 The foyer, good evening, I'm Ruth Bergren, Director of the Center for Medical Humanities and Ethics. We're all so very pleased to have you here for our twelfth annual Frank Bryant Memorial Lecture in Medical Ethics. In particular, I'd now like to welcome Dr. Frank Bryant's wife, Gloria, who is here with us tonight along with friends. Gloria, it's always good to have you with us. Our topic tonight is near and dear to our hearts, and it is especially relevant during Black History Month. Our Center for Medical Humanities and Ethics is very concerned with eliminating barriers, those that prevent people from receiving medical care, and those that discourage people from pursuing health careers. Our speaker is a role model to those interested in overcoming barriers themselves or erasing them for others. And more on our speaker in a moment, but I first must go through some housekeeping details. Those of you who seek continuing medical education credit, please make sure you sign and pick up a record of attendance form. We don't need the form back, it's for you to keep, and in one month would you please log on to the website that is listed on the form to claim your credit. For people coming from off campus, there are parking validation stickers available to you in the foyer. And now a few words about Dr. Bryant, for whom this lecture is named. Dr. Bryant was a much loved family physician and community leader in San Antonio until his premature death in 1999. He was among the first African-American students to graduate from the University of Texas Medical Branch. He went on to become an important advocate for the medically underserved living on San Antonio's east side. He co-founded the Ella Austin Health Clinic, where he was the first medical director, and he also co-developed the East San Antonio Medical Center. He served as the first African-American president of the Bear County Medical Society and the first president of the C.A. Whittier Medical Society. Our Center for Medical Humanities and Ethics is working to grow an endowment honoring Dr. Bryant. This endowment will make it possible for us to continue to hold a Bryant lecture in medical ethics every February during Black History Month. So if you or someone you know might be interested in contributing, there are brochures that look like this with additional information about the lecture near our entrance. Our speaker tonight represents the same values as Dr. Bryant and is the ideal person to deliver this lecture. Introducing him will be UT Health Science Center President William Henrich. Dr. Henrich, would you please join me at the podium? Thank you, Dr. Bergeron. Good evening, ladies and gentlemen. Welcome to the campus. It is a privilege and a pleasure to welcome to San Antonio and to the Health Science Center campus. A friend of mine, a leading physician in all respects, Dr. Griffin Rodgers, who will be giving the Frank Bryant lecture this year. Dr. Rodgers is the leader of the Diabetes Digestive Disease, Kidney Disease Institute of the National Institutes of Health and in this capacity, which he has led for the last eight years, he oversees a budget of $2 billion and a staff of 600 people. I was commenting to Griffin when I was talking to him just now. I wish it was far more than $2 billion that you had in your coffers. He is a wonderful steward of these resources and an acclaimed leader in all respects of medicine today. He received his undergraduate degree at Brown, went to medical school at Brown, trained in internal medicine at Washington University in St. Louis, and then in hematology at the NIH and at George Washington University School of Medicine. He's made contributions in clinical trials over the years, including a seminal observation that hydroxyurea would help patients with sickle cell disease, which was made in the 1990s. That observation has, of course, in a positive way affected the lives of millions of people around the world and over 90,000 individuals in the United States who suffer from sickle cell anemia. He's the author of 200 scientific manuscripts and papers. He's edited four books, four scholarly books on different subjects. He owns three patents and he's been decorated with membership in the most prestigious scientific societies in our country, including the American Society for Clinical Investigation, the Association of American Physicians, and the Institute of Medicine of the National Academy. In all ways, Dr. Rogers is a leader, a leader, of course, for leading this important institute of the National Institutes of Health. I had the privilege of working with him when I was on the counsel of the NIDDK and I can say firsthand his thoughtful, careful stewardship of this important national resource is in excellent hands in Griff Rogers' hands. His topic tonight is science, a tool for justice, a subject about which he is expert. Ladies and gentlemen, please welcome our Frank Bryant lecture to the podium, Dr. Griffith Rogers. Thanks so much. I appreciate it. Thank you. Well, thank you for that very warm welcome, Dr. Berggrin, Dr. Henrich, members and family, students, good friends. I want to thank you for this wonderful invitation. It's really always a delight to come to this beautiful city. I have to say it was my last time here, it was about 20 years ago, but I was here several times for that, and it's even better to have the opportunity to spend time with, I think, very remarkable medical professionals, scientists, teachers, and students. Though I thought it was somewhat odd when I first got the invitation, I understand that the location was going to be the basement of the Alamo. But fortunately, we're in a much finer facility, one that actually exists. And so it's definitely a pleasure to be here. And we're at really an outstanding institution of higher education, one that is doing great work preparing our future physicians, nurses, dentists, biomedical researchers, and caregivers of all stripes. Most impressive is this Center for Medical Humanities and Ethics. This is really a singular place in this country because you're really going beyond the technical knowledge to emphasize ethical practices and community services, to put student skills and talents in the service and the compassion and justice, which are really important efforts. There's so much I have to say that I admire about this place, your academic excellence, your focus on nurturing empathy and humanitarianism, your efforts to ensure that all students will be attentive to the patient's thoughtful care throughout the patient's life, and your interdisciplinary community service learning program that's so important, it connects students, what students learn in the classroom to what they experience out in the community, your commitment to serving the underserved, and your dedication to diversity. These are all so important. So with that in mind, I would have to say that it's especially important, it's a special privilege to be here today, but it's also a very humbling honor to deliver the lecture that honors the life and legacy of Dr. Frank Bryant, Jr., a pioneer who you've heard about, who've overcome adversity to make groundbreaking improvements in medical career for the people of East San Antonio. I never had the privilege to know Dr. Bryant, but I do know of his work, and in more ways than one, I think all of us stand on his very broad and strong shoulders. Dr. Bryant was not a great African American