Professor Jaspal Kooner: 15 odd years ago, I went to the bank manager, I said, look, you know, we are in this position, hospital is very supportive, but 10 is going to become 20 and if we do this, it's not going to work long time. So I need to buy a warehouse to put these freezers. So, I had identified a warehouse where I think we could have put these freezers. So he said, how much is it? I said, it's a million pounds. And he said, how much money do you need? I said, I need a million pounds.
Dr Rupy: Welcome to The Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition, and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. If you are listening to this and you are of South Asian descent, this episode might be a bit of an uncomfortable listen because what we're chatting about today is why, despite the advances in medicine, people of South Asian origin are twice as likely to suffer from cardiovascular disease, three times as likely to have diabetes, as well as many other related diseases that you can think of, including cancer and dementia. And I know the title of this pod is why South Asians are at worst risk, but the honest answer is we still don't have a good idea. And this is why if you are between the ages of 18 and 85 and of South Asian heritage, look at the description in the podcast show notes on your pod player right now. There is a link right at the top of this episode for the biobank study at sabiobank.org, that's S A B I O bank.org. Click on the link, stop listening to this pod for about five minutes and book an appointment immediately. You'll get a free, full health assessment, including bloods, lipid assessment, body composition, retinal photography, plus a full breakdown on your risks and advice on where you need to get your numbers. Your data is completely anonymised and you'll be contributing to a major worldwide resource for medical researchers for decades to come who can finally answer these important questions that explain the disparity in health between South Asians and others. Now, I've done a bunch of these well-being assessments in the past myself because as someone who is interested in nutritional medicine, preventative health and someone from South Asian descent, I know my risk is much higher than my colleagues and my risk is further multiplied by the fact that I have had cardiac arrhythmia. Thankfully, that has resolved, but my history alone puts me at further risk, which is why I need to be really hot on prevention. And trust me, these assessments cost hundreds of pounds each, if not thousands, but the trial will give you the assessment absolutely free and you'll be contributing to the most ambitious research study of a generation, which could generate personalised medicine recommendations for a quarter of the world's population who are largely underrepresented in current research. We've talked about underrepresentation in research in previous podcast episodes as well. My guest today is Professor Jaspal Kooner, who is leading the South Asia Biobank study. Professor Kooner is one of the leading cardiologists in the country with over 30 years experience in the treatment of general cardiovascular disorders. He is a consultant at Imperial College Healthcare Trust and an active researcher who has pioneered some major discoveries and published numerous times in journals such as Nature, including research revealing novel genetic variants that underlie coronary heart disease, type two diabetes, obesity and other highly prevalent disorders. I think this podcast is going to be a real inspiration, particularly for young medics out there or people just thinking about medicine because Prof shares his stories of upbringing in Nairobi and his move to Kent in England, plus his journey to medicine, through medicine, his thoughts on medical education today, when he first learnt of the disparity between health in certain populations, as well as how he navigated the system. I really hope by the end of the podcast you realise the graft it has taken to get here. There are some absolutely amazing stories, including about how he sold the vision for this study and others preceding it through sheer determination, asking a bank manager for a million pounds when he had no money himself and having to store research freezers in hospital corridors, all will become clear when you listen to the pod. And remember, they're looking to recruit over 200,000 people of South Asian origin for this study. And I've already contributed and if you're of South Asian background, please just go check it out, sabiobank.org. It was a pleasure to sit down with him for about an hour and a half. I honestly could have chatted for longer, but for now, please do enjoy my conversation with Professor Jaspal Singh Kooner. I want to start by talking a bit about your career, okay? So most people will know you as one of the most eminent cardiologists in the country. You've been published in multiple journals, you know, you've got incredible academic colleagues and you've had papers in Nature and, you know, everyone sees that side of things. That's the, that's the stuff that people can find online. What we can't find about, find out about is a bit about you as a person, your, your clinical career. So tell us, first of all, where did you, where did you grow up?
Professor Jaspal Kooner: So I was born in Nairobi in Kenya. Um, and we arrived at the time of the big rush in the 1960s. Uh, I was around 10 at the time. So we found ourselves in Gillingham in Kent. And that's where I grew up. I went to school in Gillingham in Kent. Um, so I went to Gillingham, ultimately Gillingham Grammar School, which was a great, great school to be in. And, um, so yeah, having done my O levels, A levels and so on, then I progressed on to medicine at St Thomas's.
Dr Rupy: Amazing, amazing. I did not know that, that you grew up in Nairobi. And so when, when you came over here, it must have been a very different environment. I mean, how, how did you, how did you fit in? I mean, you're clearly Sikh, you have a turban, what was that an easy transition for you or?
