Latha Palaniappan, Deepa Prahalad: “Changing the Course of Chronic Disease […] | Talks at Google

Latha Palaniappan, Deepa Prahalad: “Changing the Course of Chronic Disease […] | Talks at Google

SPEAKER 1: Today
at Google, we are delighted to welcome Latha
Palaniappan and Deepa Prahalad. Dr. Palaniappan is a Professor
of Medicine at Stanford, where for the last 20 years,
she has studied and worked on cardiovascular disease
and diabetes in South Asians. Ms. Prahalad comes from
a management consulting background specializing
in emerging markets, and is now on the
board of Arogya World, where she focuses on
growth and design. And she wrote a book titled
“Predictable Magic,” which attempts to unite strategy
and design thinking. They are here today
to discuss their work at Arogya World, a global health
nonprofit organization working to prevent non-communicable
diseases, e.g. diabetes, heart disease, cancer, and
chronic lung diseases through health education
and lifestyle change. Please join me in welcoming
to Google Latha Palaniappan and Deepa Prahalad. [APPLAUSE] LATHA PALANIAPPAN: Thank
you for coming out today. I’m going to tell you a
little bit about myself. My name’s Latha Palaniappan. I’m currently a Professor
of Medicine at Stanford. I spend most of my
time doing research in heart disease and diabetes. I do work on electronic health
records, mortality records. And I do clinical trials
in Type 2 diabetes, trying to promote
physical activity in people with Type 2 diabetes. And I teach first-year medical
student population health. So that’s how to take care
of large groups of people. And I also see patients in
Stanford’s Executive Medicine program. And we’re trying to start a
genetic and pharmacogenetic testing program there to bring
evidence-based genetic testing. So I want to, before
we start today, have us think a little
bit about diabetes. And I’m going to be presenting
some statistics on diabetes around the world. But if you could think for a
moment why you think diabetes is increasing so
much in prevalence. Now, you probably have
heard in the papers that diabetes is increasing. And I wonder if
anyone in the audience has any thoughts on that. Maybe what brought
you here today? If you have a family
member with diabetes. AUDIENCE: Standard
Standard American diet. Any more color to that? What is the standard
American diet? AUDIENCE: Too much
sugar and fat. LATHA PALANIAPPAN: Too
much sugar and fat. And in fact, one of my
colleagues at Stanford recently wrote a paper that
was published in “JAMA” showing that both low-fat and
low-carb diets, when healthy, promoted weight loss. So that kind of put an end to
the low-carb/low-fat debate, I hope. I think we will
continue to debate about that because people
feel that certain diets work for them more than another. But it did show in the end
that a calorie is a calorie. And having the
appropriate amount of calories for
your body size is helpful for maintaining
a healthy weight and preventing chronic
diseases in general. OK. So let’s talk about the
global epidemic of diabetes. And particularly,
what we’re trying to do in preventing
this epidemic. So this is a graph of
diabetes cases in the US. So you can see, the US– around the world and in the US. So you can see in
the US in green, there are 37 million
cases of diabetes. And the black part
on the side shows you what percentage is undiagnosed. So you can see in different
areas of the world, there are different proportions
of undiagnosed diabetes. And I hope that
you in the audience have gotten tested for diabetes. But can anyone tell me
how we test for diabetes? AUDIENCE: Something to do
with insulin and blood sugar. LATHA PALANIAPPAN:
Insulin and blood sugar. Great answer. So that’s the absolute
correct answer. So we try to check
your blood sugar. So we check either
a fasting number in the morning of
your blood sugar, or what we call a glycosolated
hemoglobin, hemoglobin A1c. Because as we have more
glucose in our bodies, it attaches onto our hemoglobin. And we can measure those levels. And then, another
way that we can do it is through an oral
glucose tolerance test. And that’s sort of
drinking a glucose load, and then checking your
glucose after two hours to see how your body
processes glucose. So all of these things,
you can imagine, are a little hard to do because
they involve blood tests in resource-limited settings. So I hope in partnership
with technology companies like Google, that we’ll
be able to improve the diagnosis of
diabetes, and be able to do it without expensive
blood tests going forward. So you can see in the
world, 382 million people are living with diabetes. And about half of
those are diagnosed and half are undiagnosed. OK. So the top 10 countries by
number of diabetes cases. So the top countries
are China and India. The prevalence of diabetes
is about the same. So about 10%. It ranges in these
countries from 7% to 14%, depending on if
you’re urban or rural, and what your familial
risk factors are. And the reason that