physician. He was a great physician, period. No qualifiers are necessary, nor should they be for any of us. But he was certainly a strong inspiration to anyone wanting to enter the field of health or science, anyone who experienced discrimination or disrespect, or anyone who had ever been told that they're not likely to amount to very much, anyone who was judged by the color of their skin and not for the way that you think and how deeply you think. So in a sense, by his very example of pursuing his passion as a physician, as a healer, as an advocate to the highest possible level, Dr. Bryant showed us all one way that science and medicine can be powerful tools for justice. And that's one of the things that makes me so passionate about NIDDK, the institute that I had the privilege to be the director of, the National Institute of Diabetes, Digestive, and Kidney Diseases. It's because of the areas that were within our mission areas. These disorders are really at the core of our portfolio, obesity, diabetes, kidney disease. They're all chronic, they're common, they're consequential, and they're costly, and many of them are likely to afflict African Americans, Latino, and other people of color disproportionately, which means that each time we make a new groundbreaking trial in preventing or in better treatments of this disorder, we're really striking a blow for justice. And we often hear the term health disparities, but we can also think of this in another way as really health injustice. And I want you just for a moment to consider the facts that as an African American adult, compared to a non-Hispanic white adult, you're more than 1.5 times more likely to have diabetes, you're 70% more likely to be diagnosed with diabetes, you're more than twice as likely to die from diabetes, and you're nearly three times as likely to go on dialysis. Of course, in this country, diabetes is a leading cause of end-stage kidney disease, which requires dialysis. Despite this fact that African Americans are only 13% of the population, they represent 33% of the population on dialysis, or those patients who require a kidney transplant. And unfortunately, they generally end up being last on the list of the transplant recipients. Look at the Hispanic population. These numbers are quite likely, are quite the same. They're 1.5 times more likely to be obese, they're 1.7 times more likely to be diagnosed with diabetes, 1.5 times more likely to die of diabetes, again, about 60% more likely to start treatment for end-stage kidney disease related to diabetes. And Mexican Americans and Puerto Ricans are really the most likely among all Hispanic to fall into this category. Very example of health injustice. Asian American Indians, Native Alaskans, Native Hawaiians, and Pacific Islanders also fall into these categories, obesity leading to diabetes, leading to kidney disease. It's not only the fact that they're more likely to have these conditions, but it is clear that one's ability to pay for things that would improve your likely outcome of these diseases, eating better, taking your medication, following what are generally the best available prescribed methods will change in these populations as well. Here's a study that we funded in a group from Boston who looked at the issue of healthcare resources and they measured various measures of economic insecurity. What they found that in 39% of the respondents, they all reported at least one material needs insecurity, 19% reported food insecurity, 28% pointed out that the cost of medication was a reason that they underused the medication as prescribed. Housing instability over 10%, energy insecurity, not knowing whether you would have fuel in your house or fuel in your car to either get you to work or keep you warm during the winter months. These are quite dramatic. Most striking finding in this study that was just recently published about two months ago is that even despite the fact that many of these patients had comprehensive health insurance or some type of health insurance, 46% of these respondents who were all diabetics because of these insecurities, this led to poor diabetes control. Of course, we know that poor control will lead to the secondary complications associated with diabetes and shorten one's overall survival. What I'd like to tell you a little bit about and some of the time a lot of this, the type of integrated research program at NIDDK that we're involved in to try to work on what we consider these health disparities or these health inequities or health injustice. We're a principal institute responsible for obesity research. It's the obesity epidemic in this country that's driving the diabetes, specifically the adult onset or type 2 diabetes. In turn, it's type 2 diabetes that's driving the kidney disease problem that we have, specifically chronic kidney disease leading to end stage kidney disease, patients requiring dialysis or a transplant. Now I mentioned in my series of slides the fact that they're common and they're costly. Let me give you an example of that. Obesity in this country is thought to affect two-thirds of the U.S. adults are considered to be either overweight or obese. Approximately one-third are considered obese. This is increasing in the young as I'll show you in a moment. The average cost or the estimated cost is $147 billion a year associated with the obesity problem. Diabetes is thought to affect 29 million Americans or 9.3% of the adult population. This is an entirely type 2 diabetes, about 5 or 10% of that may be type 1, but nonetheless it's projected that if we don't do anything differently that by the year 2050, 50 million Americans will be affected by diabetes. Again increasing in the young studies actually from this institution have pointed that out and put that in very sharp contrast that when these kids develop what we used to call adult onset diabetes, it's a much more aggressive disease. The complications are occurring much earlier. So we have to do something to stem this tide. The annual cost estimated two years ago now, and I'm sure this number is much higher, an annual cost of $245 billion a year. And then diabetes leading to chronic kidney disease, 23 million Americans affected by CKD, leading cost diabetes, the annual cost, because all of these patients once they develop end stage kidney disease, go on dialysis, are covered by Medicare, an underestimate but a number coming in at $29 billion. These are just the economic costs. I mentioned that the condition is common and let me just show you on this slide that it is really this obesity epidemic that's driving the type 2 diabetes. Our sister institute, the Centers for Disease Control or the CDC put together these pictures every five years. You can see that in the last 20 years, the prevalence of obesity in this country has greatly increased from less than 14% in a few states in the Midwest and the far West, 14 to 17%. But then moving into 2010, you can see a much larger number of states with over 26% obesity. And if you look at the similar analysis that they do for diagnosed diabetes, you can see that as the states change colors, those states are also changing colors for diagnosed diabetes. I have to say that one of the first things that I did actually when I became the director, I was asked to give a congressional briefing to the Congressional Diabetes Caucus. This is a bipartisan group that wanted to hear this information and when