Professor Jaspal Kooner: Um, it wasn't easy in those days. So Gillingham had a population of about 100,000 people. Uh, there were, I think no more than five Asian families. Uh, we were the only turban Sikhs, my brother and I in our school. Uh, so, you know, we, we confronted a mixture of curiosity, intrigue, uh, periodic bullying as one might expect. Uh, but actually on the whole, I think, you know, it was incredible how well we were embraced at all walks of life. You know, you imagine that scenario in the 1960s and everything that went on at that time, we felt so incredibly lucky to be in an environment where we were, you know, nurtured, uh, our parents were appreciated, uh, you know, our hard work in various areas was appreciated. Uh, our, um, you know, sporting prowess was, uh, appreciated. So I played a lot of hockey.
Dr Rupy: Ah.
Professor Jaspal Kooner: And so that gave me a kind of a, a bit of an edge at school and allowed that level of integration actually with my, uh, with my friends.
Dr Rupy: Yeah, I, I find, um, sport is a fantastic connector as, as well as food and other attributes, but, but sport, I find is something that really rallies people, uh, together across different cultures. And I think if you can have a shared interest in something like that, it, it definitely breaks down barriers.
Professor Jaspal Kooner: I think definitely and more so at school. Uh, because, uh, you know, academia at schools is, is not necessarily the priority and certainly wasn't the priority in those days. And the schools like to have good teams, uh, and, you know, if you went round with your friends, that was one area where you could actually find a great deal of commonality. And if you had something to contribute, uh, then that was, uh, you know, a positive thing, positive to develop those friendships.
Dr Rupy: Mm, yeah. And were your parents in medicine as well? Was that, was that something that was in the family?
Professor Jaspal Kooner: No, no, not at all. I think my father, uh, went out to Kenya from India in his teens. Um, he, uh, I think may even have been 16 or 17, he presented to be 21. He joined the British Army in Kenya. And soon after the war, he then joined the East African Railways. So he actually worked in the East African Railways. And my mother, she was a housewife in Kenya. So when, uh, we came across here in the 1960s, he went and worked in the local factory for 15 years while he was here. And my mother became a seamstress. That's what she did at home in Nairobi. So she joined a women's factory as a seamstress. And they, you know, like our parents put an incredible amount of effort, uh, into educating us, looking after us. So medicine, um, is this generation. My mother comes from a family of people in the armed forces. My father comes from a family of farmers. Um, they found themselves, uh, doing kind of factory work while they were here. And it just so happens that in this generation, I mean, you know, I obviously went to medicine at St Thomas's. Uh, my, I have two brothers, they went to University College to do dentistry. Uh, and my sister went into teaching biology. Uh, and then, you know, as we look at the next generation coming on, I don't know, I think we've got about 13, 14 doctors and 12, 13 dentists in the next generation. The family's just mushroomed into a kind of medical family from, from, you know, my father's generation, which was nothing to do with medicine.
Dr Rupy: Wow, wow, single-handedly the family is, uh, populating all the staff needed in the NHS. Well, you know, I think, uh, you can, you see it's, you see the challenges of the NHS from different dimensions. Uh, I mean, I see it from my angle, my wife is a GP. Uh, so I see it from the GP angle and the kids are training, uh, and so I see it from the junior doctor's angle, you know, from a window of a family as opposed to multiple, uh, you know, junior colleagues which I've worked, had the pleasure of working with over many years. So it gives you a different perspective and different pressures, um, in the NHS and family life.
Professor Jaspal Kooner: Yeah, yeah, yeah, absolutely.
Dr Rupy: And, and so, I mean, it seems like, um, everyone, uh, including your siblings were, were interested in science at a very early age. Where, where'd you, where'd you think that fascination for science came from if it wasn't from your, your parents?
Professor Jaspal Kooner: Uh, I think because, uh, personally, I was just so bad at arts. Uh, so you gravitated, you gravitated to something that you could do. And initially it was maths and science. And so, you know, you start working at things where you're good at and then, uh, you know, took on science subjects at school. Uh, that's how it happened.
Dr Rupy: Mm, amazing. So, so walk us, uh, through your career a bit because, um, you went to St Thomas's. What, what was it like after you graduated, um, and, and how did you decide to follow your career which eventually led you to, uh, both academia but also with the specialty in cardiology?