the number of cases are so high in
China and India is because the absolute number
of people are so high right. In China, India, they’re our
largest countries in the world. And so you can see
the US is third there. A distant third. And the number of cases
of diabetes in the US are increasing as well. And the greatest
projected increase is in the Western Pacific. So China, Korea, Japan Vietnam,
Indonesia, and Australia. The number of
cases are projected to increase by about 50%. And this is just a graph
showing the economic background of these countries. So high income is yellow,
upper middle is orange, lower middle is pink,
and low income is red. And so you can see there
again, that the proportion of undiagnosed changes depending
on the economic background and situation of
those countries. With a really high proportion
undiagnosed, again, in India and China. And the high-income countries
having a little bit less undiagnosed, but still a
significant proportion. Even in the US, we have
a significant proportion of undiagnosed diabetes,
simply because people aren’t going in and getting tested. And it does take some
effort to go ahead and get tested for Type 2 diabetes. And Asia represents about 60%
of the diabetic populations worldwide. OK. So we are focusing today
particularly on South Asia. And this is– Dr. Prahalad, who
will speak after me, is the purpose of the
nonprofit reducing diabetes in South Asia, which has a
particularly high prevalence of diabetes. So this is a map of South Asia. We commonly think of India
representing South Asia. And it is a major part
of the subcontinent. And 90% of the South Asians
in California are from India. But also, South Asians are
from Pakistan, Nepal, Bhutan, and Bangladesh, and
Sri Lanka as well. And this is a map
of the Bay Area of the Census in this area,
and what percent of people are Asian Indian by county. So you can see
there, particularly around Alameda in the
Fremont area particularly, it’s about 10% Asian Indians. So 1 out of 10 people
are South Asian. And in Santa Clara, where we are
now, about 1 out of 15 people are Asian Indian. So this is a study I
did earlier in my career looking at mortality
records of California, and looking at
coronary heart disease. Because diabetes is a risk
factor for heart disease and diabetes prevalence is so
much higher in South Asians, particularly among
young Indian men. So 25 to 44. Their risk of heart disease is
almost three times as high– so that tall red bar. Compared to the
total population, which is in green, the
non-Hispanic white population in orange, the Hispanic
population in blue, the African American or
black population in brown, and the Chinese
population in blue, and Japanese population
in yellow there. And the Indian
population is in red. And what got me into
the business that I’m in is that my father died
of a heart attack at 39. I grew up in Michigan and
lived there at the time, but he represented that
three times higher risk in the young men 25 to 44. So I encourage you, if you
know of anyone in this race ethnic group, they’re at
particularly high risk for heart disease
and should be tested for diabetes and other risk
factors for heart disease. So this is another study that
I did using data from Palo Alto Medical Foundation. So we collected race
ethnic information at Palo Alto Medical
Foundation, because it is so highly prevalently Asian. So the Bay Area is
about 30% Asian, and it has good
representation of all of these Asian subgroups. Anyone here get their care from
Paul Alto Medical Foundation? It’s a great place. It’s a good place to get care. So you can see that all Asians
in general have higher odds. So this is the likelihood
of having diabetes among that group compared to
non-Hispanic whites, about double the risk. So men are on the
left, women are on the right in all the arrows. And the statistically
significant numbers are in bold there. So you can see that among
the Asian subgroups when you aggregate them, there is
a higher risk of diabetes. And when you disaggregate
the Asian subgroups, some groups have much higher
risk than other groups. Namely, Asian Indians and
Filipinos in this case have three to four
times the risk. And other Asian groups
also have higher risk, like Chinese,
Japanese, and Korean. And these are all
age-adjusted as well given the slightly younger
age substructure of Asians in the US. OK. So why do Asians and perhaps
Asian Indians in particular have more risk of diabetes? So this is a paper
that was published in “Lancet” by two of the people
that I consider my mentors, [INAUDIBLE]. And they’re at an
Indian wedding, so you can see the
saris in the background. And [INAUDIBLE] is the
non-Hispanic white researcher on your left and [INAUDIBLE]
is the Indian researcher on your right. And you can see that they have
an identical BMI, Body Mass Index, of 22.3, but
their body fat– and sorry, it’s covered
there by the notation– the slide advancer. But it’s three times as high