I showed them these slides, I realized halfway in the middle of this that I was showing them these blue states that were becoming red states and I realized quickly that I didn't want to make a political statement, so I attributed this to the Centers for Disease Control where this data is housed. Of course, everything is being in Texas, right? This slide of Texas just clearly indicates that while San Antonio here has generally the national average in Bayhara County, the incidence of diabetes is pretty close to the average. But there are a cluster of counties going out to the east and even to the west, Fayette, Gonzales, DeWitt, Lovaca counties, down to the coast, the rate of diabetes is much higher. That's also another cluster of counties in the west, including Gillespie, Kerr, and Bendera counties, in which these counties really have extremely high prevalence of diabetes, much greater than the national average. One of the things that's driving the adult obesity problem is childhood obesity. I think everyone is quite familiar with this because this has gotten a lot of public attention very recently, including efforts by the Surgeon General, the First Lady, and a number of others. But overweight in youth is really a problem. And again, as I said, youth who are overweight are driving the type 2 diabetes in the youth, and this is really a major problem, something that we have to do something about. It turns out that we haven't always had this problem with overweight or obesity in childhood. In fact, in the early 70s, when kids all had physical education and we were eating home cooked meals, there were generally only about 2 to 4 percent of the population of kids, either 6 to 11 indicated here in the red or in the blue, 12 to 19 were considered overweight or obese. Of course, the way one considers obesity or overweight in childhood is slightly different than what we attribute this to an adult, the body mass index, it really results from looking at them on so-called growth charts. But it's clear that something happened here in the mid-70s, first in the young kids in which there was a pronounced increase followed by a little bit of a lag period, and then one saw this coincident rise in the older kids, 12 to 19 years of age. And of course, I'm sure there were many variables that occur, but let's consider a few things that happened around the mid-70s that may have led to that. The introduction of the first cell phone was in 1973. Can you imagine walking around with this thing in your pocket today? In 1973 also, the Egg Mac Muffin sandwich was first introduced in this country. The first drive-through McDonald's actually in 1975 in a neighboring state in Arizona, Sierra Vista, Arizona, came into existence. The very first portable computer shown here came out in 1977, and in 1977 Atari launched its very first video game, the Atari Console. Now, I don't want to give direct attribution to these events, but what I think that this led is to a culmination event associated with, again, less physical education in schools that really set a stage for a series of events that led to the fast availability of high caloric food readily available, as well as things that would encourage a more sedentary lifestyle, such as sitting in front of a computer, TV screen, and of course cell phones that are not quite that big, but allowing one to always be relatively inactive. What are the consequences of obesity? In addition to diabetes that I will focus on, here's a picture that appeared in the National Geographic by one of our investigators. This is what's called a sagittal section through an MRI section through a female, 36 years of age, 120 pounds, her height is 5 feet, 5 inches. Looking at her ratio of her height to weight, this would give her a body mass index of 20, which would be considered entirely normal. And in fact, you see very little fat in this MRI. Now, consider a female slightly older who we also took an MRI on, age 40. She weighs 250 pounds about the same height. This gives her a BMI of 40, which makes her extremely obese. And as you look at the MRI, you see all this whitish laden area, which is fat depositing not only in the subcutaneous space, but also in these organs. Having obesity really leads to a number of complications. Stroke, cataracts, coronary heart disease, pulmonary disease, liver disease, gallbladder, it's now clearly associated with a number of cancers, breast cancer, uterine cancer, esophageal, probably pancreatic, gynecological complications. But for the purpose of this talk, we're gonna talk about how it's leading its association with diabetes and how this epidemic can be reversed. Diabetes really is a ticking time bomb in this country. From a perspective of 24 hours in the United States, every 24 hours there are over 4,600 new cases of diabetes in this country. There are 200 non-traumatic amputations of the lower limb that occur in operating rooms throughout the United States. About 136 people begin dialysis because of kidney failure attributed to their diabetes. And 641 patients will die with diabetes. Diabetes is listed as a seventh leading cause of death in this country. But because it's such a great contributor to stroke and to heart disease, as I'll show you in a moment, and also associated with those cancers, that seventh leading cause is probably a gross underestimation. Diabetes can affect anyone. Fame and fortune really are no deterrents. As you can see on this slide, here are some very famous personalities with diabetes. In the center you see Paula Dean, of course, who spent the champion recipes and foods that were very conducive to developing the disease. In a sort of ironic way now, she's actually a spokesperson for some of the pharmaceutical companies that actually have drugs to treat diabetes. On the right, you might recognize this famous singer, Luther Vandross. Not only did Luther Vandross have diabetes, but his father, several brothers, many other first degree relatives. Luther Vandross had a stroke and lived in a coma basically for two years when he eventually died. And at the time, not many people associated, they realized that diabetes could cause blindness, kidney failure, but not many people associated diabetes with an increased risk of cardiovascular disease and stroke. But that was his case, as well as the case of his other family members. So on the lower panel here is the mayor for life in Washington, DC, Marion Barry. Marion Barry had diabetes, complicated also with high blood pressure, which led to his heart failure, which caused him to die. He also had end-stage kidney disease. And despite the fact that I told you that African-Americans with kidney disease are less likely to develop to get a transplant, a campaign donor actually donated a kidney to Mr. Barry in 2009. And he had that for quite some time. But he ultimately succumbed to his disease last November. Just want to point out here in the corner, because she's been a very good spokesperson, Selma Hyatt, who some of you may recognize. She had gestational diabetes, which affects somewhere between 4% to 6% of pregnancies. It's especially common in the Hispanic community. Many of these women will go back to normal glycemia once they deliver their child. But they're always at very high risk for developing type 2 diabetes. And she's been a very powerful advocate for this. So with all of this, what is the role of research? What can we do about this national