Brigid: Good morning everyone and good evening! I’m Brigid-

Sam: And I’m Sam, and we are your hosts for this installment of Coffee and Conversations!

[00:10] Brigid: Welcome! Coffee and Conversations is a monthly interactive sit-down event hosted by CSOFT. Every month we’ll feature honorary guests and experts from a diverse range of industries and fields to lightly discuss topical themes important to the life sciences and language services industry. So, sit down and relax, pour yourself a coffee or a hot drink and enjoy!

Brigid: This month, we are joined by our special guest, Dr. George King from Joslin Diabetes Center to discuss patient diversity and its role in patient centric care, specifically regarding the care and treatment of patients with diabetes.

[00:51] Sam: Great, thank you very much, Brigid. To begin, patient centricity is a concept that has been taking the life sciences sector by storm for the past several years. Basically, this concept means designing treatments and clinical trials that are centered around the patient. Already, it is a well-established fact that different ethnic groups have different reactions to medications. In addition, different ethnic groups, may be affected by diseases differently. Therefore, to develop truly patient-centric care solutions, clinical trials and research must be conducted on a wide variety of diverse ethnicities, genders, genetic backgrounds, and lifestyles.

[01:29] Brigid: Embodying patient diversity is vital to providing patient centric solutions for major global diseases such as diabetes. It is predicted that by 2045, the number of people with diabetes will increase by over 50% in the Middle East, Africa, and in South and East Asia. In fact, by 2045, China, Pakistan, and India will be the top 3 countries with the highest number of adults with diabetes. Because these ethnic minorities usually develop diabetes at different BMIs and react differently to diabetes treatments, incorporating patient diversity in clinical trials is essential for developing patient centric solutions for diabetes treatment in the future.

 
[02:13] Sam: Thanks Brigid, that's really fascinating. Ok, so now let’s introduce today's guests, Dr. George King and Ms. Shunee Yee.

[02:20] Sam: Dr. George L. King is the Chief Scientific Officer at the Joslin Diabetes Center, Founder and Director of the Asian American Diabetes Initiative or AADI, and Professor of Medicine and Ophthalmology at Harvard Medical School. Dr. King founded the Asian American Diabetes Initiative (AADI) in 2000 to research diabetes’ impact on Asian Americans and provide them with culturally appropriate diabetes education materials, outreach programs, and clinical treatment programs. Dr. King has won numerous awards for his research, such as the Champalimaud Award, the most prestigious award for vision research in the world. Dr King’s pivotal research led to legislative change pertaining to the screening of Asian Americans for diabetes at a Body Mass Index (BMI) of 23, which is a lower BMI screening than for the general population.

Welcome, Dr. King! We’re so glad you can join us today!

[03:10] Brigid: Shunee Yee is the President and CEO of CSOFT International and CSOFT Health Sciences, which provides end-to-end medical translation services for all phases of the product lifecycle, as well as market access consulting, medical writing, and CTD/eCTD submissions with the FDA, EMA, and NMPA. Shunee is passionate about education and has contributed to Michelle Obama’s Let Girls Learn Initiative, the Hopkins-Nanjing Center for Chinese and American Studies, and the Dexter Southfield School. Recently appointed the co-chair of A Taste of Ginger, an initiative by the Joslin Diabetes Center, Shunee continues to work towards promoting health equity across the world.

Welcome Shunee and thank you for joining us!

 Shunee and Dr. King, the floor is yours!

[04:00]Shunee: Thank you Brigid, thank you Sam. Good morning Dr. King! How are you today? 

Dr. King: Good morning - thank you for having me! 

[04:10] Shunee: It looks like another beautiful day in Boston, and we're so excited having you join us today! So Dr. King, so my first question, the pandemic has affected almost every country in the world and has changed the way we access healthcare. People with preexisting conditions, such as diabetes, has increased the risk of severe complications. There are over 422 million people across the globe who have been diagnosed with diabetes, including 34 million in the United States. So, Dr. King, can you give us some insights how diabetes has been managed during the pandemic at Joslin Center, what are the challenges to your diabetes patients to care for themselves during this crisis?  

