April 4, 2025 • 25 mins
An interview on a life in diabetes care with Dr. V. Mohan, MD, PhD, DSc, Chairman and Chief of Diabetology at Dr. Mohan’s Diabetes Specialities Centre at Chennai in South India
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David (00:16):
Hello, welcome to Diabetes Technology Report.
I'm David Klonoff.
I'm an endocrinologist atSutter Health in San Mateo,
california.
We have a very special guesttoday, who's approximately 12
time hours away from where I am,and my colleague, interviewer
Dr David Kerr, will introducehim.
David Kerr (00:37):
Thanks, david, and hello everyone.
I'm David Kerr, again speakingto you from Santa Barbara,
california.
It is a real pleasure today wehave the doctor who is the face
of diabetes in a particular partof the world in India.
Dr Mohan, welcome.
It's a real honour to have youon board.
I'm always interested howpeople end up spending their
(01:02):
life being involved in diabetesand diabetes technology, so can
you just give me a briefthumbnail of how you've ended up
being a superstar in diabetestechnology?
V. Mohan (01:13):
Thank you both the Davids, for having me on the
show.
Mine is a very peculiar storywhich probably very few people
would have had the opportunityto even tell the story.
So I wanted to be.
I never wanted to be a doctorin the first place, I wanted to
be a poet, a writer, whichexplains why I write so much.
And my father, my late father,was like the Jocelyn of India,
(01:37):
professor Vishwanathan, and hestarted the first diabetic
clinic in India, actually in mycity, in Chennai.
Halfway through his career hehad to leave the government for
reasons we won't go into, but hehad to leave.
And so he just summoned me andhe said you're my eldest son,
and what are your plans to do?
(01:58):
So I said I want to be aprofessor of English and write
poetry and books.
And he said no, you switch overto scientific writing, you
become a doctor, and I want youto help me.
And of course I was auniversity topper, so there's no
problem getting into a medicalschool.
In fact I got into four medicalschools.
So he said that's not an issue,you just have to make up your
(02:19):
mind to help me and work indiabetes with me.
So I joined to.
To cut a long story short.
I thought it's not a bad ideato switch to scientific writing.
So I joined him when I was 18years old.
So I joined in medical school.
So we go to medical school veryearly here, not like in the US.
You finish a degree and thenyou go, so here, straight from
school, you go to medicalcollege.
(02:40):
So I was 18 and I was inmedical college.
So I told my father look, ifyou're, if you have asked me to
do medicine to help you to dodiabetes, what's the point in
waiting 10, 15 years for me tograduate, finish postgraduation,
specialize.
You'll be so old and thenthere's no point in in my
helping you.
So let me start today.
(03:00):
I mean, I can start workingwith you today.
So while I was doing medicine onone side, the medicine was just
to get my degree and so on Istarted working on diabetes
straight on at the age of 18.
So he had a lot of medicalrecords, even in his private
practice, which he had not builtup, but he was a meticulous
record keeper, so he had allrecords and so on.
(03:21):
So I said, why not startanalyzing these records and
start writing something?
And so he said yeah.
So then I said no, that's notenough, you have to build a
small lab for me.
So we had a garage, so weconverted that garage into a lab
and bought some mice and rats.
And here I am doing anatomy onone side anatomy, physiology,
(03:42):
biochemistry in the medicalcollege and here doing animal
experiments trying to producediabetes and rats and mice and
so on.
So he hired a PhD and I startedworking with him half day and
half day medicine, half dayresearch and started publishing
when I was 18, 19, 20.
I already started publishing toan extent that my teachers
started getting jealous of me.
(04:03):
So they would say what's thisguy?
He's not even finished hismedicine 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 theexams and so on.
But the good news was that I gotright into diabetes.
It was good and bad, becauseyou know, when I go to medicine
and I study something likeanatomy, some insertion of some
(04:26):
muscle here and something,what's this to do with diabetes?
I mean, why am I studying allthis rubbish?
You know, my aim is only to dodiabetes.
So I went through medicine witha complete bias, but then
that's a negative side.
The positive side is that isreading diabetes journals and
everything every day.
You know I would get diabetescare and diabetes and all the
(04:47):
journals I'd read.
It cover to cover all thediabetes books, jocelyn's
textbook Everything I wasreading when I was 18, 19, 20
years old.
So that's how I started workingon diabetes and for 20 years I
worked with my father and thenat the end of 20 years I told my
father you know, we have toexpand and go on and now I want
(05:07):
to build this big researchcenter.
And he was growing old by thattime because he already finished
one innings in the government20 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 andat the age of 38, I've only
finished 20 years in diabetes.
You know, now I want to reallyspeed up and you're slowing me
(05:28):
down.
So he said okay, in that case,you leave.
So I said okay, I leave, youset up a center for me and I
leave.
He said I'm setting up nothingfor you.
You take the stethoscope andleave.
So I took my stethoscope.
I had no money, I had nothingand I had to start my second.
Of course, my wife is anophthalmologist, which is a
(05:50):
great advantage.
She had all her equipment andlaser and we already had a
diabetic retinopathy unit eventhen.
So I said okay, let's go andstart from.