Professor Jaspal Kooner: So, uh, St Thomas's, when I joined St Thomas's, uh, you know, again, like Gillingham in Kent, uh, I was one of two, three Asians in St Thomas's. St Thomas's was a small medical school. Uh, we had 60 graduates, uh, uh, in our, in our year, which is a far cry from what you see of hundreds of, you know, graduates in each year at medical school. Uh, so it was very, very, uh, kind of, uh, cozy environment, everyone knew everyone. Working your way through a medical degree. And the incredible thing about training in those days was mentorship. Um, we had incredible physicians and surgeons at St Thomas's. Um, in a way that even now, looking back, uh, I find it difficult to find those kind of role models in this day and age to what we had in those days. That mentorship, um, uh, was crucial. You saw people, you know, at a, delivering at a very high level and that was inspirational. So we had, you know, very good cardiac, uh, physicians, cardiologists who were innovating at the time. And that sort of drew me to a specialty in my undergraduate year. And I did a house job at St Thomas's. My first house job was in cardiac surgery actually, uh, working with two cardiac surgeons and, um, a chap called Mark Bainbridge and Bryn Williams and, uh, Mark was an incredible teacher in addition to a good surgeon. And, uh, you know, these guys used to do three or four cases in a day. Uh, and bypass operations in a day. Now I have to tell you today, if a surgeon does four in a week, he's considered to be a busy surgeon. Uh, okay, so that's 2021. In those days, he and Bryn Williams used to do four cases a day. And there was the two of them, there was a senior registrar, a registrar and myself as a houseman. So I was, as a houseman, had to look after all the patients on the ward because they were so busy operating and when I'd done the wards, I was called into theatre and my job was actually to come and take the vein out, to harvest the vein so that I could hand over the vein for the bypass and then they would get on and do the bypass and I would end up closing the leg. And, you know, in those days, uh, you know, I was the first one to start and I was the last one to finish and, uh, that's, that's, that's how it went. So I enjoyed that job. I enjoyed that job because it gave me an insight into cardiovascular medicine and then I joined, uh, the ITU at St Thomas's, which was also very, very high-powered unit, uh, Mead Ward, it was called and we had an incredible ITU, uh, kind of a position. Um, and, uh, these guys used to, didn't used to write many papers, but they used to write monographs and books and the monographs and books were actually world famous because of it had distilled down their experience, uh, in terms of managing patients at a very high, high level. So that's where I kind of was drawn into cardiovascular medicine and I felt that if I had the opportunity, that's what I'd like to be able to do. Now, you know, so, uh, and of course in those days, uh, you didn't have, uh, the kind of, um, the structured environment that we see nowadays in the training. Uh, you know, there were no QR codes. You couldn't punch in a QR code and go off and do your training program and emerge six years later as a gastroenterologist or something. So you had to do, you had to do the groundwork yourself. So you went into the BMJ adverts and you applied to, uh, work in centers which you felt were going to be good for you. And more importantly, actually, you hunted down people in the country who you thought, uh, you would like to be able to work through and would give you that mentorship, uh, and the inspiration to continue. So, I did my house job, uh, at St Thomas's, I went to Worthing to do my second house job in Worthing with another incredibly good physician, uh, David McBrine. And then I came back to, uh, Guys. Uh, I did some jobs at Guys, worked on the renal unit at Guys, uh, again with three incredible renal physicians. And, um, then I went off to Blackpool to do a job in Blackpool. And that was very interesting because it wasn't the done thing. You know, if you wanted to have a career in medicine, you stuck to the top end centers. Yeah. The golden circuit was, uh, Mead job at St Thomas's, the renal unit at Guys, Queen Square for neurology, and then you did a job at Hammersmith and then you could go on your happy career. That was the golden routine in those days. That was the kind of training program if you see what I mean.
Dr Rupy: Yeah, yeah. So what, what led you to Blackpool? Because that, that sticks out quite a bit.