epidemic of obesity and diabetes and its dire health consequences, modern inequities that place an unequal burden, in a sense, on people of color? One critically important step is research to develop new ways to prevent obesity and diabetes before it occurs. Because I think we would all agree that prevention is preferable to treatment. But because we have so many individuals suffering from diabetes this day, we obviously have to develop a better treatment methods as well. That really brings me to my next slide. And again, on diabetes, when we talk about health and justice. Diabetes affects 29 million Americans. But roughly 8 million of them are unaware that they have the diagnosis. If you're not diagnosed, of course you're not being treated adequately. The disease is taking a cumulative toll on you. And therefore, the secondary complications are likely to be much greater. And a shortened survival is likely to be in store for you. But that's just the tip of the iceberg. There are now estimated to be about 86 million Americans who suffer from prediabetes. A condition in which the blood sugar is not high enough to actually be called diabetic, but it's much higher than normal. And certainly these individuals with prediabetes are at extreme high rate of risk of going on to develop diabetes some time within their life span. So how do we begin to chip away at some of these patients so they don't actually develop a diabetes? That's what I'd like to tell you about over the next few minutes. We now know from studies from a number of centers, including here in San Antonio, that there is a progression between normal to the prediabetic state, to the type 2 diabetes state, and then finally to complications. And as a direct result of this, in NIDDK we've put together a number of trials, both in adults and children. Some of them will be familiar to many of you in the audience who participated in these trials to prevent people at high risk from developing even prediabetes. Are those with prediabetes from going on to develop type 2 diabetes? And trying to treat people early in the onset of their type 2 diabetes to try to reverse this to a more normal stage. One of the most frequent questions I'm asked by someone with diabetes is, Doctor, am I going to have this for the rest of my life? And is there a way to reverse that? And that's something that we're very actively working on. What I'd like to tell you, though, about is our diabetes prevention trial, a trial set up to really do exactly that. Prevent people or delay people who have prediabetes from going on to develop diabetes, let's see. The DPP study involved some over 3,200 participants, 45% of whom were minority, because again, this is a population at greatest risk. There were three treatment arms, standard instruction plus placebo, standard instruction with metformin, and a lifestyle intervention in one of the groups. And they were roughly allocated and randomized to each of these groups. Let me tell you a little bit about the lifestyle intervention, because of the very much the success of this study. This was an intensive behavioral modification program with the goal of a 7% weight loss accompanied by a reduction in their calorie intake and also with exercise, 150 minutes per week of physical activity, 30 minutes a day, five days a week, largely just walking. You don't have to join an expensive athletic club. Just walking was sufficient. This intervention, this behavioral intervention was delivered at 16 sessions, a core curriculum done on a one-on-one basis over a period of 24 weeks, and then there was a monthly visit to reinforce what was learned during these 16 sessions. What was the outcome? Over this three-year period, you can see that in general, the people receiving placebo went on to develop diabetes somewhere between 8% to 10% of them developed. But in every ratio and ethnic group, the observation was the same. That metformin showed some degree of protection, but the best protection was the individuals who were in this lifestyle group. Again, that was in every ratio and ethnic group. I'm sorry, I'm losing the point here. Every racial and ethnic group that we examined. Now, while there weren't very much differences in these interventions in these racial and ethnic groups, as it turns out when we look at other variables, it turns out that there were. These are not as readily known, and so I want to bring them to your attention. When we look at the group receiving this drug, metformin, which as many of you may know is the first drug that's usually used for treatment for people with diabetes. While in the very young group, metformin seemed to be as effective as a lifestyle intervention. In the older group, you can see that metformin shown here in red, I'll just have to point it out, was really not statistically different than what one sees in the placebo. So obviously, metformin has its greatest effect in the younger population. In contrast, and almost counterintuitively, the lifestyle intervention involving exercise and diet use was actually very effective. While it was effective in all groups, it was most effective actually in the group who at the beginning of the study were over the age of 60. In fact, if you looked at the reduction between placebo and the lifestyle, in fact, they enjoyed a 71% reduction in the prevention of developing diabetes. And so this is what I say was counterintuitive, because going into this study, there are many critics to say you'll never get people over 60 to exercise 30 minutes a day, five days a week. And even if you can get them through that 16-week period, they're not going to maintain this for over a period of three years. While the critics were wrong, this beneficial effect was seen, and it was most prominent in those adult patients. Now, something I did want to come back to is that when I referenced Selma Hyatt, what this study clearly showed was that women with a history of gestational diabetes or GDM were really at a severe high risk of developing diabetes. If you consider those women who received placebo, who had a history of gestational diabetes, and compare those to women who did not have a history of gestational diabetes, there was a 71% increase in them developing diabetes in that group. So if you have gestational diabetes, this puts you at a very high risk of developing. You have to watch them very carefully. In this group, the metformin, again, was just as effective, about a 50% reduction in the development of diabetes compared to placebo. And you can see the metformin was not very effective in these women without a history of gestational diabetes. So to summarize, metformin seems to be extremely effective in the young, and particularly in women with a history of gestational diabetes. Whereas, of course, this lifestyle intervention is effective in everyone, but is especially effective in people over 50 or over 60, is dramatically effective. This slide just summarized what I just said about that. Initially in this trial, there was a 31% reduction with metformin compared to placebo, 58% with lifestyle. These effects were durable. After if you follow these patients for 10 years, there was still an 18% reduction with metformin arm and 34% with lifestyle. This led us to do a follow-up study, because obviously it's too costly to provide this one-on-one intervention with these 86 million Americans that have prediabetes. So we figured if we're going to make