So we took a couple of rooms ina rented place and the rest is
history.
From there we grew and grew andgrew and grew and I can't tell
you the number of patients, whomwe have now 665,000.
My goodness, yeah, close to amillion patients with diabetes.
(06:14):
We have 50 centers now, 50branches in 32 cities.
More than 100 diabetologistswork for me and my next
generation.
My daughter and son-in-law havealso joined, and now my next
generation, my grandson, isabout to join medicine next year
and my daughter.
When I started at least when Iwas 18, doing research on
(06:36):
diabetes, she started when shewas 12 or something, and so she,
when she was in school, shestarted.
One of my teachers jokinglyasked me when did she first get
into diabetes?
So I said you know, when shewas three years old, she used to
operate my wife's slides and myslides.
You know the old projectors sheused to project, and so she
(06:56):
knew diabetic retinopathy whenshe was three years old.
So he said he was so jealous ofme that he said you wasted
three years of her life.
You should have started whenshe was born.
So I said, okay, I'll do thatfor my grandson.
So when my grandson was takenout of the labor room and they
brought him to me like thatthere's your grandson.
You and my daughter had notseen.
So the first word he heard wasdiabetes.
(07:18):
So the first word in his life heheard was diabetes.
David Kerr (07:22):
This is what a story .
This is terrific for the futureof diabetes research and
innovation.
For sure.
There's a whole dynasty there.
So, coming up to today from adiabetes technology perspective,
what's your kind of main areaof interest at the moment?
V. Mohan (07:41):
Yeah, two areas.
One is precision diagnosis ofdiabetes using technology, and
right now, with Dr Klonoff, weare involved in a project trying
to separate out, type out whichtype of diabetes, using
electronic records and using AIand machine learning to
understand.
That's one part of thetechnology.
The other part of thetechnology is using technology
(08:17):
itself in the treatment.
So continuous glucosemonitoring and insulin pumps and
automated insulin deliverysystems, so all of those we
adapt very quickly into theclinic and then start using that
and also start collecting dataon that.
So we were the first tointroduce CGM, first to
(08:37):
introduce pumps, first tointroduce auto.
Now the latest thing we havejust done, just two days ago.
What we have done is that we, ofcourse, in all our centers we
have retinal cameras.
Across India, all the centerswe have retinal cameras, but we
used to have ophthalmologistsreading all of them.
Now we've introduced AI.
So some of those centers don'tneed any ophthalmologist
(09:00):
oversight at all.
So the retinal picture, thecamera itself, has an AI built
in and the report comes.
It's normal there is diabeticretinopathy, there's more severe
retinopathy which needs areferral, all that the AI is
able to say.
So that's how we use technology.
David (09:17):
Mohan, you're in India, which has a very large number of
people with diabetes.
How many people do you think inIndia have diabetes, and why is
it so common in your country?
V. Mohan (09:29):
Yeah, so we have done the ICMR in-diab study and in
fact the methodology of the ICMRin-diab study was published in
the Journal of Diabetes Scienceand Technology many years ago by
Dr Klonoff and so that studyhas now been completed.
We have completed the wholecountry, every state in the
country representative sample.
(09:50):
So based on that, we have 101million people with diabetes in
India and 136 million peoplewith pre-diabetes in India.
So put both together it's 237million people with either
diabetes or pre-diabetes.
To answer your question why wehave so many people with
diabetes despite not having thekind of obesity rates that you
(10:12):
have.
So we call the Asian Indianphenotype and this was the
lecture I gave at the ADA forthe Kelly West Award last year
we call it as a thin fat Indian.
So the BMI may be low, a BMI maybe only 23, 24, 25,.
But we have fat, we havevisceral fat and this is because
(10:34):
subcutaneous stores ofadiposity, of adipose tissue, is
very limited.
So very quickly the fat spillsover into the visceral, then
goes into the liver, producesinsulin resistance.
The fat goes into the pancreas,so insulin secretion also is
affected.
So we have thin Indians whohave a lot of insulin secretory
(10:56):
defect and this seems to havesome kind of a genetic basis as
well, but largely driven by thehigh carbohydrate diet that we
take A lot of rice, so rice andwheat is what is a staple food
in our country and this seems tobe putting a big load on the
pancreas, drawing out more andmore insulin and very quickly
(11:18):
they exhaust and developdiabetes.
So on a background of geneticfactors, the very high carb load
plus, there's not enoughphysical activity, so obesity
comes in and then the visceraladiposity comes in.
So that's the main reason whywe have so much of diabetes.
David (11:35):
Mohan, I visited you 13 years ago and saw your setup
both in town and on theoutskirts of town, and I learned
about pancreatic diabetes there.
We don't see that in the US.
I wonder if you could explainto our listeners.
I'll bet many of them don'tknow what it is.
V. Mohan (11:55):
Yeah, so this is a form of diabetes, secondary form
of diabetes, secondary tochronic pancreatitis.
Now when you think of chronicpancreatitis in the West it is
usually alcoholic chronicpancreatitis where you get small
stones, small speckled kind ofstones, mainly in the tail
region of the pancreas and notinside the duct.
(12:15):
These are huge stones.
They block the pancreatic duct,mostly from the head region of
the pancreas.