for the Indian researcher. It’s about 9% versus 27%. So at an identical level of body
mass index, there’s more fat. And so next to them,
they have DEXA scans. So these are scans that
we normally do for bone. But you can also see fat
and muscle in those scans. And in a DEXA scan,
muscle is more white. So you can see the
non-Hispanic white researcher has more muscle. You can see it particularly
around the thighs, in the abdominal area. Whereas, the Indian
researcher does, it is more sort of
dark on that DEXA scan. So that’s indicative
of more fat. So Asians– based on data
like this and other work that I’ll show you, the WHO
recommended a lower body mass index cut point for Asians. So it’s 23 and lower. And for non-Hispanic
whites, it’s 25 and lower. So this is a study
that I did showing that at similar levels
of body mass index, there is higher
risk of something called metabolic syndrome,
which is pre-diabetes. It’s a combination of
triglycerides, low HDL, which is the good cholesterol; high
glucose, obesity, as well as blood pressure greater
than 130 over 85. So you can see on the x-axis,
on the horizontal axis, is the body mass indices. And on the y-axis
is the probability of having metabolic syndrome. And Asian Indians
are on the red curve and non-Hispanic whites
are on the blue curve. And you can see that at every
level of body mass index, that Asian Indians
have higher probability of having this pre-diabetes. And it is very difficult
to have a BMI of 23. At this moment, I stand in
front of you with a BMI of 23. But sometimes, on Mondays after
a weekend of lots of parties, I gain 3 pounds. And I’m a very short
person, and my BMI is 24. So it’s very hard to
maintain that BMI of 23. But I have to do it because I
have to practice what I preach. So you can see here– and this
is also from Palo Alto Medical Foundation– the
range of body mass index for non-Hispanic whites
on the left and Asian Indians on the right, for women on
the left and men on the right. And you can see that a BMI of
25 and higher– so 50% of women in the Palo Alto Medical
Foundation Electronic Health Record Database. So there’s about a million
people in that database. 50% of non-Hispanic women
were at at-risk BMI. And about 60% of
Asian Indian women had a BMI of 23 and higher. So we have a long way
to go to get people at the appropriate
level of weight. And for men, it was 8
out of 10 non-Hispanic white men were not at the
appropriate or optimal weight. And 9 out of 10
Asian Indian men. So when I was at Palo
Alto Medical Foundation, I had a specific clinic
for South Asians. And 9 out of 10 of the people
that I saw, we had to do work to get them down to a
lower level of body weight. So when you go to
see your doctor, your doctor might use your
clinical data, including your gender and your HDL,
your good cholesterol, and your total cholesterol. And whether your blood
pressure is high or low or whether or not
you smoke to estimate your risk of atherosclerotic
cardiovascular disease. This is called an
ASCVD risk calculator. So one thing that I
want us to be aware of is that these risk
calculators are mainly based on non-Hispanic
white European populations. And they might underestimate
the risk in some groups, such as South Asians. I also do work in disaggregating
Hispanic subgroups. So Puerto Ricans and Cubans
can also be underestimated. So you should be aware that our
current risk calculators may not be accurate in all groups. And we should be
aware of what data was used to create
those risk predictions. And I hope that with aggregating
larger and larger data sets, that we’ll be able to
improve our risk prediction. OK. So what can we do? And Dr. Prahalad, who
will speak after me, will speak a little bit
more about the nonprofit and what they are
doing specifically. But you know, we heard that it’s
sort of the Western lifestyle. And you sort of hit it right on
the head with red meat, sugar, sitting at a computer, smoking,
refined grains, traffic, alcohol, sort of
all of these things that are contributing to
the diabetes epidemic. But one thing that I want to
sort of point out in a point that I make is that
in rural areas that have agrarian lifestyles,
diabetes rates are actually quite low. Subsistence farming
isn’t a great way to live for a lot of reasons,
but diabetes is not very high. So people tend to have a lot
of physical activity, not a lot of calories, not a lot of
trans fats or saturated fats. And diabetes rates are low. But then, when they go to
more of an urban lifestyle with eating Big Macs and
fries, so high-fat diets as you mentioned, these
rates of diabetes and cardiovascular
disease can go up. But then, we get to
live, maybe in an area like we do in the
Bay Area, where we have access to
exercise, like SoulCycle, and Orangetheory, and Pilates. And also, access to great
food, like Sprouts and– I don’t know. l think there
must be 10 different salad places here. And so when we improve
our socioeconomic status in this country, we can
also lower diabetes rates. So in the US, people with