Professor Jaspal Kooner: Yeah, it surprised, it surprised my colleagues. Uh, actually, at some level it was an opportunity because I felt I wanted to see what happened in the district and this then shaped actually also what I went on to do later. Uh, it was good to be in the centers, uh, but, you know, to be out where, uh, you could do some real medicine, uh, and do more practically. That's what led me to Blackpool and that was where two, two consultants and two SHOs, you can just imagine it's now a regional center with God knows, uh, 15, 20 cardiologists and scores of trainees. Uh, in those days there were just two and that's you, you did the, you know, you, you looked after the population as best you could. And again, the consultants used to be quite busy in doing angiograms and catheters and, um, you know, as, uh, the two SHOs, you had to pick up all the other stuff. So I spent nine months, uh, learning, uh, a lot of cardiology and doing a fair number of angiograms as an SHO, putting about 70 odd pacemakers as an SHO. So when I came back having done Blackpool after nine months, I remember attending a job at Hammersmith and there was this incredulity how, you know, you've done 70 pacemakers, that's not possible. Uh, because, uh, you know, our registrar doesn't do 70 pacemakers here in a year. So, you know, the world was different to what it was at the sticks, to what it was in the centers and even then it wasn't appreciated just like now. Very easy to be working in centers in your own little narrow area and be oblivious to what's happening out in the districts. So those are the kind of, you know, uh, it shaped my views that if I ever did become a consultant, that I would like to maintain a very strong hold, uh, in a population who I could look after, uh, rather than be stuck in a center doing fairly narrow things.
Dr Rupy: Mm, yeah. That, that really resonates with me quite a bit because I remember when I qualified, um, in 2009, I made the decision quite contrary to what a lot of other Imperial medical students were doing at the time, which is staying in Northwest Thames or, or somewhere around London. I actually went out and I went to, to Essex to, to go and work in a DGH. And that's kind of where I found my love of medicine again, I think, um, because you were put in the deep end, nowhere near to your experiences, uh, 30 years ago. But that experience there and also working in, uh, a rural environment in a GP practice in Truro down in Cornwall, that gave me a, a real, like, feel for that experience. I didn't think I was going to ask you this today, but I, I wonder, considering, you know, you, you have so many family members who work in the NHS, uh, at varying degrees of, of stage of training, do you, do you think there are pros and cons with how we now train medics today, uh, considering, you know, your experience of hunting down the, the best in, in class and, and, you know, working towards a goal that you, you have to essentially build yourself rather than having a very structured training regime?
Professor Jaspal Kooner: There were good things, uh, about, uh, finding your way, uh, finding, uh, the people you wanted to work with, uh, um, having the opportunity of working with the best people. It didn't always work because you didn't always get the jobs you wanted. Um, and you moved around at leisure, you know, six monthly, one yearly, depending on when the jobs came up. Uh, but it did give you that, uh, edge which you don't get now. I mean, I lament at the, uh, training programs these days. The good thing, I guess, is that people go in and come out, uh, with STs, um, and, uh, become consultants. So there's some degree of security. Um, but it's been done at a cost. Um, you know, a training program now involves you filling in your details online, you get assigned to go to a particular area and work in particular hospitals and that's no choice of your own. And you get to work with people who you may not want to work with and you may not enjoy the jobs that you're doing, but you have to go through this kind of sausage machine and come out, you know, rather gray at the end. And I, I, I really feel for some, you know, the really bright people who are in this sausage machine who, who have a potential to innovate, who have a potential to contribute and are dumbed down by this process where they do not get that leverage to be able to, um, train with the people that they want to, explore things whilst they're training, go slightly off piste, if they have an idea, uh, they want to do a research project, they can't do it because, you know, their day is structured. Uh, in, in my days, if you had a research project, you know, you talked to your consultant, you sat around on the coffee table and you got on and you did it. And, you know, that happened even actually, uh, when I started at Hammersmith in 1990, you know, we had three registrars. And Hammersmith was one of those places in those days which had, uh, you know, worldwide reputation. The Royal Postgraduate Medical School, Hammersmith Hospital was the place to be in the world. And we had three registrars. And the registrars came to work with us every year. They were expected to do clinical medicine because that was part of their training. They were also expected and did research. And they all produced high-level research by the time they left after just one year. And many of these guys went off, uh, to become consultants elsewhere. Now that, that you see doesn't happen these days. It just doesn't happen. Uh, you know, there's a timeliness about research. There's a timeliness about ideas. And if you do not nurture the idea that you might have waking up, having a cup of coffee, seeing a patient, that timeliness is gone. And that, you know, the wind out of your sail has gone. And that is what this current training program has lost. And I think the people who are in charge of these programs, uh, perhaps do not see.
Dr Rupy: Yeah, yeah. On the subject of research, let, let's talk about, uh, your experience in academia. Um, it sounds as if that you've had the, um, space to go and explore ideas throughout your training, uh, when you saw fit. When was your sort of first experience in that element of medicine and, and what were the, the initial ideas that piqued your interest that's led to you now with this huge research project that we're going to talk about a bit later?