They block and therefore thepancreatic juice cannot flow and
therefore it leads topancreatitis, stone formation
because the juice juice, theflow becomes obstructed, it
becomes sluggish.
(12:36):
The mucus plugs get depositedaround that, calcium starts
forming and so the big stonesform and this can even lead to
malignancy.
The the prevalence of pancreaticmalignancy in those with this
pancreatic forms.
We call it as fibrocalculuspancreatic diabetes.
So there is calculus, there'salso fibrosis, so the gland gets
(12:57):
shrunken, the pancreas becomesmuch shrunken, like a cirrhosis
of the pancreas, and then theydevelop a lot of them develop
pancreatic cancer and they havesevere abdominal pain because of
the stones and then it leads todiabetes stunting.
And then they also havemalnutrition because they have
diarrhea and oily stools,steatoria, and so it's a very
(13:20):
peculiar form of diabetes.
It was largely due to there aresome genetic factors, the
sphincter gene and so onassociated with it, but largely
due to some micronutrientdeficiencies.
Today it's kind of going downbecause the nutrition of people
is improving.
We occasionally see this typeof diabetes, but not as much as
I used to see 20 years ago, andso the incidence has kind of
(13:44):
gone down.
Alcoholic pancreatitis is nowincreasing because people can
now afford drinking alcohol, andso alcoholic pancreatitis
slowly replacing this tropicalform of pancreatitis.
David Kerr (13:56):
Dr Mohan.
I'm also intrigued from a type1 diabetes perspective.
In the United States we'reseeing a crossover.
It was traditionally a whiteperson's disease.
It's now increasing in theblack community, the Hispanic
community.
What's happening in India withtype 1 diabetes?
V. Mohan (14:13):
So we have always had a fair proportion of type 1,
unlike China where they stillsay that type 1 diabetes is very
rare.
So for that reason because it'sdefinitely lower than, say,
finland or Scandinavia, wherethe highest prevalence of as you
go away from the equator tomore temperate places, we don't
(14:37):
know if it's due to viruses orbecause autoimmunity is more
there Definitely if you go toScandinavia, denmark, sweden,
norway, finland particularly,the prevalence of type 1
diabetes is very high.
So it's not as high as therebut certainly as high as the
rest of Europe.
For example, you take France orSpain or England, we don't have
much difference in theprevalence of type 1 diabetes.
(14:59):
Now, a lot of type 1 diabeteswe may be missing because the
children may be dying.
In a rural area, some remoteplace, child goes into coma,
diabetic ketosis and coma.
They'll think it's meningitisor thinks that something else.
They don't check the bloodsugar.
So we could still be losingsome children.
The prevalence of type 1diabetes is not low.
(15:21):
The estimated numbers,according to the International
Diabetes Federation it was250,000 children, but a more
recent report by the JDRF nowcalled Breakthrough Type 1D,
they have put the number as850,000 children with type 1
diabetes, which is more than theUS actually in terms of our
(15:41):
population.
So we actually have the highestnumber of type 1, followed by
US and then Brazil, and fourthonly is China.
Because China, somehow theystill keep saying that type 1 is
less common in their country.
So it's not uncommon to havechildren.
It's not an epidemic like thetype 2.
Type 2 in the young is actuallyrising much faster because of
(16:05):
obesity, and that's well.
Even in the US, the Hispanicpopulation, the Pacific
Islanders and Asian, indian,south Asians we have higher
prevalence of type 2 diabetesthan, say, the white European
population.
But type 1, of course you havehigher prevalence rate and
because of the sheer populationwe have large numbers of
(16:26):
children.
David Kerr (16:27):
And are you?
In the US, there's a lot ofdiscussion about screening for
type 1 diabetes.
You know, is that somethingthat 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 todayand it'll be normal.
How do you know that threemonths 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 isthere?
Obesity is there?
Acanthosis, nigricans is there?
(16:55):
We'll screen for type 2 becausethat's common enough.
Type 1 is like 1 in 100,000children.
So you'll have to screen100,000 children to pick up that
one child and the child willanyway become symptomatic within
give it three, four weeks andthey'll become symptomatic and
they'll go rush to the hospital.
If they don't die and they'repicked up, then it's good.
(17:16):
So screening as such we are notable to do.
The other thing we're not ableto do is to screen for
antibodies in the generalpopulation.
We are beginning to screen thesiblings of type 1 because we
think we'll pick them up morethere.
(17:37):
But if you start screening thewhole population, it's too many
millions and millions ofchildren we have to screen.
The cost of screening is justtoo high to pick up.
And then the other problem isokay, if they have three
antibody positive, we'll have togive them teplizumab, which is
too expensive.
It's not available in India, sonow we are seeing whether
verapamil or something else canbe given.
So as long as we don't have adrug to give them if we find
them antibody positive, it's notethical to screen, because you
(18:01):
screen them, tell them you'regoing 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 theschool and just check for the
(18:21):
child and if the child hasraised blood glucose,
immediately refer them to anearest hospital.
That's what we are trying to do.
It's not possible to screen allchildren.
David (18:32):
Mohan, with the large number of patients that you have
, what type of an electronichealth 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 plus25, 34 years now, when I've run
these clinics, we have hadelectronic records right from
day one.