[05:02] Dr. King: Thank you Shunee for having me. So, it is true that diabetes has dramatically changed. When the economy, and the government, and all the healthcare pretty much, on an outpatient-basis shut down about a year ago, with the exception of caring for people with COVD-19 infection, diabetes care also slowed down, and we pretty much convert 90% to telehealth, either with video or with telephone connections. The care continued; however, it has not been optimal due to the fact that for us to care for people with diabetes, which have complications such as heart disease, kidney disease, eye disease, leg problems, feet problems, we need really to be able to see them and have lab tests and various measurements for them at each visit. So even though we could see and talk to them we cannot actually listen to their chest, listen to their heart. Most of the time, we cannot have lab tests done. So, I think the advances in medical care if we want to switch to telehealth has to improve in those aspects, for example, everybody should have blood pressure measurements, somehow, we have to listen to their chest or listen to their heart. We need to have lab tests done on their kidney function. How are we going to examine their eyes? Because it is a major cause of blindness in the world, diabetes is. So that has been a major obstacle. Now, in the last 6 months we have slowly come back to the clinic. Now what telehealth can do, is allow us to see patients more often perhaps in between our usual 4-5 months per visit, for the interval between each visits with patients. Therefore, potentially we can actually enhance their care by a hybrid of telehealth and in-person visit. I hope that provides some information...

[07:30] Shunee: Yes, Dr. King, what are the most challenging things, you know during pandemic, have to care for themselves, and do they, I think...maintaining a healthy kind of living style is important. So what are the things particularly in Joslin Center are providing guidance on during this period of time to your patients?

[07:54] Dr. King: Well, it’s a huge amount of challenge for people with diabetes as you may know that if you have diabetes, the chances of having severe COVID, either being hospitalized or intubated, or death, is actually at least two, if not, three- or fourfold higher. So, it is incredibly important to have the vaccine, if you have diabetes, or do protective mechanisms, wear a mask, avoid crowds, in order to avoid getting infected. Now what can you do to improve those odds?  You obviously need to control your diabetes better. So, if your glucose is high, or A1C, which is a measurement of glycemic glucose control over the last 3 months needs to be low, like around seven. That has clearly been shown to decrease the severity of COVID if you have diabetes. In addition, if you can lose weight, this is another important factor that has shown to decrease the intensity of COVID infection. So, if you are overweight, you need to lose about 5% of your weight. Other things you could do.... now if you have diabetes, one thing during COVID, you have to be careful of, is actually to have ability to have your medications. There's been some difficulty in accessing your healthcare providers to get a prescription in addition to get the medication from the pharmacy. So, make sure you have three to four month supplies of your medication in case there’s some interruption of supply. And also the care for how to measure your glucose and so forth. And lastly, certainly nutrition has been very very important. So, eating the correct diet for people with diabetes is critical. So make sure you have good access to food, to fresh food especially. And so, these something you can do for yourself in order to manage your diabetes and prevent the inflection with COVID.
 
[10:14] Shunee: Thank you, thank you Dr. King. So I have a data that, Brigid or Sam can you put on the screen. So this is a map provided by IDF, International Diabetes Federation, and it provides the latest figures, information and projections on diabetes worldwide. It is estimated that by 2045, there will be over 700 million diabetes, or prediabetes, patients worldwide, and see as Brigid indicated at the beginning. So there is a rising rate across the globe, particularly in Africa, Middle East, Southeast Asia. One in two Asian Americans will develop diabetes or prediabetes in their lifetime, and 51% of them are currently undiagnosed. So Dr. King, you, I know in the upcoming Xtalk, you’re going to talk about health disparities. So the disadvantage differences in health are either due to health policy or science. And the conceptual model of health disparities in clinical trials is related to science and largely due to lack of information. So can disparities in clinical trials be overcome? And why did you initiate AADI some 21 years ago? What progress has been made? What is unique about Joslin's Asian clinic? 

