to leave the government for reasons we won't go into, but he had to leave. And so he just summoned me and he said you're my eldest son, and what are your plans to do? So I said I want to be a professor of English and write poetry and books. And he said no, you switch over to scientific writing, you become a doctor, and I want you to help me. And of course I was a university topper, so there's no problem getting into a medical school. In fact I got into four medical schools. So he said that's not an issue, you just have to make up your mind to help me and work in diabetes with me. So I joined to.

V. Mohan: 2:25

To cut a long story short. I thought it's not a bad idea to switch to scientific writing. So I joined him when I was 18 years old. So I joined in medical school. So we go to medical school very early here, not like in the US. You finish a degree and then you go, so here, straight from school, you go to medical college. So I was 18 and I was in medical college. So I told my father look, if you're, if you have asked me to do medicine to help you to do diabetes, what's the point in waiting 10, 15 years for me to graduate, finish postgraduation, specialize. You'll be so old and then there's no point in in my helping you. So let me start today. I mean, I can start working with you today.

V. Mohan: 3:02

So while I was doing medicine on one side, the medicine was just to get my degree and so on I started working on diabetes straight on at the age of 18. So he had a lot of medical records, even in his private practice, which he had not built up, but he was a meticulous record keeper, so he had all records and so on. So I said, why not start analyzing these records and start writing something? And so he said yeah. So then I said no, that's not enough, you have to build a small lab for me. So we had a garage, so we converted that garage into a lab and bought some mice and rats. And here I am doing anatomy on one side anatomy, physiology, biochemistry in the medical college and here doing animal experiments trying to produce diabetes and rats and mice and so on. So he hired a PhD and I started working with him half day and half day medicine, half day research and started publishing when I was 18, 19, 20. I already started publishing to an extent that my teachers started getting jealous of me. So they would say what's this guy? He's not even finished his medicine and he's publishing more papers than we can publish. And so I had a rough time with, you know, some of them who threatened to fail me in the exams and so on.

V. Mohan: 4:16

But the good news was that I got right into diabetes. It was good and bad, because you know, when I go to medicine and I study something like anatomy, some insertion of some muscle here and something, what's this to do with diabetes? I mean, why am I studying all this rubbish? You know, my aim is only to do diabetes. So I went through medicine with a complete bias, but then that's a negative side. The positive side is that is reading diabetes journals and everything every day. You know I would get diabetes care and diabetes and all the journals I'd read. It cover to cover all the diabetes books, jocelyn's textbook Everything I was reading when I was 18, 19, 20 years old.

V. Mohan: 4:54

So that's how I started working on diabetes and for 20 years I worked with my father and then at the end of 20 years I told my father you know, we have to expand and go on and now I want to build this big research center. And he was growing old by that time because he already finished one innings in the government 20 years later and he was saying no, no, you're thinking too big, you shouldn't do this, you shouldn't do that. And I said no, but I want to do. I've started precociously and at the age of 38, I've only finished 20 years in diabetes. You know, now I want to really speed up and you're slowing me down. So he said okay, in that case, you leave. So I said okay, I leave, you set up a center for me and I leave. He said I'm setting up nothing for you. You take the stethoscope and leave. So I took my stethoscope. I had no money, I had nothing and I had to start my second. Of course, my wife is an ophthalmologist, which is a great advantage. She had all her equipment and laser and we already had a diabetic retinopathy unit even then. So I said okay, let's go and start from. So we took a couple of rooms in a rented place and the rest is history. From there we grew and grew and grew and grew and I can't tell you the number of patients, whom we have now 665,000. My goodness, yeah, close to a million patients with diabetes. We have 50 centers now, 50 branches in 32 cities. More than 100 diabetologists work for me and my next generation. My daughter and son-in-law have also joined, and now my next generation, my grandson, is about to join medicine next year and my daughter.

V. Mohan: 6:33

When I started at least when I was 18, doing research on diabetes, she started when she was 12 or something, and so she, when she was in school, she started. One of my teachers jokingly asked me when did she first get into diabetes? So I said you know, when she was three years old, she used to operate my wife's slides and my slides. You know the old projectors she used to project, and so she knew diabetic retinopathy when she was three years old. So he said he was so jealous of me that he said you wasted three years of her life. You should have started when she was born. So I said, okay, I'll do that for my grandson. So when my grandson was taken out of the labor room and they brought him to me like that there's your grandson. You and my daughter had not seen. So the first word he heard was diabetes.

V. Mohan: 7:18

So the first word in his life he heard was diabetes.

David Kerr: 7:22

This is what a story. This is terrific for the future of diabetes research and innovation. For sure. There's a whole dynasty there. So, coming up to today from a diabetes technology perspective, what's your kind of main area of interest at the moment?