That's been a great blessingfor us.
So the 660,000 patients that Itold you, they're all on
(19:02):
electronic records, not justonce, but every time they come
we have the electronic records.
So for some people you have 30a 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'relooking at this data on type 1,
type 2 for the collaborationthat we're doing.
So we have data mining peoplewho we tell them what we need
(19:24):
and they can go into theelectronic records, set the
filters and take out whateverdata we want.
So the tremendous number ofpublications that we have had is
partly due to this richdatabase.
So if you think of an idea, forexample somebody came.
Another area I work on isgestational diabetes.
So somebody came to UK and saidyou know we are interested to
(19:45):
look at recurrent GDM, not justGDM1s, but those who had, say,
three times GDM.
Compare them with those who hadonly once GDM, are they
different or not?
So we just have to put inrecurrent GDM and it will come
out.
All the data will come out.
So that's a tremendous resourcethat we have no-transcript.
David Kerr (20:07):
Dr Mohan, one of the challenges in the United States
is ensuring that people withdiabetes have regular screening,
but the screening rates youmentioned retinopathy screening,
the screening rates forretinopathy screening and food
screening are actually not wherethey need to be.
I mean in India.
Is it the same challenge or areyou more successful, less
successful?
V. Mohan (20:33):
we're successful as far as our clinics are concerned
, the whole network across these32 cities.
We are driven by protocols, sowe have standard operating
procedures.
Every year the medical recordwill tell us it's time for the
eye checkup.
A pop-up will come saying aprompt, saying it's now due.
At this visit you should check.
Suppose a lady is pregnant.
It'll say please don't do anx-ray.
The lady is pregnant.
(20:54):
So all this is kind of built in.
So because of that, ourscreening rates are very good.
And today we have this AIsystems.
We have very low cost camerasmade in India and so we are able
to do handheld cameras and soon.
So we are able to do that verywell.
Now, outside our systems, Iwon't say it's great there are
(21:16):
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'thave symptoms.
Now symptoms come very late.
You have to have a macularedema or a proliferative
(21:37):
retinopathy which is bled, and avitreous hemorrhage.
Only then you get symptoms.
Then it's too late.
You're going to lose yourvision.
So that's when they go rushingto the ophthalmologist.
In fact we had a problembecause my wife was an
ophthalmologist.
So when we first started we saidas 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 youfor diabetes, not for an eye
(21:58):
check.
I've already got my glasses, sowhat are you trying to do?
You're trying to make money.
We said no, this is part ofdiabetes checkup.
Take it or leave it.
We have to see your eye, justlike.
Then.
Don't tell me not to check yourblood pressure, not to check
your feet, not to check it.
You can't separate it out.
(22:18):
This is part of diabetespackage.
You have to do it.
So it took a lot of initialeducation to do that, but then
people started realizing thevalue of that because we'll pick
up some retinopathy and then wecan give them laser treatment
or screening and then they arevery happy.
So eventually they startedrecognizing it's a one-stop shop
kind of a thing.
You come in and get everythingdone in one place, and that
became our unique sellingproposition.
David (22:40):
Moen in this country we find that we have pretty good
rates for screening but poorrates for follow-through.
After someone is told they needlaser 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 tomake sure that it's really
needed, because very oftencommercialization, people do
procedures not needed and so on.
So they will always check withtheir family doctor or with
somebody else.
But if we teach them, we showthem pictures, we'll show them a
(23:18):
retina and say this is a normalretina, 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 peoplewill.
Once you teach them, they willcome for the follow-up.
But some people, of course, noteverybody, you can get to think
(23:39):
but generally the follow-upwithin our system, within our
clinics, it is very good.
But the problem is to find thepeople, screen them.
But one of the things which weare disappointed about is that
they don't come for the nextyear's checkup.
And you know I have a lot offriends who walk with me, you
know, every morning and some ofthem have diabetes and I'll tell
(24:02):
them hey, I haven't seen youfor a year, I'm fine, doc, I
have no problem.
So when I have a problem I'llcome.
I said no, you should come andyou don't have a problem.
You know we should see you whenyou don't have any symptoms.
So to get that message throughit's not easy.
That it's not when you have aproblem that you go.
You have a foot ulcer and it'sturning gangrenous and then you
(24:23):
go.
It's too late.
You should prevent thatgangrene.
You should prevent that footcancer.
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 thenumber of services that you
provide, it's no wonder that youreceived two very prestigious
awards from the AmericanDiabetes Association the Rifkin
International Service Award andthen last year, the Kelly West
Award for Epidemiology.
Very few people will ever getone award, but two is
(24:53):
essentially unheard of exceptyou, so I'd like to thank you
very much for spending this timewith us and updating us on
diabetes, especially diabetes inIndia.
This has been very fascinating.
I hope to continue working withyou.
We've got a project now andwe'll find other projects in the
future.
So, on behalf of Dr Kerr, Iwant to thank you, and thank you
(25:17):
for being on this interview andthank the listeners.
Diabetes Technology Report isavailable at the Apple Store and
on Spotify and we look forwardto 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 ournext session and until then,
goodbye.