this very practical, we had to translate this somehow in a community based way that could potentially give this type of instructions in a group setting. So we chose the YMCA to do the so-called translation research. Why the why? Well, there are 2,600 YMCA's in this country, and about 68 million households live within a three-mile radius of a YMCA. So you see, with that in mind, we're now be able potentially to get a crack at that 86 million Americans who are at high risk. And when you do this in a group setting, you're actually able to reduce the cost of providing this intervention. You're able to reduce this by about a fifth. So it then becomes quite cost-effective to deliver it. And in fact, the studies from the YMCA, in fact, showed that the weight loss reduction and the prevention of diabetes at three years were quite similar to what we were able to achieve on a one-on-one basis. And therefore, it's a great possibility of scaling up this intervention. When one looks at this from a provider standpoint, if you had to actually pay the cost, in fact, this was published in the Diabetes Care a couple of years ago, but from a provider standpoint, lifestyle intervention was highly cost-effective. What that means is that if you look at the cost, hospitalizations, medicines, loss hours, and the people receiving placebo, and you add that up, and you put those same costs together with the people receiving lifestyle, despite the fact that you're paying so much upfront to actually give them these instructions, over a 10-year period, lifestyle was still highly cost-effective. Metformin, on the other hand, even though it was only about a half as effective as the lifestyle, because it's a generic drug readily available, in fact, it was actually cost savings. So these type of health economic studies are really embedded in all of our large clinical trials. We began to ask the question, though, at that point, since this was a fairly large, randomized trial, we asked the question, well, what is that's preventing us from preventing type 2 diabetes? Because this would have enormous economic and human benefit if one could expand these types of studies. And so my colleagues and I wrote a perspective in the New England Journal, and what we realized at that time, well, there was really limited coverage for testing for either diabetes or pre-diabetes. And so if you're not tested, and the people who are in charge of this is the United States Preventative Task Force, they hadn't actually given it either an A or B rating, which was necessary in order for Medicare and Medicaid to pay for these testing and then treatment and ultimately for the management. And limited coverage for lifestyle intervention. But I have to say that having presented this a number of times and beginning to agitate the U.S. Preventative Task Force, I'm pleased to say that just in October, they did consider it and now have given a B rating to screening for abnormal blood glucose for type II diabetes in adults at high risk. Once this is implemented, I think that this is really gonna have a major impact to begin to bend that cost curve that I pointed to you, the $245 billion. Unfortunately, at the moment, Metformin is still not FDA-approved because the company that actually supplied the drug for this trial, Bristol Myers-Gwip, who held the patent, there's really no financial incentive for them to put in an IND for a drug that's now generic. There's likely to be a return on investment. And then there's an enormous cost associated with putting this in front of the FDA. But again, that's another area that we continue, another place that among colleagues we're continuing to edge and nudge a bit. So how do we translate this into a public health setting? DPP has partnered, NIH has partnered with the CDC to form the National Diabetes Education Program in which we target the message about diabetes prevention and treatment to specific groups. We work very closely with the Indian Health Service because of the very high rate of diabetes among the Indians. And here I think we are beginning to make a major difference in terms of the prevention because they were employing these prevention program in their special diabetes prevention program in the Indian population. As I mentioned, we partnered with the Y. The results of this trial has now led the CDC to develop their own national diabetes prevention program in which the CDC is actually certifying people who are being instructors to teach this lifestyle intervention. And we continue to move even further with this. One way that we figured we could get a two for in a translational effort that's underway is to actually instruct people who have diabetes themselves to be instructors for people who have pre-diabetes. In that sense, they actually are not only teaching them how to prevent developing diabetes, but in the process they're actually taking better care of their diabetes themselves. And we're actually seeing enormous benefits on actually both occasion. And hopefully if we can replicate these in other centers, we may be able to advance this effort in a much greater way. What I've told you is really focused on adults, but now we realize that the environmental factors are very important in terms of developing diabetes. When we think about the environment, we frequently think about the air we breathe, the food we eat, the pollutants that we come in contact with, but now we know that actually our environment begins very early. In fact, probably in the womb, we have signals and exposures that actually can determine in advance the likely chronic diseases that we're likely to develop. In fact, in studies on the Pima Indians in Phoenix, Arizona, in which we've had an intramural program now for the last 45 years, that group have shown very conclusively that a pregnant woman, particularly if she is obese, who either has diabetes or develops gestational diabetes, is likely to pass that trait on to the infant. And in fact, unfortunately, if that infant is a daughter, she is likely to become a young woman with obesity and or diabetes. And that vicious cycle will continue to swirl. And in fact, this cycle would actually predict that the children would or that the incidents of diabetes would begin to occur at a much earlier age, this is exactly what we're seeing. These results have now been substantiated by several other investigators. And it's actually led us to work with our colleagues at the NIH to develop ways to try to prevent the excessive weight gain during pregnancy, which would potentially have enormous benefits both to the mother as well as to the infants. Everything in the government has an acronym. This is called Life Moms, which stands for Lifestyle Interventions for Expecting Moms. And we're looking at a variety of behavioral interventions that might decrease the excessive weight loss, that weight gain that can occur during the course of pregnancy, and actually following both the moms as well as the infants for one to two years after the delivery to see the impact of those behavioral interventions. It's important that we base any recommendations ultimately that we give on this type of evidence-based science to try to counteract some of the mixed messages that one might see in the community. Here's a picture that I took in Washington actually very recently. Here's the kind of mixed messages that people are seeing. You see, on the top, childhood obesity, don't take