higher socioeconomic status have lower diabetes rates. And this is changing in
developing countries. But in general, people with
lower socioeconomic status in developing countries had
lower rates of diabetes. And this is called the
epidemiologic transition, when you go to higher
socioeconomic status in developing countries
and have higher rates of chronic disease. But we’re seeing that flip
a little bit now as well. But how can we avoid this
lifestyle transition? How can we in
developing countries go from this Agrarian
lifestyle to one in which we can translate to more– higher SES in higher-income
countries’ lifestyles? So I think there’s
many ways to do this. And Dr. Prahalad will talk a
little bit more about these. And this is from a paper I
wrote for the American Heart Association looking at the– it was called “The Community
Guide,” about how communities can improve rates of diabetes. So there’s many axes on legal,
community, as well as risk factors and early diagnoses. So one of the things that we did
for diet was banned trans fats. So many countries have
banned trans fats. And that has helped. It has bent the curve in terms
of lowering diabetes rates. Also, the sedentary lifestyle. And I think Google has
been wonderful in providing all the wonderful bikes
outside and other healthy– encouraging healthy habits. I saw lots of fruit
available outside. And trying to decrease
even sitting at a computer. So getting up and taking breaks. I ask my patients
to do that a lot. It will go a long way
towards preventing diabetes and other chronic disease. Tobacco. So we don’t have
tobacco advertising on our TV stations for
our kids to see in the US. But this is something
that could be implemented in developing countries. And unfortunately,
developing countries are the place that
the tobacco companies are going to advertise
more and get more smokers. So that’s something
that hopefully, we can prevent going forward. And treatment of high
blood pressure and lipids. So guidelines on how
to screen for this. I talked a little
bit about that. As well as early recognition
of symptomatic disease, perhaps with screening
with coronary artery calcium and other newer
biomarkers that are coming out. So I think we’ve come
a long way in the US. I think that we
have learned lessons here that would be great to
transmit to other developing countries. And I’m looking forward
to hearing more about how we can do that. [APPLAUSE] DEEPA PRAHALAD: Thank you. It’s an honor to be here. And I am just going
to load my present– how do I get the [INAUDIBLE]? OK, there we go. Thank you, everybody,
for coming. And I would like to just
spend a little bit of time– I think Dr. Latha Palaniappan
has done a fantastic job of talking about some
of the unique challenges from a medical standpoint. And as a nonprofit, we really
have this additional challenge of saying, we have
this information, but how do we make
it actionable? And how do we create awareness? Because I think we all
know in emerging markets, the awareness is an issue. The education levels. And a lot of people who
are in rural areas– culturally, there are
even terms that said, diabetes is a rich
person’s disease. So the awareness that
this could happen at all is not there in many cases. And we also really said when we
looked around at our community here, there really isn’t
a single family that hasn’t been touched by one of
these diseases in some manner. And so that’s how
I got involved. I don’t have a
clinical background. But we really are trying to
use design and innovation to help drive awareness and
some kind of actionable steps in this process. So what we really did is
we have a nonprofit called Arogya World. Arogya is a Sanskrit
word that means health, to live a life without disease. And we really
said, let’s see how we can do some kind
of actionable course to change the course
of chronic disease. And we really settled on
three fundamental pillars of awareness, action,
really providing people tools, not just information. And creating alliances
with people who had information that we could
bring to a new audience. Currently, we’ve reached
about 3.7 million people. And we have plans to double
our outreach by 2020. And I’m not going to
spend a lot of time on this, because I think it
was especially well-covered. 66% of the deaths
in the world are from non-communicable diseases. And these are 80% of the
deaths in developing countries. And the economic impact of
that is absolutely devastating. And this is really
kind of the challenge in emerging markets is you
have a lot of what I would call this good/bad news,
where a lot of this is because of increased life
expectancy from dealing fairly well with infectious disease. So now, people are
living long enough. But because of the
demographics, you have this challenge where you’re
dealing with malnutrition, and diabetes, and heart
disease at the same time, which makes it extremely difficult
to get information across. And we know ultimately
that three behavior changes can really change the