Thank you, dr Klonoff.
Thank you, dr Kerr, it's agreat pleasure to be with you,
thank you.
Hello, welcome to Diabetes Technology Report.
I'm David Klonoff.
I'm an endocrinologist atSutter Health in San Mateo,
california.
We have a very special guesttoday, who's approximately 12
time hours away from where I am,and my colleague, interviewer
Dr David Kerr, will introducehim.
David Kerr (00:37):
Thanks, david, and hello everyone.
I'm David Kerr, again speakingto you from Santa Barbara,
california.
It is a real pleasure today wehave the doctor who is the face
of diabetes in a particular partof the world in India.
Dr Mohan, welcome.
It's a real honour to have youon board.
I'm always interested howpeople end up spending their
(01:02):
life being involved in diabetesand diabetes technology, so can
you just give me a briefthumbnail of how you've ended up
being a superstar in diabetestechnology?
V. Mohan (01:13):
Thank you both the Davids, for having me on the
show.
Mine is a very peculiar storywhich probably very few people
would have had the opportunityto even tell the story.
So I wanted to be.
I never wanted to be a doctorin the first place, I wanted to
be a poet, a writer, whichexplains why I write so much.
And my father, my late father,was like the Jocelyn of India,
(01:37):
professor Vishwanathan, and hestarted the first diabetic
clinic in India, actually in mycity, in Chennai.
Halfway through his career hehad to leave the government for
reasons we won't go into, but hehad to leave.
And so he just summoned me andhe said you're my eldest son,
and what are your plans to do?
(01:58):
So I said I want to be aprofessor of English and write
poetry and books.
And he said no, you switch overto scientific writing, you
become a doctor, and I want youto help me.
And of course I was auniversity topper, so there's no
problem getting into a medicalschool.
In fact I got into four medicalschools.
So he said that's not an issue,you just have to make up your
(02:19):
mind to help me and work indiabetes with me.
So I joined to.
To cut a long story short.
I thought it's not a bad ideato switch to scientific writing.
So I joined him when I was 18years old.
So I joined in medical school.
So we go to medical school veryearly here, not like in the US.
You finish a degree and thenyou go, so here, straight from
school, you go to medicalcollege.
(02:40):
So I was 18 and I was inmedical college.
So I told my father look, ifyou're, if you have asked me to
do medicine to help you to dodiabetes, what's the point in
waiting 10, 15 years for me tograduate, finish postgraduation,
specialize.
You'll be so old and thenthere's no point in in my
helping you.
So let me start today.
(03:00):
I mean, I can start workingwith you today.
So while I was doing medicine onone side, the medicine was just
to get my degree and so on Istarted working on diabetes
straight on at the age of 18.
So he had a lot of medicalrecords, even in his private
practice, which he had not builtup, but he was a meticulous
record keeper, so he had allrecords and so on.
(03:21):
So I said, why not startanalyzing these records and
start writing something?
And so he said yeah.
So then I said no, that's notenough, you have to build a
small lab for me.
So we had a garage, so weconverted that garage into a lab
and bought some mice and rats.
And here I am doing anatomy onone side anatomy, physiology,
(03:42):
biochemistry in the medicalcollege and here doing animal
experiments trying to producediabetes and rats and mice and
so on.
So he hired a PhD and I startedworking with him half day and
half day medicine, half dayresearch and started publishing
when I was 18, 19, 20.
I already started publishing toan extent that my teachers
started getting jealous of me.
(04:03):
So they would say what's thisguy?
He's not even finished hismedicine 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 theexams and so on.
But the good news was that I gotright into diabetes.
It was good and bad, becauseyou know, when I go to medicine
and I study something likeanatomy, some insertion of some
(04:26):
muscle here and something,what's this to do with diabetes?
I mean, why am I studying allthis rubbish?
You know, my aim is only to dodiabetes.
So I went through medicine witha complete bias, but then
that's a negative side.
The positive side is that isreading diabetes journals and
everything every day.
You know I would get diabetescare and diabetes and all the
(04:47):
journals I'd read.
It cover to cover all thediabetes books, jocelyn's
textbook Everything I wasreading when I was 18, 19, 20
years old.
So that's how I started workingon diabetes and for 20 years I
worked with my father and thenat the end of 20 years I told my
father you know, we have toexpand and go on and now I want
(05:07):
to build this big researchcenter.
And he was growing old by thattime because he already finished
one innings in the government20 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 andat the age of 38, I've only
finished 20 years in diabetes.
You know, now I want to reallyspeed up and you're slowing me
(05:28):
down.
So he said okay, in that case,you leave.
So I said okay, I leave, youset up a center for me and I
leave.
He said I'm setting up nothingfor you.
You take the stethoscope andleave.
So I took my stethoscope.
I had no money, I had nothingand I had to start my second.
Of course, my wife is anophthalmologist, which is a
(05:50):
great advantage.
She had all her equipment andlaser and we already had a
diabetic retinopathy unit eventhen.
So I said okay, let's go andstart from.
So we took a couple of rooms ina rented place and the rest is
history.
From there we grew and grew andgrew and grew and I can't tell
you the number of patients, whomwe have now 665,000.