[11:52] Dr. King: Well that is a very important question that you have asked and is a huge topic. So the topic of disparity, of development of diabetes in different ethnic groups and their care is really hard to cover in the next five minutes. So, let me just cover a narrow part of it after making a couple of broad statements. Diabetes, the prevalence of diabetes is as you said, is increasing rapidly. So around the world, in Asia, it's really the epicenter, so to speak, of diabetes. China alone, you have 12% of people over age of 20 who have diabetes and similarly in India. So each of those countries alone, you have about 150 million people, so that alone is a huge number of people. Then the different story with Asian Americans, we are certainly a minority in the United States, but Asians with diabetes are a majority for the world. Why is that? Well, we don't really know the Asians have so much diabetes, and they're different type of Asians, there are East Asians, South Asians, and Southeast Asians, and, you know many different countries and cultures. But one commonality amongst all the Asians is that we develop diabetes at very low body weight, and this is what got me started, long time ago, is in my family we are not overweight, yet many of us have diabetes, or with a BMI (body mass index) of only 23. So in other ethnic groups, the risk of diabetes actually doesn't increase until BMI of 27. So one disparity is biology, why is it that Asians from all countries seems like have increased rate of diabetes and low body weight? So that is one reason why we started the AADI. The second reason is, we noticed Asian Americans were not being diagnosed with diabetes because we look thin. Second, the care for Asian Americans for diabetes was not good. So we started AADI in order to improve the care of diabetes in Asian Americans and we think that these findings can also be applicable in Asians in Asia. Now you asked a question of clinical studies, it is very important to participate in clinical studies, that is how we find out whether the medication works or not. It is true that in different ethnic groups and racial backgrounds the medication can work at a lower dose, or they work better, or they don't work better, and that's been shown over and over again. Perhaps due to genetic differences, or actually due to our lifestyle. For example, there are diabetes drugs that work very well in Asia, but they don't work that well in the United States, even if you are Asian or Asian American. So it is very important to test medications in different ethnic groups. Now, this is another issue with disparity with Asian Americans because the FDA wants the medications to be approved in the United States to reflect the population of the US, so Asian Americans are only 5-7% of the US population, so therefore, 5-7% of the people in clinical trials to be approved by the FDA have to be Asian. Now many Asian Americans really do not want to participate in clinical trials for multiple reasons, we're the worst group in the country of any ethnic group to volunteer for clinical trials so therefore most of the clinical trials conducted by companies especially, use Asians in Asia mostly coming from China, India and maybe Philippines. So they may not reflect the Asian Americans in that ethnic background. Secondly, the food and environment in Asia is very different from US, so using the study population of Asians from Asia which is 90% of all Asian studies, will not reflect the Asian American responses to medications. So these are some of the reasons why there is a disparity in testing and that is why it is so important for a drug to be approved or a device to be approved, it needs to be studied in the population or the country where it will be sold or be approved. I hope that answers a little bit of your question. 
 
[17:03] Shunee: Thank you so much, Dr. King. So, this is definitely, I am sure in the Xtalks we look forward to talking more about it. So I do have one other questions, I understand almost one in two, particularly Asian Americans, and all the population in general undiagnosed, have prediabetes. So you know, encouraging particular certain ethnic groups to participate in the clinical trials is so important. My question is, what are the most, let's say, two to three most practical tips you could offer people to either avoid getting diabetes or prevent it or if you have it control it or even reverse it? 

[18:03] Dr. King: Yes, that is an incredibly important question. Diabetes in general can be prevented, even reversed, this what we call Type 2 diabetes. So diabetes are usually in two major groups. One is Type 1 diabetes, that occurs mainly in children that your body's autoimmune destruction of your body in the pancreas, cells in the pancreas, is making insulin. Those are difficult to control and to avoid. However, most people have what is called, Type 2 diabetes. Type 2 diabetes is also genetically related but fortunately we have multiple ways to delay it, prevent it or even reverse it. So, most Asians and Asian Americans, 95% have what is called Type 2 diabetes. So one usual way is that you need to control your weight, as we mentioned before, your Body Mass Index should be below 23. Second is increase activity. For some reason, Asians and Asian Americans don't like to exercise. So we really need to increase our activity. If you don't want to so-called exercise, you could increase activity, you know, walk to your car, walk up the stairs in the office, don't sit there all the time, make sure every 30 minutes to an hour you get up and walk around for 5 minutes. We recommend everyone to have smart phones to make sure you accumulate 5000-70000 steps a day. Those are the simple things you can do. Third part, is also incredibly important that we found recently, is sleeping. Sleeping is very very important. You need to sleep between 6-8 hours a day. If you have too little sleep, you will have an increased risk of diabetes, if you sleep too much you have an increased risk of diabetes. And again, for reasons not clear, Asians and Asian Americans sleep the least of all the ethnic groups, so we really need to sleep about 6 hours. So those are the three most important. Obviously food, the type of food you eat, fresh vegetables would be wonderful. Traditional Asian diet is what you want. Traditional Asian diet is about 60-70% carbohydrate except its vegetable carbohydrate, complex carbohydrate. So not white rice, or baos (steamed bun), or mian or noodles, but brown rice, vegetables and don't overcook your vegetables. So a traditional Asian diet can actually prevent, even reverse your diabetes. So these are some of the things we can do to prevent, delay, or even reverse our diabetes. 