V. Mohan: 7:41

Yeah, two areas. One is precision diagnosis of diabetes using technology, and right now, with Dr Klonoff, we are involved in a project trying to separate out, type out which type of diabetes, using electronic records and using AI and machine learning to understand. That's one part of the technology. The other part of the technology is using technology itself in the treatment. So continuous glucose monitoring and insulin pumps and automated insulin delivery systems, so all of those we adapt very quickly into the clinic and then start using that and also start collecting data on that. So we were the first to introduce CGM, first to introduce pumps, first to introduce auto. Now the latest thing we have just done, just two days ago.

V. Mohan: 8:45

What we have done is that we, of course, in all our centers we have retinal cameras. Across India, all the centers we have retinal cameras, but we used to have ophthalmologists reading all of them. Now we've introduced AI. So some of those centers don't need any ophthalmologist oversight at all. So the retinal picture, the camera itself, has an AI built in and the report comes. It's normal there is diabetic retinopathy, there's more severe retinopathy which needs a referral, all that the AI is able to say. So that's how we use technology.

David: 9:17

Mohan, you're in India, which has a very large number of people with diabetes. How many people do you think in India have diabetes, and why is it so common in your country?

V. Mohan: 9:29

Yeah, so we have done the ICMR in-diab study and in fact the methodology of the ICMR in-diab study was published in the Journal of Diabetes Science and Technology many years ago by Dr Klonoff and so that study has now been completed. We have completed the whole country, every state in the country representative sample. So based on that, we have 101 million people with diabetes in India and 136 million people with pre-diabetes in India. So put both together it's 237 million people with either diabetes or pre-diabetes. To answer your question why we have so many people with diabetes despite not having the kind of obesity rates that you have.

V. Mohan: 10:13

So we call the Asian Indian phenotype and this was the lecture I gave at the ADA for the Kelly West Award last year we call it as a thin fat Indian.

V. Mohan: 10:24

So the BMI may be low, a BMI may be only 23, 24, 25,. But we have fat, we have visceral fat and this is because subcutaneous stores of adiposity, of adipose tissue, is very limited. So very quickly the fat spills over into the visceral, then goes into the liver, produces insulin resistance. The fat goes into the pancreas, so insulin secretion also is affected. So we have thin Indians who have a lot of insulin secretory defect and this seems to have some kind of a genetic basis as well, but largely driven by the high carbohydrate diet that we take A lot of rice, so rice and wheat is what is a staple food in our country and this seems to be putting a big load on the pancreas, drawing out more and more insulin and very quickly they exhaust and develop diabetes. So on a background of genetic factors, the very high carb load plus, there's not enough physical activity, so obesity comes in and then the visceral adiposity comes in. So that's the main reason why we have so much of diabetes.

David: 11:35

Mohan, I visited you 13 years ago and saw your setup both in town and on the outskirts of town, and I learned about pancreatic diabetes there. We don't see that in the US. I wonder if you could explain to our listeners. I'll bet many of them don't know what it is.

V. Mohan: 11:55

Yeah, so this is a form of diabetes, secondary form of diabetes, secondary to chronic pancreatitis. Now when you think of chronic pancreatitis in the West it is usually alcoholic chronic pancreatitis where you get small stones, small speckled kind of stones, mainly in the tail region of the pancreas and not inside the duct. These are huge stones. They block the pancreatic duct, mostly from the head region of the pancreas. They block and therefore the pancreatic juice cannot flow and therefore it leads to pancreatitis, stone formation because the juice juice, the flow becomes obstructed, it becomes sluggish. The mucus plugs get deposited around that, calcium starts forming and so the big stones form and this can even lead to malignancy.

V. Mohan: 12:45

The the prevalence of pancreatic malignancy in those with this pancreatic forms. We call it as fibrocalculus pancreatic diabetes. So there is calculus, there's also fibrosis, so the gland gets shrunken, the pancreas becomes much shrunken, like a cirrhosis of the pancreas, and then they develop a lot of them develop pancreatic cancer and they have severe abdominal pain because of the stones and then it leads to diabetes stunting. And then they also have malnutrition because they have diarrhea and oily stools, steatoria, and so it's a very peculiar form of diabetes. It was largely due to there are some genetic factors, the sphincter gene and so on associated with it, but largely due to some micronutrient deficiencies. Today it's kind of going down because the nutrition of people is improving. We occasionally see this type of diabetes, but not as much as I used to see 20 years ago, and so the incidence has kind of gone down. Alcoholic pancreatitis is now increasing because people can now afford drinking alcohol, and so alcoholic pancreatitis slowly replacing this tropical form of pancreatitis.