course of chronic disease– healthy eating, exercise,
and avoiding diabetes. And the gains from that
are quite significant. We can actually prevent 80%
of diabetes and heart disease and 40% of cancers. That is provided the information
is available and acted upon. And so that’s what we
have tried to address. And I think where we
realized how important this is, is because despite all the
economic growth that people are excited about, this can actually
cripple any economic gains made in many emerging countries. We have 50% of the population
that dies from chronic disease. 20% of the population
has at least one of these– heart
disease, diabetes, or some type of cancer. And Indians also get these
diseases much earlier in their prime working life. So you can see the
statistics of $4.8 trillion in lost economic output
by 2030 is significant. And if people don’t
have that themselves, they tend to be very concerned
because they tend to be caregivers for their parents. Young professionals
of both genders tend to take on
that responsibility. So it’s an issue even
for people who are not suffering from one of these. And what we realized
when we did, I think the first
10,000 women survey, is that this economic impact is
particularly severe for women. Women have been the focus of
a lot of development efforts. And what we did was take 10
countries around the world. And we surveyed 1,000
women and said, what is the impact in your lives? And what we’re finding
is that 50% of people– women are saying,
yes, we are having to be the primary caregiver for
even one person with an NCD. That can cut family
income by half. And it also means that
about 25% of people who were in our
survey were saying that they have been
forced to leave the workforce for
extended periods. So we decided to say, all right. How do we empower women? And that was a fine line,
because I think many efforts today in wellness– while their focus
is women, they tend to overwhelm and place
a lot of extra burden solely on one person who may
be overburdened in any case. And we said, we need
to design something that’s flexible, lean,
and can be adapted. Because India is a very
rapidly-changing environment. The types of phones that people
have where they could receive messages, where they can
understand what their risk factors are changing. And many of the rural
areas, what has happened is that they are
very exciting targets for multinational companies. What can be offered
cheaply however, is not the Sprout stuff. It’s the junk food that stays– has a very long shelf life and
it doesn’t wear out easily. And what’s happening is that
those are the first things that are offered, because
kind of an entry point to a new
group of consumers– and there isn’t a
lot of awareness. People tend to like
those because they’re in small sample sizes
and because they’re seen as very hygienic. So it’s a huge problem. And this is the first
generation in many cases in some of those
areas that can afford to give these kids treats
that they never had. So we knew we had to really
have a low-cost, scalable, and user-friendly
way to do this. And what we settled on is what I
call our doorstep health model, where we basically say the best
way to help women and families is to make sure that they
are not the sole person. They are trying to take charge
of their family’s health. We know that
they’re the drivers. But we have a
school program where children in seventh
and eighth grade get a set of really interesting
game-based exercises where they have the awareness
created at an early stage. We have a workplace initiative. Many employers are really
interested in making sure that their employees get
this information early on. And for many people who are
out in very disparate areas, we have mHealth
messages that come over. And they are very simple,
action-based messages. We don’t give anybody
statistics about diabetes. We tell them concrete
things they can do– reduce your intake
of these grains. So we’ve created a
very friendly voice that is geared toward inspiring
people to take action. And quickly, we have actually
a list of our genesis we’ve created. Our newest thing
is an initiative called MyThali, which is
basically similar to the US government’s
MyPlate, where we’ve taken nutritional
guidelines and tried to create an icon-based system
so people actually understand visually what these
guidelines mean. And what we have found
in terms of our focus is really saying that we
want to use technology to spread awareness,
but we’re not going to become a
technology company. That’s not our focus. We’re not trying to create tons
of cool add-ons to our text messages or even our
app in the workplace. What we’re really trying
to do in the workplace– we will have an app that allows
people to measure and record. But for that text message
program, what we’ve really done is give people very
simple messages. And we’ve tried
to motivate them. We didn’t want to have
the voice of a clinician. We all love and
respect our doctors. And we get the most expensive