Professor Jaspal Kooner: So I went, uh, having done my registrar job, uh, I, uh, was really lucky actually. It was a lucky break. There was a lucky break in those days. So I'm here because of the lucky breaks in my career as are many people in my generation. Um, so I, um, had done my two-year registrar job, got my membership and it was a done thing to go and do research and I was looking around where I could possibly do that. And the chap I was working with at the time, David Thomas, who's a neurologist, uh, said, look, I think you really need to go and speak to Stan Peart, Chris Mathias at St Mary's, they're doing good work and I think they, you will enjoy working with them. So I had no idea about the medical unit at St Mary's. It was led by Stanley Peart, who's, uh, probably one of the finest physicians of his generation, incredible clinician, incredible researcher, and, uh, ran the Wellcome Trust. And, um, uh, so I went and worked with him, the chap called Chris Mathias, who was working on autonomic function, uh, Roger Bannister, Roger Bannister, who, uh, was working on autonomic function at Queen Square, but was also at St Mary's, and Peter Sever, who was actually, who's still working with us now, incredible, uh, clinician and clinical trialist. So I had the opportunity of actually working closely with these, uh, uh, very, very accomplished people. And my initial work was, uh, with no ideas of my own. I mean, you had no ideas, you just joined a unit and you see what they're doing and they said, well, I think you should try to look at this. So my initial work was actually on the control of circulation of the circulation by the nervous system. So I was working on the autonomic nervous system. I was working on how hypertension was, uh, uh, renal hypertension was not driven, uh, just by renal artery stenosis, uh, but was driven by the brain. I worked on paraplegic patients, I worked on tetraplegic patients. Um, I worked on patients with brachial plexus injury because these were natural accidents which had led to injuries where you could explore the circulation, um, and see how the circulation was controlled by the brain, by the spine and in the periphery. So that, that was kind of my research degree. And then towards the end of that, I felt, well, I think, I think I would enjoy that for the rest of my career, but I had to grow up like everybody else, had to finish my research, write up and go on and do other things. So I then worked with, uh, the cardiovascular unit at St Mary's with Rodney Falk, uh, learned, uh, to work in cardiovascular medicine, started my training program with him on cardiovascular medicine. Uh, he was a great patron, very good cardiologist, he's still working with us, uh, very, very sound, accomplished cardiologist. And so I did that and then another break came up and that was my job at Hammersmith.
Dr Rupy: Mm, mm. I, um, I came across this quote from someone the other day, um, because just as you're talking about breaks there and, and luck, it seems that the harder you work, the luckier you get. Would you agree with that?
Professor Jaspal Kooner: I think, uh, yeah, I think, you know, if you work hard, that's what I've always found. If you put the hours in, you, your work gets appreciated. You may not always be successful, you may not, you may not publish where you want to publish, you may not, uh, discover what you might want to discover, you may not see your name on neon lights, but if you just work hard and you have the right intent, then people at all walks of life appreciate that. And I think in that walk of appreciation, doors open up, people make it possible for you to walk through open doors. And I think that's a very important thing, you know, in, in medicine in general, being honest, uh, having that integrity and putting an incredible amount of hard work in for no, for no expected gain. Uh, which is this is what the career, this is what our careers are about actually as physicians and surgeons and medicine. And that's how medicine has evolved over centuries.
Dr Rupy: Yeah.
Professor Jaspal Kooner: Uh, and that mindset, uh, is sometimes difficult to understand, um, you know, with, um, uh, in, in the modern day environment, I find kind of graduates moving out of medicine, uh, into other walks of life where they think that maybe they'd be better rewarded, uh, both in terms of their, uh, personal achievements or, you know, financial rewards, but I think few, few careers really meet that deep satisfaction you get from medicine.
Dr Rupy: Yeah, yeah, I, I agree. Um, I want to, uh, frame our conversation now about the, the work, the huge project that you're doing at the moment. And just to sort of anchor the listener to frame our conversation, I want to give some insight into, into folks listening about cardiometabolic risk triggers, if you like, uh, that might lead to someone having pathology. So, uh, obesity, particularly central obesity, um, the ratio of fats and perhaps even lipoprotein abnormalities, so that's how we, we transport different molecules, inflammation, raised CRP or other acute phase reactants, um, blood pressure, which is a whole other topic in itself and, and metabolic disturbances. So insulin resistance or even how we might transport glucose in the body. Um, what I guess we want to be talking about is the reasons why there is a predisposition to some if not all of those different factors, particularly amongst the South Asian population with a heavier focus on the genetic predisposition that I gather you've had most experience in. Does that, does that sound, uh, like a, a nice starting point for you?