David Kerr: 13:56

Dr Mohan. I'm also intrigued from a type 1 diabetes perspective. In the United States we're seeing a crossover. It was traditionally a white person's disease. It's now increasing in the black community, the Hispanic community. What's happening in India with type 1 diabetes?

V. Mohan: 14:13

So we have always had a fair proportion of type 1, unlike China where they still say that type 1 diabetes is very rare. So for that reason because it's definitely lower than, say, finland or Scandinavia, where the highest prevalence of as you go away from the equator to more temperate places, we don't know if it's due to viruses or because autoimmunity is more there Definitely if you go to Scandinavia, denmark, sweden, norway, finland particularly, the prevalence of type 1 diabetes is very high. So it's not as high as there but certainly as high as the rest of Europe. For example, you take France or Spain or England, we don't have much difference in the prevalence of type 1 diabetes. Now, a lot of type 1 diabetes we may be missing because the children may be dying. In a rural area, some remote place, child goes into coma, diabetic ketosis and coma. They'll think it's meningitis or thinks that something else. They don't check the blood sugar. So we could still be losing some children.

V. Mohan: 15:18

The prevalence of type 1 diabetes is not low. The estimated numbers, according to the International Diabetes Federation it was 250,000 children, but a more recent report by the JDRF now called Breakthrough Type 1D, they have put the number as 850,000 children with type 1 diabetes, which is more than the US actually in terms of our population. So we actually have the highest number of type 1, followed by US and then Brazil, and fourth only is China. Because China, somehow they still keep saying that type 1 is less common in their country. So it's not uncommon to have children. It's not an epidemic like the type 2. Type 2 in the young is actually rising much faster because of obesity, and that's well. Even in the US, the Hispanic population, the Pacific Islanders and Asian, indian, south Asians we have higher prevalence of type 2 diabetes than, say, the white European population. But type 1, of course you have higher prevalence rate and because of the sheer population we have large numbers of children.

David Kerr: 16:27

And are you? In the US, there's a lot of discussion about screening for type 1 diabetes. You know, is that something that you're embracing in India?

V. Mohan: 16:34

It's difficult for us because we have too many children and screening them. See, we may screen them today and it'll be normal. How do you know that three months later they won't develop, because it's an acute condition? So while we screen for type 2, in adults as well as in children family history of diabetes is there? Obesity is there? Acanthosis, nigricans is there? We'll screen for type 2 because that's common enough.

V. Mohan: 16:59

Type 1 is like 1 in 100,000 children. So you'll have to screen 100,000 children to pick up that one child and the child will anyway become symptomatic within give it three, four weeks and they'll become symptomatic and they'll go rush to the hospital. If they don't die and they're picked up, then it's good. So screening as such we are not able to do. The other thing we're not able to do is to screen for antibodies in the general population. We are beginning to screen the siblings of type 1 because we think we'll pick them up more there.

V. Mohan: 17:37

But if you start screening the whole population, it's too many millions and millions of children we have to screen. The cost of screening is just too high to pick up. And then the other problem is okay, if they have three antibody positive, we'll have to give them teplizumab, which is too expensive. It's not available in India, so now we are seeing whether verapamil or something else can be given. So as long as we don't have a drug to give them if we find them antibody positive, it's not ethical to screen, because you screen them, tell them you're going to get type 1 and then we don't have anything to do. So we don't do it. Educating in schools and so on, saying if a child has these symptoms, look for type 1, immediately send for a screening, or have a glucometer in the school and just check for the child and if the child has raised blood glucose, immediately refer them to a nearest hospital. That's what we are trying to do. It's not possible to screen all children.

David: 18:32

Mohan, with the large number of patients that you have, what type of an electronic health record do you keep and what do you do with the data?

V. Mohan: 18:41

Yeah, so from day one I told you I left my father and started on my own in 1991. So since that time, nine plus 25, 34 years now, when I've run these clinics, we have had electronic records right from day one. That's been a great blessing for us. So the 660,000 patients that I told you, they're all on electronic records, not just once, but every time they come we have the electronic records. So for some people you have 30 a follow. So this is a goldmine of data, 30 a follow-up. So this is a gold mine of data. So, for example, now we're looking at this data on type 1, type 2 for the collaboration that we're doing. So we have data mining people who we tell them what we need and they can go into the electronic records, set the filters and take out whatever data we want.

V. Mohan: 19:31

So the tremendous number of publications that we have had is partly due to this rich database. So if you think of an idea, for example somebody came. Another area I work on is gestational diabetes. So somebody came to UK and said you know we are interested to look at recurrent GDM, not just GDM1s, but those who had, say, three times GDM. Compare them with those who had only once GDM, are they different or not? So we just have to put in recurrent GDM and it will come out. All the data will come out. So that's a tremendous resource that we have no-transcript.