it lightly, and that's right under that is a slide saying my kind of shopping spree at McDonald's. I don't have anything against McDonald's. I eat at McDonald's from time to time, so please don't, anyone in the audience who happens to be a journalist, please don't say that I'm saying bad things about McDonald's. These are the kinds of messages that we all see day in and day out, and we have to somehow balance these types of messages with evidence-based messages targeted at specific populations to try to get them, at least the message to resonate for a period of time because unless a message sticks, it's not likely to be followed. So based upon the types of research that we've done, we've developed a number of information networks. One is called WIN, or the Weight Control Information Network. We've tried to instill in these messages that are on the website as well as in literature that are readily available. Information from people at all ages on healthy eating, on exercise, as well as nutrition. And we again try to target it to specific populations at greatest risk. A subset of this WIN is our program called Sisters Together, Move More, Eat Better. Based upon the observation that somewhere between 20 to 25% of African American women are thought to be obese, and perhaps 50% or even two and three may be considered to be overweight. In this particular program, we try to target messages again at all ages, giving helpful tips on both exercise, physical activity, as well as nutrition. And I would definitely encourage people to visit the website to learn more about that. We also have that National Diabetes Education program that I mentioned that we do in partnership with the CDC and 200 private and public partners. We have all this material in both English and Spanish, and it's not just translating from English to Spanish, but we get in the groups of individuals to make sure that this is tailored linguistically, appropriate, and socially acceptable manner that it's likely to stick and resonate so that people are likely to follow what our message is. Because type two diabetes is becoming more common in adolescents, we have information for adolescents. It's actually written now in some 14 Asian and Pacific Islander languages, and we're seeing that this is being picked up by a lot of the pharmaceutical chains as their definitive information to provide to individuals in these populations on either treating or preventing diabetes. It's not all about the behavior in the last few minutes, let me just say something about the genes. Normally, when people give these types of talk, they spend a lot of time about the science of the genes and the proteome and the genome and the other ohms that I guess, omics are really big or are really in. I think there's proteomes, there's ribosomes, there's nucleosomes, there's epigenome. It's really only limited, I guess, by echinomes. But in any case, in terms of the genome, we're trying an experiment which is somewhat unprecedented. Actually, we have worked now with 10 biopharmaceutical companies and 12 non-profit organizations to develop a way based upon people's genetic predispositions to develop better ways to treat people with diabetes or to prevent complications associated with diabetes. There are three groups or three diseases that are actually targeted in this accelerating medical partnerships. Not only type two diabetes that I'll tell you a little bit about, but lupus and rheumatoid arthritis as well as Alzheimer's. And the whole goal of this project is really to develop better promising biological targets of the disease or at least in the case of Alzheimer's and lupus to develop better biomarkers or diagnostics for these conditions. Now in diabetes, we have the advantage that for a number of years, we've actually been working on the genetics of type two diabetes. In fact, shown on this slide are the 26 pairs of human chromosomes and the site of specific mutations in genes or in regions of the genes that either increase or lowers one's risk for diabetes. In 2011, there were 49 examples of these specific regions, but this has really been an area of virtual explosion. Just within the last three years, there have been an additional 28. So we're up to close to 80 genes or gene regions. And again, we've now have available descriptions and populations close to about 200,000 individuals that we're studying. About a half a year ago, a very interesting mutation arose from this. Mutation in a particular gene called SLC388, which is a zinc finger gene, is a transporter in islet cells for the metal zinc. And what we found is that in certain populations, there are mutations in this particular gene that causes a gain of function. So this put people at extremely high risk of developing diabetes, but we've also found very rare mutations, which actually result in a loss of function of this gene, particularly in individuals who are overweight and elderly, individuals who you would expect would be at a very high risk of developing diabetes. They seem to be protected from diabetes. And in fact, when we went back in, our investigators went back in and actually searched various ethnic groups, you can see here African Americans, Europeans, Southeast Asians, Southern Asians and East Asians. It turned out that there are certain of these mutations that increases one chance of developing diabetes, but there are other rare mutations which seems to occur in each of these populations, which actually protect people. So essentially knocking out one of these genes actually protects ones from developing diabetes. And so what we're doing in this partnership is making all of this information readily available on a knowledge portal so that not only researchers but people from the pharmaceutical industry can come in and interrogate these genes to allow one to look for new targets that could either prevent diabetes or better treat diabetes or prevent some of the complications associated with diabetes. And I think you're gonna be learning more and hearing more and more about this in over the next four or five years. The way we're developing this knowledge portal though is somewhat agnostic, although we're using it for type two diabetes, we can similarly use such a portal and we're exploring opportunities with people to look at schizophrenia, to look in that lupus and rheumatoid arthritis cohort in Alzheimer's and other diseases and use the same general approach to develop better treatments for these patients. Well, just to conclude then, I think research is certainly one area and the research that we do at NIHs really led to better ways to manage and perhaps prevent some of these diseases. Type two diabetes, I've given you most of the information on what we learn really empowers people to be well enough in a sense to be emancipated from these crippling diseases that are really associated with a degree of health injustice. I think we have just begun the journey, we're certainly not at the end, but I think there are very fruitful things that we're seeing in the future. I really see all of this as an attempt really for NIDDK to respond and it's very appropriate in Black History Month to what Dr. Martin Luther King issued a charge to really all Americans and a quote that any of you who ever visit the Martin Luther King Memorial will see, this is one of many quotes, is that life's most persistent and urgent questions are what are you doing for others? What