My goodness, yeah, close to amillion patients with diabetes.
(06:14):
We have 50 centers now, 50branches in 32 cities.
More than 100 diabetologistswork for me and my next
generation.
My daughter and son-in-law havealso joined, and now my next
generation, my grandson, isabout to join medicine next year
and my daughter.
When I started at least when Iwas 18, doing research on
(06:36):
diabetes, she started when shewas 12 or something, and so she,
when she was in school, shestarted.
One of my teachers jokinglyasked me when did she first get
into diabetes?
So I said you know, when shewas three years old, she used to
operate my wife's slides and myslides.
You know the old projectors sheused to project, and so she
(06:56):
knew diabetic retinopathy whenshe was three years old.
So he said he was so jealous ofme that he said you wasted
three years of her life.
You should have started whenshe was born.
So I said, okay, I'll do thatfor my grandson.
So when my grandson was takenout of the labor room and they
brought him to me like thatthere's your grandson.
You and my daughter had notseen.
So the first word he heard wasdiabetes.
(07:18):
So the first word in his life heheard was diabetes.
David Kerr (07:22):
This is what a story .
This is terrific for the futureof diabetes research and
innovation.
For sure.
There's a whole dynasty there.
So, coming up to today from adiabetes technology perspective,
what's your kind of main areaof interest at the moment?
V. Mohan (07:41):
Yeah, two areas.
One is precision diagnosis ofdiabetes using technology, and
right now, with Dr Klonoff, weare involved in a project trying
to separate out, type out whichtype of diabetes, using
electronic records and using AIand machine learning to
understand.
That's one part of thetechnology.
The other part of thetechnology is using technology
(08:17):
itself in the treatment.
So continuous glucosemonitoring and insulin pumps and
automated insulin deliverysystems, so all of those we
adapt very quickly into theclinic and then start using that
and also start collecting dataon that.
So we were the first tointroduce CGM, first to
(08:37):
introduce pumps, first tointroduce auto.
Now the latest thing we havejust done, just two days ago.
What we have done is that we, ofcourse, in all our centers we
have retinal cameras.
Across India, all the centerswe have retinal cameras, but we
used to have ophthalmologistsreading all of them.
Now we've introduced AI.
So some of those centers don'tneed any ophthalmologist
(09:00):
oversight at all.
So the retinal picture, thecamera itself, has an AI built
in and the report comes.
It's normal there is diabeticretinopathy, there's more severe
retinopathy which needs areferral, all that the AI is
able to say.
So that's how we use technology.
David (09:17):
Mohan, you're in India, which has a very large number of
people with diabetes.
How many people do you think inIndia have diabetes, and why is
it so common in your country?
V. Mohan (09:29):
Yeah, so we have done the ICMR in-diab study and in
fact the methodology of the ICMRin-diab study was published in
the Journal of Diabetes Scienceand Technology many years ago by
Dr Klonoff and so that studyhas now been completed.
We have completed the wholecountry, every state in the
country representative sample.
(09:50):
So based on that, we have 101million people with diabetes in
India and 136 million peoplewith pre-diabetes in India.
So put both together it's 237million people with either
diabetes or pre-diabetes.
To answer your question why wehave so many people with
diabetes despite not having thekind of obesity rates that you
(10:12):
have.
So we call the Asian Indianphenotype and this was the
lecture I gave at the ADA forthe Kelly West Award last year
we call it as a thin fat Indian.
So the BMI may be low, a BMI maybe only 23, 24, 25,.
But we have fat, we havevisceral fat and this is because
(10:34):
subcutaneous stores ofadiposity, of adipose tissue, is
very limited.
So very quickly the fat spillsover into the visceral, then
goes into the liver, producesinsulin resistance.
The fat goes into the pancreas,so insulin secretion also is
affected.
So we have thin Indians whohave a lot of insulin secretory
(10:56):
defect and this seems to havesome kind of a genetic basis as
well, but largely driven by thehigh carbohydrate diet that we
take A lot of rice, so rice andwheat is what is a staple food
in our country and this seems tobe putting a big load on the
pancreas, drawing out more andmore insulin and very quickly
(11:18):
they exhaust and developdiabetes.
So on a background of geneticfactors, the very high carb load
plus, there's not enoughphysical activity, so obesity
comes in and then the visceraladiposity comes in.
So that's the main reason whywe have so much of diabetes.
David (11:35):
Mohan, I visited you 13 years ago and saw your setup
both in town and on theoutskirts of town, and I learned
about pancreatic diabetes there.
We don't see that in the US.
I wonder if you could explainto our listeners.
I'll bet many of them don'tknow what it is.
V. Mohan (11:55):
Yeah, so this is a form of diabetes, secondary form
of diabetes, secondary tochronic pancreatitis.
Now when you think of chronicpancreatitis in the West it is
usually alcoholic chronicpancreatitis where you get small
stones, small speckled kind ofstones, mainly in the tail
region of the pancreas and notinside the duct.
(12:15):
These are huge stones.
They block the pancreatic duct,mostly from the head region of
the pancreas.
They block and therefore thepancreatic juice cannot flow and
therefore it leads topancreatitis, stone formation
because the juice juice, theflow becomes obstructed, it
becomes sluggish.