ones that we can afford, but we don’t want to
talk to them every day. Nor do we want to be gentle– have gentle reminders
from friends and family about what we should eat,
when we’re over-eating. And so having that encouragement
was really important. What we also realized after
we had text messages going out for many months in
different languages is, of course like anything
else, it becomes easier to tune out. So we partnered with a
company called [INAUDIBLE] that does periodic voice
messages as well, where you actually get a phone call. A message of encouragement. You get a story from
somebody else to say, oh, this is what I tried. Here’s a recipe. Here was my success story. And so we really designed
to inspire action. And we have this
self-reinforcing model of workplace, school,
and text messages. So that we make sure that we
have the same thing coming in from various places. And what we were very
encouraged to find in our very first survey when we
reached a million customers is that for an mHealth
initiative, we actually were able to
achieve a 15% impact based on our surveys,
which is highly unusual. Nokia was our initial partner
in sending out these messages. And people reported–
15% of people reported 4 behavior changes. In the workplace context over
time, what we would like to do is really do some kind of
clinical measurement for people who opt-in. And we had a very good response
from the younger generation, which was the most encouraging. We had a lot of students
reporting that they had no idea about diabetes. They had kind of heard a
little bit about junk food, but a lot of teachers said that
these simple activities really brought the message home. So in seventh
grade, what we do is we have children take
part in activities. But in eighth grade– they do a two-your
curriculum with us. In eighth grade, they bring
their parents and families in to also receive this information
and get concrete tips. And people said that
was incredibly helpful. We’ve partnered with some of
the leading NGOs in India, like [INAUDIBLE]. And we basically give
them training materials and expand our reach that way. One of the really exciting
things we’re doing is this initiative
called MyThali, which we are doing for both
North and South Indian food. The nutrition
guidelines in India are very complicated, even
for highly-educated people to understand. When they say, we need 250
grams of rice or we need this, what does that actually mean? So we’ve created an
icon-based pictorial model. We are also working to over
time, physically create a plate and serving spoons
of appropriate sizes, so people are able to
quickly and easily comply. So a lot of our focus is exactly
on that, is really creating a lot of ease of compliance. And then, our school
program we also were able to achieve a 14% impact. And what we really
had was simple things relating this battle
to snakes and ladders. You know, this is just such a
fundamentally different issue for India, because the entire
health system has been really geared toward
infectious disease, where you do need to have
these limited interventions, where you have to
convince someone to take a vaccine or something. But lifestyle diseases
are different. And the system is
not set up for that. So we found that these
very easy, visual ways of communicating
and giving people the idea of what the impact of
obesity can be, wear a backpack and try to do a race with all
these extra pounds on you. Those are the kind of
things that make it real and tend to have a really
experiential component that stays. And we have also signed up a
lot of leading Indian corporates and organizations, like
the Indian Railways, which is the largest
employer in the world. And with 1.3 million
employees, Reliance, Wipro, many of these
companies, to say, here. Here is a simple,
downloadable app. Get the text messages. And now, we have
worked with them and we have partnered with
activity tracking companies and created an
app so that we can be a one-stop shop
not only for diabetes, but for overall wellness. And we are testing and
measuring the impact of that going forward. And we are covering about 2.3
million employees currently. And we’re expecting
that to increase. And what we knew also was that
anything that we designed, we know that both the
tools, the information, the guidelines around
all of these diseases are evolving very rapidly. So we didn’t want to be
too rigid in our design. We just saw this exciting
news about Google having an AI eye scan that
can detect your cardiac risk. We know that we’ve been able to
limit the pinpricks with some of the diabetes
measuring devices. Even our understanding
of what healthy eating is continues to evolve. So we realize that kind
of positioning ourselves as experts wasn’t the way to
gain long-term credibility. What we wanted to
be was somebody who was a friend and
partner along the journey and able to create
a conversation to have information exchange. We also want to always be able