Professor Jaspal Kooner: Yeah, I think, so, that takes me back to when I moved across from St Mary's to kind of Hammersmith and Ealing. My, uh, post which I still occupy at the moment was a joint position at the Royal Postgraduate Medical School, now Imperial College, and Ealing Hospital. And Ealing, as you know, is, um, in West London serving a population, uh, in West London of which 30% are South Asians. So I sort of started my consultant job there with, with no cardiovascular kind of unit, uh, and, uh, that's what I came across. I came across patients who were young, I came across patients who had central obesity, uh, had high blood pressure levels, um, had a lot of diabetes, patients who had high abnormal lipids, principally high triglycerides, low HDL levels, perhaps cholesterol not so high, and had incredible, uh, premature severe heart disease. So it became obvious to me that if, um, I was going to stay in this position for long enough, that one of the things that I had to do was actually to re, to reorientate myself, uh, A, to be able to looking after these people clinically, and secondly, to be able to understand, um, this disease.
Dr Rupy: Yeah.
Professor Jaspal Kooner: Um, and, uh, so in the 1990s, um, we started, uh, in earnest, uh, working on, on this area.
Dr Rupy: And was this a well-recognised phenomena back then in the 90s? Uh, had, had we known about this disparity or is this a relatively new recognition?
Professor Jaspal Kooner: It was becoming known in the 1990s. So in 1990, so in 1991, Paul McKeague, Mike Marmot had published a paper in the Lancet in 1991, drawing attention to the fact that Asians had, uh, uh, premature severe coronary disease, high rates of disease, and there was this emergence of this syndrome, uh, of insulin resistance. Um, and, uh, so they had drawn attention to it and that was timely, uh, because I was in the thick of it, uh, and so it was a very natural thing for me to pick this up and to, uh, develop this research program. And, uh, so, you know, um, uh, I was the only cardiologist, I had no team on the one hand, so I was had a huge challenge, uh, with myself, half a secretary, half a technician to build a clinical service, which took me about 10 years to build. And, uh, that was actually building a clinical service from scratch. In those days, money was tight, uh, really tight, uh, and so much of the building of this unit was through gathering up funds from the communities, uh, grants, going to government with a begging bowl, and just getting money for where you could, buying furniture, buying machines, hiring on staff, writing grants. And then parallel to that was actually starting a research program. Now, if clinical work was difficult to get off the ground because there were no resources and you just had to do everything yourself, you can just imagine that if you wanted to start a research program, that, that also had its challenges. Firstly, it was a new area, secondly, you had to structure it. So, um, uh, I, uh, you know, when I started, I had a, uh, registrar at the time, a chap called John Chambers, who again still works with me. And he and I sat down and said, well, look, you know, this is a great thing to do and what we needed to construct was a proper long-term study to be able to understand, um, this kind of disease. Um, because, you know, uh, even now, the existing studies of, uh, diseases amongst South Asians, uh, are really small scale, retrospective study designs, they look at very narrow range of risk factors and that doesn't allow you to understand the contribution of exposures, whether they're environmental or genetic, uh, in a kind of a proper way. So we put together a study at that time called the Lollipop study. Okay, the Lollipop study, uh, was named simply because between us, we had nothing and couldn't even afford a lollipop at the time. Uh, so that's what it was, the lollipop, no money, but we had big ambitions. And we had ideas to cultivate a long-term population study. And, uh, so we, uh, put together a framework, we got together with about 50 odd GPs locally and we said, look, we are all in this together. You have your patients, we have the patients who are seeing in hospital. Let's just put a team together and let's put together a long-term cohort. Uh, and, uh, we were lucky because, you know, we were busy delivering a clinical service for their patients, they appreciated that, and they also saw the merit in putting, uh, together a study and being part of a team, uh, who could perhaps look towards answering these questions. So when it got a bit serious after a couple of years, uh, Lollipop, uh, became a bit of a joke because, um, you know, it wasn't the done thing to be doing a serious study with a rather odd acronym. So we had to go back and revisit this, what could we call it? So we then called it the London Life Sciences Population Study. Okay, so that translates into the Lollipop study. So the Lollipop study is now 32,000 people, which we put together. It is coming over to a 15-year follow-up. Uh, it is, uh, uh, I think, uh, the world's largest prospective population study of South Asians, uh, who have been followed up for 15 years for disease outcomes and in whom we have, uh, detailed phenotypic data, detailed biological data, stored samples for genetic analysis. So that was how it came together and now, uh, obviously with the success that Lollipop study has enjoyed over the years, it has become, uh, you know, world-famed because it is the only population, uh, prospective cohort with large biological data, uh, amongst Asians. And, uh, yeah, but that was the, uh, that was how it started. Lollipop started with no resource, no money.