are you doing for others? Well, serving others is really the ultimate mission of NIDDK, serving others was Dr. Bryant's mission, whatever field of healthcare, medicine or science you're involved in or you seek to go into, I hope it'll be your mission too, because every time we identify a new way to prevent diabetes or we develop a new pathway that can be targeted to better treat people with kidney disease, I think we are doing a lot. For every day, really in every way, it's really an important question, what are you doing for others? These are irreplaceable precious human beings that we're talking about. Someone's son or daughter, someone's father or mother, someone's brother or sister. I just wanted to conclude by showing you a picture of the NIH and as we focus really our collective efforts on developing new targets for disease, particularly for those who are least likely to receive proper treatment, those most at risk of dying, we serve them, we serve the society, we serve the world and we serve the cause of justice. Thank you again for this invitation. I hope I haven't gone too far over and I certainly like to prepare to answer questions if there are some, please use the microphone if you can. As you approach the microphone, please do identify yourself and state your questions succinctly for Dr. Rogers and we do invite you, we have microphones on either side of the audience here to please come and engage with Dr. Rogers. Hi there, I'm a journalist, I write for the Revard Report, but I'm also a social work grad student at the other school in town. I just wanted to ask you, if based on this research you see some opportunity for mentoring as a way to transmit these healthcare concepts? A mentoring is clearly important. This is an area that we focus on actually quite heavily because if there aren't mentors for the next generation of scientists, of physicians and other biomedical researchers, I think the field would be dead. And we begin at least within our institute of a process of training and mentoring very early. We think because of some of the deficiencies that we see in STEM education, now that high school isn't early enough, we really wanna capture people's attention about the excitement of science and engineering and math. And what we realize now is that, particularly for some of these novel inventions, we, there really is an intersection between classical biomedical research and engineering, mathematics. One example, a case in point in which again the importance of having mentors is in the case of patients with type one diabetes, we're trying to develop artificial pancreas, something, an external device that can replace the pancreas that's been destroyed because of their autoimmune process. Here's a case in which you obviously need endocrinologists who understand the disease, but you need engineers to develop smaller and smaller devices that can be used. You need mathematicians and engineers to come up with appropriate algorithms to not only deliver insulin but other hormones in a way that the body normally does it in response to eating and fasting and exercise and other things. And so it's important that one has, not only these sciences, but you have to have people that have a more holistic view of the issue in mind in place. And so that's an extremely important thing. And we spent an incredible amount of time actually both in our summer programs and our year-round programs to try to encourage mentoring and trainees at appropriate levels. Yes. Thanks a lot for the talk and for making the facts and figures so accessible. So there's some work that's being done here in the Health Science Center by Ralph DeFranco's group looking at early indicators of pre-diabetes and they think, if Ralph is here, I don't wanna speak for Ralph, but I don't know if he's here, but that looking at blood glucose and glucose tolerance tests is finding problems late to too late in the ball game and they've come up with really cool ways to look earlier at islet cell function, which may be earlier indication that you're gonna develop diabetes. The problem is those tests are expensive. They revolve like a lot of sophisticated hardware. So you wanna make diabetes prevention accessible to lots of people, but it's an expensive technology to get them early. How's that gonna figure into things? That's a very good point. By the time that they've already reached that threshold where their glucose tolerance test is abnormal, they may have not sufficient beta cell mass to preserve, to actually reverse that pathway. Actually in that diabetes prevention program, we're able to do a number of things as ancillary studies since in this particular trial, up until about six months from the time that they developed that we know very precisely in this effort. And of course, all of the serum and other biosamples from these individuals who at the time had pre-diabetes had been stored, we've actually set up a number of trials including using metabolomics in general non-biased proteomics. There are actually groups, and you may be familiar with a study that was in nature that said that it's actually a small number of amino acids actually predicted perhaps five years and maybe as much as seven years in advance of the people who would go on to develop diabetes and who are at the highest risk. So these types of early preventive biomarkers are critically important. And again, I know that there are expensive, but again, as the technology evolves, certainly people said that about the first human sequence which cost over a million dollars. That's now under $1,000. And then we hope, there's another reason to bring in engineers and other people from other disciplines to try to bring more cost sensitive approaches to doing these more generally, given the numbers that we're working with. Yes, hi. Thank you so much for the lovely talk. I have a really quick question. If you don't mind for, I guess, illustration purposes, can you please go back to the slide entitled Trends in Childhood Overweight Slash Obesity? I can try, but those of you in the audience who might have problems with seizures, please close your eyes. You're unlearned at all. Forget what I said. Here's, oh, well. Yeah, so when we're comparing the overweight slash obesity rate in 1963 to present, are we using the same definition? Yes. Oh, okay. Yeah, so this again, the definition of obesity in adults, 20 or older or 18 or older, is really based upon the ratio of your height and weight, the so-called body mass index. And in general, anyone with a body mass index of 20, as I showed you on that slide, are considered to have normal weight. If you're 20 or 24, you're considered to be overweight. 