to learn from the people we’re trying to serve. So for example, in our schools
program, what we learned is we gave people information
about a healthy breakfast. And we realized, there’s
a component of 10% to 15% of people who maybe don’t
get a breakfast before they come to school. And their primary
meal during the day is actually at their school. So we said, how do we
then revise, and rethink, and help families understand
what they can still do? And we realized that
this two-way information flow was going to be critical
for us going forward. And that’s how we have
structured all of our programs, with continuously
getting feedback as well as giving suggestions. We are very excited. We’ve been able to reach
this kind of impact only because we’ve had
amazingly committed partners who have helped us really expand
in schools, workplaces. This is a very small
number of them. And what we got as we learned
a lot is people saying, we need this
information in the US. What you’ve learned
and the cost at which you’re able to
deliver impact really could make a
difference in the US, in Europe, in other
emerging markets. And we agree So what we are trying
to do is actually take what we’ve learned
and expand our reach here. We’re experimenting with
an Indo American Center here in Chicago, and trying
to see how we can best adjust some of our
programs to audiences in different parts of
the world because there’s different access and
a different awareness. We started a California
working group last year. And as far as going
forward, how would we like to expand our reach
is really getting feedback, having people get involved. Never ones to turn
down a donation, we’re at But what we really want to do
is have people share information with us on how they were able
to create those lifestyle changes for themselves,
for their family. Because we really believe
now we have a channel to distribute that
information far and wide, and help us really spread
the word and have an impact. And I think the cost at which
we were able to reach people is pretty amazing. Given other alternatives,
we’re able to create outreach for $0.50. We can actually create impact
and behavior change based on our surveys for about $6.50,
which is highly unusual in this type of an effort. So we’re really proud of
what we’ve done so far, and happy to take any questions
and get your feedback as well. Thank you. [APPLAUSE] SPEAKER 1: I have a question. DEEPA PRAHALAD: OK. SPEAKER 1: So you showed the
picture of the Google scan. I think it was of an eye. And I guess that’s one
example of something Google is doing on this front. Is there anything else that you
admire that Google is doing, or that you would like to
perhaps partner with Google on, or some technologies that Google
is working on that you think might be able to help
Arogya on its mission? DEEPA PRAHALAD: Well,
I think one thing– do you want to come up here? One thing that we have seen some
interest from in our workplace offerings is really saying– you know, young employees
in India, for example. Even if they are not
personally affected, the burden of caring
for parents is something that really looms
large for a lot of people at a very young age. And kind of the social
contract culturally is that children really
take care of their parents in their old age. And because they get the
disease so much younger, really helping young
employees understand how to care for their
parents is one thing. We have seen, even
in the US now, because so many people
wear activity trackers, they’re able to integrate
some of that information into city planning. India is at a stage where now
you’re saying, OK, there– to prevent this migration from
rural areas to urban areas, and all the consequences
that entails, people are able to use
that data from activity trackers to do smarter planning. There are probably 400
to 500 cities in India that are saying, we need
to create infrastructure so people stay where they are. So understanding,
how does that work? What does that mean? That’s one of those
really interesting things. And I know the tech
companies and the pharma have been really
involved in trying to create new diagnostics
and new ways to monitor. So anything that lets
people do that at a lower cost will make this
disproportionate impact, I think, in
countries like India. LATHA PALANIAPPAN: So I agree. And to build on
that, for my patients I would love some type of
noninvasive glucose monitoring, because I think
it is really hard. Currently, you have
to prick your finger, and put it on a
little piece of paper, and stick it in the machine,
and see what the number is. So some way– and I’ve worked
with some companies that are using light technology to
perhaps look at the wavelengths on hemoglobin to see what the
glycosylation of the hemoglobin is to detect the glucose levels. So noninvasive glucose
monitoring as well as continuous glucose monitoring. So my patients are
so surprised by when they eat, if they
prick their finger, their glucose is higher. And sort of really