Dr Rupy: It seems to me that, you know, you're not convinced entirely by the environmental argument, which obviously has some bearing on the disparity between South Asians and Caucasian counterparts with regards to the, their risk, uh, profiles for a whole suite of different diseases. Um, what, why, do you, do you think it's pointing more towards genetic variation in terms of the grandeur of effect versus environment or do you think it's a blend of both considering we are, you know, talking about something where we have imperfect information about the, uh, the, the reasons as to why?
Professor Jaspal Kooner: So I, it's very important, I think it has to be a blend of both. Uh, so, you know, it's, as I said, these diseases amongst, excess of these diseases are not explained amongst Asians. Now, that is partly due to the fact that, uh, the environmental exposures have not been captured properly. No one's really looked properly in a longitudinal manner at the contribution of diet. There's no longitudinal study of diet and South Asians and these diseases, whether it's heart disease or diabetes. Similarly, there's no, uh, good data on physical activity, uh, and its contribution to these diseases and of course obesity amongst South Asians. Um, and then, uh, when you sort of go on to other environmental exposures, you know, it's possible that they've been captured but not been captured accurately. So there may well be a very strong contribution from the environment. I think the case we're making is that, look, we just need to do these things properly, uh, and accurately, and have a large sample size to assess their contribution. And then of course, there is a genetic component as well. And that cannot be ignored because the makeup of South Asians, uh, in terms of genetics is different. And, you know, we, we did publish, uh, a paper in Nature a few years ago, three, four years ago, where we demonstrated that, uh, obesity, obesity in South Asians, which, you know, you could argue is driven by unhealthy eating and physical inactivity, uh, is responsible for 200, uh, different differential methylation markers. Uh, so methylation at 200 loci is different in Asians compared to Europeans and it's driven by obesity. And of those 200 methylation markers, five are responsible, we think, for 30% of diabetes in Asians. So you could trace yourself back and say, look, actually, deal with it at source, deal with it at diet, deal with it at environment, you can prevent obesity and you may actually at the other end, uh, be able to reduce the burden of diabetes. So I think the answer to your question is it's very likely that there's going to be a blend of environmental and genomic exposures to this. And what we need, which is the brainchild of South Asia Biobank, is now to put together this 200,000 cohort. So, you know, your fantastic, uh, podcast viewers need to engage with us on South Asia Biobank, um, and, uh, be part of research. Uh, and contribute to this, uh, journey by, uh, coming and having a one-hour assessment of, uh, their health for us to be able to capture some of their data and an opportunity to follow them up for years to come in terms of their health. And then to be able to understand, you know, which direction are these exposures and the genetic variation taking us. Now, the brainchild of South Asia Biobank is actually that we are in a position now, if we get this cohort together, of actually following up longitudinally multiple diseases at the same time. So cardiovascular disease, diabetes, hypertension, obesity, dementia, Alzheimer's disease, you've got major depressive disorders, you've got emerging diseases like long COVID. We can follow up the cohort for all these diseases and then to be able to take a step back and say, okay, we are collecting good data in terms of the phenotypes. And now, let's now open up another investigation line. We will sequence their genome. We will, we will look at all the methylation markers. We will do an epigenome-wide screening. We will look at their transcriptome, we will look at their proteome, we will look at their metabolome. So then you actually have hard outcomes of these diseases. And you say, well, for, for argument's sake, let's say you've got, you know, 5,000 cases with coronary heart disease and 5,000 controls which have emerged from this cohort, you can then say, okay, well, if we actually adopt a multi-omics approach to the investigation of these diseases where you're not just capturing the genetic variation, but you are capturing the downstream biological pathways. So you're not necessarily just looking at an association of one gene or, you know, just genetic variation in general, but you actually looking at the consequences of that variation in terms of how that translates into downstream biological pathways, you can then begin to get an insight into the underlying causes of why 5,000 people may have wandered down and had heart attacks and why the other 5,000 may have been protected from heart attacks. So this is a new field of medicine where you are actually looking at, uh, you know, uh, a multi-omics approach, uh, backed up with this, uh, kind of a, uh, large population sample with different exposures and the bioinformatics in this day and age allows us to be able to bring these resources together to be able to answer these fundamental questions which actually would not even have been possible, uh, you know, three, five years ago.