24 to 30, you're considered to be obese. If you're 40, you're considered to be, we don't like to term morbidly obese, but excessively obese. These are the patients that bariatric surgery are usually applied to. And kids is slightly different, and if I recall this correctly, this is really based upon being greater than the 90 or 95th percentile. There are pediatricians in the audience who can tell me whether I'm accurate or not. Based upon growth curves that were published by Metropolitan Life Insurance Company, I think largely out of Iowa. So I don't know how generalizable those figures are, but I think that that's the broad idea. So if you're over 90% on that curve, you're considered to be overweight, and you're certainly in the 95th percentile you're considered to be perhaps obese. That definition, I guess, seems to be really dependent upon what the growth curve is at the time of the study, right? I guess what my concern is, are we comparing apples to apples as we look in time and try to compare the current rates of childhood obesity to the present? Yeah, these slides, with these pictures indicate that they take from the CDC is that, on an annual basis, they go out, mostly a lot of this is done with questionnaires, but there are some physical measurements that are taken by the so-called NHANE study. They actually do these measurements. The one thing that we know, particularly in adults, is that if you ask males, they generally overestimate their height, and women generally underestimate their weight, and everyone overestimates how much exercise they get. But in this case, they actually measure their height and weight, and so they actually know precisely. So they measure, they don't measure obviously all the kids, but they measure a substantial swath that they can then, based upon what the population is, at that rate, they can tell what general percentage of the population fits these criteria. And so, from early 60s through mid 2000s, they've been applying the same criteria each time they do this, and so it's not a, it is an apples-to-apples comparison. And that's a good thing, apples-to-apples. Thank you. You're welcome. Yes. Yeah, hi, Richard Yucitin, I'm a family physician. I actually work in the center with Ruth Berggrin and many of the other wonderful people at the Center for Medically Managing Ethics, and thank you so much for your presentation, for your advocacy. I have a few questions. First, I just want to say that I have no doubt that we're seeing greater obesity. I have a nine-year-old girl in my practice who weighs 220 pounds, age nine. So, but the one thing that always seemed like a great missed opportunity in our country is our public education. And I still, to this day, don't understand why we don't teach more about health, why we don't use more good diet, good exercise programs, not just one health class when you're a senior, but actually putting health education throughout the whole curriculum through all the years of our public school. And there are all these fights about whether there's soda in the school, but to me it's so much more than that. And I just wonder what we can do or what is being done to reach kids where we have them in our public schools. Yeah, yeah. Well, I think you raise a very important point. Obviously there's been a lot of attention to the issue of childhood obesity. A number of people have been really making a very public effort, including the Surgeon General, the First Lady, and others. Robert Wood Johnson Program has a program called NCOR, which stands for National, everything is an acronym, something for childhood obesity research, National Coalition for Childhood Obesity Research. And they really attempt to try to take the best practices in certain groups to extrapolate them more broadly. But I think absolutely schools have to be more involved. It's perhaps above my pay grade, but all I can do is recommend studies that come in, that we fund, two of which were actually involved here in San Antonio that were extremely important, the today study, which is a treatment option for diabetes of adolescents and youth, and also the healthy study, which tried to target kids at high risk of developing diabetes. And this involved active participation of the schools, especially that healthy program, where in fact the school is a unit of randomization. Healthy is, by the way, one of the few studies that we funded in which that's not an acronym, that's actually what the kids decided the name of their study should be. But it did run into issues and there are people in the audience who are more, who were actually participating, this could tell you about some of the issues related to taking and changing the school vending machine choices, or making sure that every kid exercised and not a few of them and everyone else watched, or what was actually in the food that were prepared in the cafeteria. These are daunting challenges, but we have to start somewhere. Thank you very much. Thanks. I think we're gonna take one final question from the young lady who's here at the front, and thank you. Thanks. Okay, my name is Andrea Medina and I work as a promotora with People with Uncontrolled Diabetes. I interact with patients every day. I go to their houses and I get to know their stories. One of the big barriers, I was expecting to hear something on your presentation, but you didn't touch much about mental health and you did talk about the insecurities, food insecurities, housing insecurities, but how I missed those, I wanted to know more like what is the NIH doing about, it's a big barrier. So these people need a lot of resources, we don't have much, many resources here, how it's a barrier for them to control their diabetes in a way, so it's really challenging as me going to them and try to help them. I was wondering if there is, like what do you know or an approach that we can use or what research? Well, you raise a very important fact in terms of mental health and diabetes. If you have, I'm sorry. Turns out if you have diabetes, you're twice as likely to have depression and if you have depression, you're twice as likely to develop diabetes. Given this coincidence of event, our institute and the National Institute of Mental Health actually had a workshop just two years ago and the goal was to have something concrete in terms of defined projects that could move forward to kind of advance the feel, to provide the types of things that you're asking. While I have to say that there were a few initiatives that were proposed, there really wasn't anything dramatic that moved forward. This area is particularly problematic, not only in type two diabetes, but also in type one diabetes because of the overlapping issues associated with adherence to using insulin and other medication. So it's a very important problem. The feel of mental health as you know is something that I think only now people are beginning to realize it has to be destigmatized so that people can actually come forward and seek help. But that coincidence with diabetes is a very troubling one and you're right. This study didn't talk about that. I was just talking about economic issues. But this is an area in which we often, we do have a few examples of some behavioral interventions but it really is nothing at the scale of some of these larger trials that I told you about. Dr. Rogers, we're very grateful for your presence here. I can imagine that for a leader in a position such as yours, it's a constant challenge to think about do we take the tools that we know work? We know that metformin can help a lot of people. We know that lifestyle changes can dramatically help a lot of people, even more so than metformin. Does the NIDDK now focus on getting those solutions to people that don't have access to them or do you focus more on advancing science and looking at the genomics? And there's no right answer to that question but considering that type of question requires wise leadership and we're grateful to know that we have such a wise leader at the helm of NIDDK. And would the audience please join me in warmly thanking Dr. Rogers for his presentation. Thank you for those kind words, they're very nice, thank you.