connecting what you’re putting in
your body and what’s happening to your glucose. And what is happening long term
to your heart disease risk is, I think– would be great to connect
the dots for our patients. AUDIENCE: I think
the health data that you showed
at the beginning, it’s mostly very broad. And I guess, it’s
quite epidemiological. Sorry about that. LATHA PALANIAPPAN:
Yes, epidemiological. AUDIENCE: But I feel
like there’s actually more detail available. For instance, with
a plant-based diet. So if you look at the
Adventist studies and so on. So I feel like it could be
a little bit more aggressive maybe, about promoting
very particular things. Say, you’ve cut out the cheese. Maybe that’s not so
big a problem in India. But like, I’m from Germany. So I was eating a lot of cheese. So basically, cut
off the cheese. How about the other thing? Basically, you go from avoiding
meat and you avoid fish. But you also look at
all the opportunities that it actually increases
your quality of life because it’s not just
about losing the weight. I think basically, the
thing is a little bit– the gist of I think what you
have in your health information is mostly lowering
your weight, so you reduce your risk of diabetes. But there’s a whole host
of other side effects which are positive basically,
by particular diet changes. And also, of course,
exercise that comes with it. LATHA PALANIAPPAN: Absolutely. I completely agree with you. And to restate a
little bit is sort of like there were some broad
strokes about diabetes rates and sort of an ecological
sort of argument that increased diabetes
is caused by increased obesity in general. When I talk to patients,
I talk about sort of kind of rough
tuning and fine tuning. So one third of the
people in this country are at normal weight. One third. One third are overweight
and one third is obese. So in that one third
that is normal weight, I agree that fine
tuning is very needed. So looking exactly at
a 24-hour food recall. So that’s what we do
with our patients, like seeing what they
ate in the last 24 hours. And seeing where there
can be more protein and a substitution for more of
a whole grain than a refined grain. And some of these interventions
that are culturally specific, like the My Thali. I did a study where
we interviewed South Asian patients. And they would go
see a nutritionist. And the patient said,
oh, they told me not to eat burgers and
fries and cheese. And they never ate those
things anyway, right? So nobody ever told them
about chapati and dal. And you know, that dal
is mostly a carbohydrate. And if you want
protein, you might have to look at other sources. I do studies on physical
activity, actually. In those normal
weight diabetics, like, is it better for them
to do strength training or aerobic training? So we have a study where
we’re randomizing people to strength training only,
aerobic training only, or a combination of both. So I agree, there’s
plenty of room for fine tuning both diet
and exercise that should be done on an individual level. So I agree with you. DEEPA PRAHALAD: And I think
from the nonprofit side, we were just
concerned that a lot of the basic-level awareness
just isn’t there at all. Because historically,
it has been a luxury to eat sweets and everything. So even if you look
at the terminology in some Indian languages,
diabetes is the king’s disease. AUDIENCE: Positive
message also, right? Here, it’s blueberries. Maybe it’s mangoes or
something else in India that people really like. DEEPA PRAHALAD: No, that is
what most of our text messages– yeah. AUDIENCE: They’re
very sweet, right? But they taste good. They taste good and
they’re healthy. DEEPA PRAHALAD: That’s the
text message program, is we really tell people what
they should do instead. We don’t give them any
statistical data at all. What we do is these
changes would help you, would help your family. But that’s the rub is that a lot
of these things that are quite healthy have become expensive. And that’s what we’re
always trying to balance. And that’s true as well here
among lower-income groups. So that’s always the challenge. You know, you can give
people information that’s not actionable. So we’re always
trying to refine. And so we have very different
messages in the workplace program for example,
versus what goes out to a more general population. LATHA PALANIAPPAN:
Sort of, how can you continue to eat like a
pauper when you can afford to eat like a king, right? That’s difficult. Thank you. SPEAKER 1: All right. Well, thank you,
Dr. Palaniappan. Dr. Prahalad. Thank you, everyone, for coming. LATHA PALANIAPPAN: Thank you. [APPLAUSE]

3 thoughts on “Latha Palaniappan, Deepa Prahalad: “Changing the Course of Chronic Disease […] | Talks at Google

  1. While she did say "when healthy".. A calorie is not just a calorie. Reductionist approach, missing the other effects, like worsening gut flora on a LCHF diet, as well as what especially saturated fat does to the cells:

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