(12:36):
The mucus plugs get depositedaround that, calcium starts
forming and so the big stonesform and this can even lead to
malignancy.
The the prevalence of pancreaticmalignancy in those with this
pancreatic forms.
We call it as fibrocalculuspancreatic diabetes.
So there is calculus, there'salso fibrosis, so the gland gets
(12:57):
shrunken, the pancreas becomesmuch shrunken, like a cirrhosis
of the pancreas, and then theydevelop a lot of them develop
pancreatic cancer and they havesevere abdominal pain because of
the stones and then it leads todiabetes stunting.
And then they also havemalnutrition because they have
diarrhea and oily stools,steatoria, and so it's a very
(13:20):
peculiar form of diabetes.
It was largely due to there aresome genetic factors, the
sphincter gene and so onassociated with it, but largely
due to some micronutrientdeficiencies.
Today it's kind of going downbecause the nutrition of people
is improving.
We occasionally see this typeof diabetes, but not as much as
I used to see 20 years ago, andso the incidence has kind of
(13:44):
gone down.
Alcoholic pancreatitis is nowincreasing because people can
now afford drinking alcohol, andso alcoholic pancreatitis
slowly replacing this tropicalform of pancreatitis.
David Kerr (13:56):
Dr Mohan.
I'm also intrigued from a type1 diabetes perspective.
In the United States we'reseeing a crossover.
It was traditionally a whiteperson's disease.
It's now increasing in theblack community, the Hispanic
community.
What's happening in India withtype 1 diabetes?
V. Mohan (14:13):
So we have always had a fair proportion of type 1,
unlike China where they stillsay that type 1 diabetes is very
rare.
So for that reason because it'sdefinitely lower than, say,
finland or Scandinavia, wherethe highest prevalence of as you
go away from the equator tomore temperate places, we don't
(14:37):
know if it's due to viruses orbecause autoimmunity is more
there Definitely if you go toScandinavia, denmark, sweden,
norway, finland particularly,the prevalence of type 1
diabetes is very high.
So it's not as high as therebut certainly as high as the
rest of Europe.
For example, you take France orSpain or England, we don't have
much difference in theprevalence of type 1 diabetes.
(14:59):
Now, a lot of type 1 diabeteswe may be missing because the
children may be dying.
In a rural area, some remoteplace, child goes into coma,
diabetic ketosis and coma.
They'll think it's meningitisor thinks that something else.
They don't check the bloodsugar.
So we could still be losingsome children.
The prevalence of type 1diabetes is not low.
(15:21):
The estimated numbers,according to the International
Diabetes Federation it was250,000 children, but a more
recent report by the JDRF nowcalled Breakthrough Type 1D,
they have put the number as850,000 children with type 1
diabetes, which is more than theUS actually in terms of our
(15:41):
population.
So we actually have the highestnumber of type 1, followed by
US and then Brazil, and fourthonly is China.
Because China, somehow theystill keep saying that type 1 is
less common in their country.
So it's not uncommon to havechildren.
It's not an epidemic like thetype 2.
Type 2 in the young is actuallyrising much faster because of
(16:05):
obesity, and that's well.
Even in the US, the Hispanicpopulation, the Pacific
Islanders and Asian, indian,south Asians we have higher
prevalence of type 2 diabetesthan, say, the white European
population.
But type 1, of course you havehigher prevalence rate and
because of the sheer populationwe have large numbers of
(16:26):
children.
David Kerr (16:27):
And are you?
In the US, there's a lot ofdiscussion about screening for
type 1 diabetes.
You know, is that somethingthat 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 todayand it'll be normal.
How do you know that threemonths 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 isthere?
Obesity is there?
Acanthosis, nigricans is there?
(16:55):
We'll screen for type 2 becausethat's common enough.
Type 1 is like 1 in 100,000children.
So you'll have to screen100,000 children to pick up that
one child and the child willanyway become symptomatic within
give it three, four weeks andthey'll become symptomatic and
they'll go rush to the hospital.
If they don't die and they'repicked up, then it's good.
(17:16):
So screening as such we are notable to do.
The other thing we're not ableto do is to screen for
antibodies in the generalpopulation.
We are beginning to screen thesiblings of type 1 because we
think we'll pick them up morethere.
(17:37):
But if you start screening thewhole population, it's too many
millions and millions ofchildren we have to screen.
The cost of screening is justtoo high to pick up.
And then the other problem isokay, if they have three
antibody positive, we'll have togive them teplizumab, which is
too expensive.
It's not available in India, sonow we are seeing whether
verapamil or something else canbe given.
So as long as we don't have adrug to give them if we find
them antibody positive, it's notethical to screen, because you
(18:01):
screen them, tell them you'regoing 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 theschool and just check for the
(18:21):
child and if the child hasraised blood glucose,
immediately refer them to anearest hospital.
That's what we are trying to do.
It's not possible to screen allchildren.
David (18:32):
Mohan, with the large number of patients that you have
, what type of an electronichealth 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 plus25, 34 years now, when I've run
these clinics, we have hadelectronic records right from
day one.
That's been a great blessingfor us.