[21:07] Shunee: Thank you Dr. King. So just to summarize a bit: sounds like we all have to control our weight, and be more active and eat fresh food, sleep well. So, there is a book, Brigid if you could show that, just a slide called “Reset”. Written by Dr. King 4-5 years ago, if any of you are interested, perhaps if you or your family, loved ones, or colleague have diabetes. So this is a great book and you could get it from Amazon. I think Brigid and Sam, that’s the question from me. Let me give it back to you and we could get questions from audience.  Thank you! Thank you, Dr. King.

[21:56] Brigid: Let us bring up some questions that people have asked ahead of time. So, we have one question, Dr. King, that people asked prior to today'. And the first one is: Are people with Type 2 diabetes more at risk of becoming hospitalized with COVID-19 than people with Type 1 diabetes, or is there a difference? 

Dr. King: No, the data analysis is very clear that if you have any form of diabetes, you have an increased risk for hospitalization and severity of COVID. So, Type 1, Type 2, or any other unusual form of diabetes.
 
[22:36]Sam: Another question that we got in, this is also related to COVID and diabetes, so, how would COVID impact someone differently that had diabetes than a person without diabetes? 

[22:49] Dr. King: Well, I am not sure there is an obvious difference but, the reason that people with diabetes have so much problems, is that one, people with diabetes cannot fight infections well, so any type of infection, including COVID, you have a more sever course. Another reason people with diabetes have a problem is lungs. People with diabetes, especially with type 2, have breathing problems, lung problems, pulmonary problems. Since COVID is a pulmonary infection, it is more severe. Another reason is people with diabetes have a lot more kidney, heart, and blood vessel problems. And since those impact greatest in people with COVID, with strokes and so forth, so those are the three major reasons for the severity of COVID in people with diabetes. 

[23:45] Brigid: Great! And then, we have one more. What have been some challenges in bringing new diabetes therapies from the Joslin Center's groundbreaking clinical research into reality, both before and after the pandemic? 

[24:02] Dr. King: Well, that is a huge question! Well during COVID, obviously it is huge because our clinical trial studies are put on hold for all new studies, so we could only bring people in for ongoing studies. So, that had just started. So, that is a major issue.  Before study, there are a lot of good ideas, but the impediment are one, obviously, funding. Funding is a difficult, clinical trials are expensive to do. To carry out the study, we need patients, now fortunately at Joslin we have lots of diabetic patients. And in addition, they are very loyal. So usually, recruitment is only 10-15% successful for a number of patients, but at Joslin, we could easily get 30-50%. So along those lines, we have an advantage. So those are some of the major advantages and difficulties of clinical trials. 

[25:11] Brigid: Thank you, once again Dr. King. Unfortunately, those are all the questions that we have time for today. On behalf of CSOFT Health Sciences, we sincerely thank Dr. King for his time, as well as Shunee Yee for a fascinating and insightful discussion about patient diversity and diabetes. For everyone who would like to hear Dr. King speak a little bit more on patient diversity and the Joslin Center's research, we highly encourage you to join us on May 7 at 12pm EST for our linguistic validation, facilitating patient diversity in clinical trials webinar with Xtalks and you can hear more from Dr. George King there. Additionally, of course we have to mention A Taste of Ginger on Sunday, May 16th, 2021, from 7-8pm EST. To purchase tickets or if you are interested in donating, please visit, www.joslin.org/ginger. We would love to see you there! If you can’t make it, the Joslin Center would definitely appreciate any sort of contribution. 
 

Brigid: Thank you for tuning in to this month’s Coffee and Conversations. Next month we will be focusing on the importance of mental health awareness and supporting each other during this time. 

[26:31] Sam: And to everyone attending online wherever you are in the world, we really hope you enjoyed this installment of Coffee and Conversations, and we look forward to seeing you next time – have a good evening, goodnight and good morning and good bye everybody!
 
 Brigid: Thank you!
 
 Shunee: Thank you! Thank you, Dr. King!

 [26:48] Brigid: For more information on CSOFT’s language translation services, visit csoftintl.com

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