David Kerr: 20:07

Dr Mohan, one of the challenges in the United States is ensuring that people with diabetes have regular screening, but the screening rates you mentioned retinopathy screening, the screening rates for retinopathy screening and food screening are actually not where they need to be. I mean in India. Is it the same challenge or are you more successful, less successful?

V. Mohan: 20:33

we're successful as far as our clinics are concerned, the whole network across these 32 cities. We are driven by protocols, so we have standard operating procedures. Every year the medical record will tell us it's time for the eye checkup. A pop-up will come saying a prompt, saying it's now due. At this visit you should check. Suppose a lady is pregnant. It'll say please don't do an x-ray. The lady is pregnant. So all this is kind of built in. So because of that, our screening rates are very good. And today we have this AI systems. We have very low cost cameras made in India and so we are able to do handheld cameras and so on. So we are able to do that very well.

V. Mohan: 21:11

Now, outside our systems, I won't say it's great there are some clinics where it is done, but by and large I don't think we are doing a good job of thing. It's a lot more needs to be, because what happens is they the patients feel that they don't have symptoms. Now symptoms come very late. You have to have a macular edema or a proliferative retinopathy which is bled, and a vitreous hemorrhage. Only then you get symptoms. Then it's too late. You're going to lose your vision. So that's when they go rushing to the ophthalmologist. In fact we had a problem because my wife was an ophthalmologist.

V. Mohan: 21:50

So when we first started we said as part of the routine, just like checking the blood pressure, we had to check the eyes. People would get angry. They would say we came to you for diabetes, not for an eye check. I've already got my glasses, so what are you trying to do? You're trying to make money. We said no, this is part of diabetes checkup. Take it or leave it. We have to see your eye, just like. Then. Don't tell me not to check your blood pressure, not to check your feet, not to check it. You can't separate it out. This is part of diabetes package. You have to do it. So it took a lot of initial education to do that, but then people started realizing the value of that because we'll pick up some retinopathy and then we can give them laser treatment or screening and then they are very happy. So eventually they started recognizing it's a one-stop shop kind of a thing. You come in and get everything done in one place, and that became our unique selling proposition.

David: 22:40

Moen in this country we find that we have pretty good rates for screening but poor rates for follow-through. After someone is told they need laser therapy, often they don't go. Do you have that situation too?

V. Mohan: 22:56

They will take a second opinion and a third opinion because they want to make sure that it's really needed, because very often commercialization, people do procedures not needed and so on. So they will always check with their family doctor or with somebody else. But if we teach them, we show them pictures, we'll show them a retina and say this is a normal retina, this is what you have. Look at the blood there. This can affect your macula, your vision can go. So this needs to be done. So I think about 80% of people will. Once you teach them, they will come for the follow-up. But some people, of course, not everybody, you can get to think but generally the follow-up within our system, within our clinics, it is very good. But the problem is to find the people, screen them. But one of the things which we are disappointed about is that they don't come for the next year's checkup.

V. Mohan: 23:54

And you know I have a lot of friends who walk with me, you know, every morning and some of them have diabetes and I'll tell them hey, I haven't seen you for a year, I'm fine, doc, I have no problem. So when I have a problem I'll come. I said no, you should come and you don't have a problem. You know we should see you when you don't have any symptoms. So to get that message through it's not easy. That it's not when you have a problem that you go. You have a foot ulcer and it's turning gangrenous and then you go. It's too late. You should prevent that gangrene. You should prevent that foot cancer. So that's what it's all about.

David: 24:30

Mohan, you're treating diabetes on such a large scale, the number of people and the number of services that you provide, it's no wonder that you received two very prestigious awards from the American Diabetes Association the Rifkin International Service Award and then last year, the Kelly West Award for Epidemiology. Very few people will ever get one award, but two is essentially unheard of except you, so I'd like to thank you very much for spending this time with us and updating us on diabetes, especially diabetes in India. This has been very fascinating. I hope to continue working with you. We've got a project now and we'll find other projects in the future. So, on behalf of Dr Kerr, I want to thank you, and thank you for being on this interview and thank the listeners. Diabetes Technology Report is available at the Apple Store and on Spotify and we look forward to our next session and until then, goodbye.

V. Mohan: 25:31

Thank you, dr Klonoff. Thank you, dr Kerr. It's a great pleasure to our next session and until then, goodbye. Thank you, dr Klonoff. Thank you, dr Kerr, it's a great pleasure to be with you, thank you.