So the 660,000 patients that Itold you, they're all on
(19:02):
electronic records, not justonce, but every time they come
we have the electronic records.
So for some people you have 30a 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'relooking at this data on type 1,
type 2 for the collaborationthat we're doing.
So we have data mining peoplewho we tell them what we need
(19:24):
and they can go into theelectronic records, set the
filters and take out whateverdata we want.
So the tremendous number ofpublications that we have had is
partly due to this richdatabase.
So if you think of an idea, forexample somebody came.
Another area I work on isgestational diabetes.
So somebody came to UK and saidyou know we are interested to
(19:45):
look at recurrent GDM, not justGDM1s, but those who had, say,
three times GDM.
Compare them with those who hadonly once GDM, are they
different or not?
So we just have to put inrecurrent GDM and it will come
out.
All the data will come out.
So that's a tremendous resourcethat we have no-transcript.
David Kerr (20:07):
Dr Mohan, one of the challenges in the United States
is ensuring that people withdiabetes have regular screening,
but the screening rates youmentioned retinopathy screening,
the screening rates forretinopathy screening and food
screening are actually not wherethey need to be.
I mean in India.
Is it the same challenge or areyou more successful, less
successful?
V. Mohan (20:33):
we're successful as far as our clinics are concerned
, the whole network across these32 cities.
We are driven by protocols, sowe have standard operating
procedures.
Every year the medical recordwill tell us it's time for the
eye checkup.
A pop-up will come saying aprompt, saying it's now due.
At this visit you should check.
Suppose a lady is pregnant.
It'll say please don't do anx-ray.
The lady is pregnant.
(20:54):
So all this is kind of built in.
So because of that, ourscreening rates are very good.
And today we have this AIsystems.
We have very low cost camerasmade in India and so we are able
to do handheld cameras and soon.
So we are able to do that verywell.
Now, outside our systems, Iwon't say it's great there are
(21:16):
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'thave symptoms.
Now symptoms come very late.
You have to have a macularedema or a proliferative
(21:37):
retinopathy which is bled, and avitreous hemorrhage.
Only then you get symptoms.
Then it's too late.
You're going to lose yourvision.
So that's when they go rushingto the ophthalmologist.
In fact we had a problembecause my wife was an
ophthalmologist.
So when we first started we saidas 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 youfor diabetes, not for an eye
(21:58):
check.
I've already got my glasses, sowhat are you trying to do?
You're trying to make money.
We said no, this is part ofdiabetes checkup.
Take it or leave it.
We have to see your eye, justlike.
Then.
Don't tell me not to check yourblood pressure, not to check
your feet, not to check it.
You can't separate it out.
(22:18):
This is part of diabetespackage.
You have to do it.
So it took a lot of initialeducation to do that, but then
people started realizing thevalue of that because we'll pick
up some retinopathy and then wecan give them laser treatment
or screening and then they arevery happy.
So eventually they startedrecognizing it's a one-stop shop
kind of a thing.
You come in and get everythingdone in one place, and that
became our unique sellingproposition.
David (22:40):
Moen in this country we find that we have pretty good
rates for screening but poorrates for follow-through.
After someone is told they needlaser 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 tomake sure that it's really
needed, because very oftencommercialization, people do
procedures not needed and so on.
So they will always check withtheir family doctor or with
somebody else.
But if we teach them, we showthem pictures, we'll show them a
(23:18):
retina and say this is a normalretina, 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 peoplewill.
Once you teach them, they willcome for the follow-up.
But some people, of course, noteverybody, you can get to think
(23:39):
but generally the follow-upwithin our system, within our
clinics, it is very good.
But the problem is to find thepeople, screen them.
But one of the things which weare disappointed about is that
they don't come for the nextyear's checkup.
And you know I have a lot offriends who walk with me, you
know, every morning and some ofthem have diabetes and I'll tell
(24:02):
them hey, I haven't seen youfor a year, I'm fine, doc, I
have no problem.
So when I have a problem I'llcome.
I said no, you should come andyou don't have a problem.
You know we should see you whenyou don't have any symptoms.
So to get that message throughit's not easy.
That it's not when you have aproblem that you go.
You have a foot ulcer and it'sturning gangrenous and then you
(24:23):
go.
It's too late.
You should prevent thatgangrene.
You should prevent that footcancer.
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 thenumber of services that you
provide, it's no wonder that youreceived two very prestigious
awards from the AmericanDiabetes Association the Rifkin
International Service Award andthen last year, the Kelly West
Award for Epidemiology.
Very few people will ever getone award, but two is
(24:53):
essentially unheard of exceptyou, so I'd like to thank you
very much for spending this timewith us and updating us on
diabetes, especially diabetes inIndia.
This has been very fascinating.
I hope to continue working withyou.
We've got a project now andwe'll find other projects in the
future.
So, on behalf of Dr Kerr, Iwant to thank you, and thank you
(25:17):
for being on this interview andthank the listeners.
Diabetes Technology Report isavailable at the Apple Store and
on Spotify and we look forwardto 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 ournext session and until then,
goodbye.
Thank you, dr Klonoff.
Thank you, dr Kerr, it's agreat pleasure to be with you,
thank you.
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