Dr Rupy: Yeah, yeah. And in terms of, um, collecting the data properly, as someone who's gone through the process, I've, uh, I've done well, well-man checks with, um, with Bupa and with Nuffield and I would say this is probably the most comprehensive assessment I've ever had and it was for free, uh, for the research. Yeah, it was amazing. I mean, like, you know, the questionnaire is really detailed. The nursing staff were fantastic. The fact, you know, you're taking bloods, I got my results, I got my assessment, I got my risk profile. There's so much stuff that I can do using that data in the present, but also the fact that I'm also contributing to this massive research project that could help save lives in the future and understand the disparities in the diseases and, and it's not just about cardiometabolic problems, you know, it's a whole suite of different issues as you've eloquently explained. It's amazing. It's a, it's, it's an incredible project and, uh, and that's why I'm so passionate about it and that's why I wanted to talk about it on the podcast today.
Professor Jaspal Kooner: Yeah, so I think, you know, again, Rupy, when we put the construct of the study together, uh, we're funded by the Wellcome Trust, an incredibly generous contribution in order to be able to get this study off the ground. Uh, and, uh, we weren't funded to generate reports for patients. So we felt that there were, you know, if thousands of people, tens of thousands of people are going to participate, give up their one hour of time and give, uh, their kind of samples for analysis, there had to be something for them. They, they, they, it was an obligation at a clinical level to be able to give them ownership of their data, to allow them to make some assessment of their health and allow them to make improvements in their health where they're, they're needed. So, um, this was a kind of a tag on, if you like, in terms of, uh, what we were doing to the, the main part of the study. And so we are now making every single piece of data that we have at hand available through the kind of report that you've seen, uh, to every, uh, participant. And that means that a person has access to, you know, their, their blood pressure levels, body fat, body composition, BMI, uh, you know, waist-hip ratios, ECGs, which are reported, lung function, uh, retinal photography, cholesterol, blood pressure. And you're quite right, if you go and have these assessments with, uh, you know, uh, commercial organizations like Bupa, you don't get that depth of report. And it's, you know, it's, it's, it's, it's just not there. And, uh, we're doing it free, uh, because, you know, we have an obligation to the people who, uh, come and participate in this research. So it's absolutely free of cost. And we're doing it free also because we've had community engagement to, you know, you know, I, you talked about, you know, how this comes together. And I gave you the example of the freezers. Well, you know, we were about to embark on the study and COVID hits us. And we were planning to do the study at Imperial College, at London Northwest Hospitals and various other hospitals. And they became no-go territories because of COVID restrictions. So we had to move the research out into the community. So I, uh, approached, uh, uh, the Singh Sabha Gurdwara in Southall and said, look, you've got this premises, it's not, uh, uh, you know, it has a potential of being used for the service to humanity. And, you know, I tell you, it took, uh, uh, Herbie, who's the general secretary of the Gurdwara and his committee members, uh, with Mr. Summer, no longer than a couple of meetings to decide that that's what they're going to do. So they leased out the building for five years to Imperial College at 100 pounds rent per year. Okay, so that's a contribution of 1.5 million pounds by the community to make a facility available onto the research program to make things happen. So to make things happen, it requires a huge infrastructure. And, uh, similarly, we've had, you know, people saying, well, you know, okay, I'll contribute to this report and I'll put some money in there. And that's how it happens. So we're looking at getting engagement from, you know, every single person who's listening to this program, who's of South Asian origin between the ages of 18 and 85, just go onto the website, log in, come and spend a nice day with us, understand your health and contribute to the health of future generations.
Dr Rupy: Absolutely. I, I had no idea that the report, uh, wasn't actually part of funding. That's incredible. And the, the sacrifice and the, the community element and what they've, uh, donated is amazing as well. I'm so glad we touched on that today because I, I wouldn't have had any idea about that. Um, I, I know we've got a hard stop in about five minutes, so I want to be respectful of your time. I just want to ask you two, uh, well, one thing is fairly big, so we can, we can shorten that. And then another thing about just the future of what you imagine cardiology to look like when you're practicing in five or 10 years time or perhaps some of your, uh, colleagues. Um, there is a growing recognition of, uh, a person's gut microbe having a role in the pathophysiology of disease, particularly metabolic risk. And, you know, we, we know, uh, there is a lot of research going on this. It's naive of, of us to think that you can do absolutely everything. You know, you've talked about retinal photography and bloods and genotyping, transcriptomics, etc. Um, but do you think there is a role to collaborate with other organizations that, uh, could help you further understand the impact of, uh, other environmental triggers as well as the microbe in particular? And I'm thinking of, you know, research, uh, institutes like the Quadrum or APC in Cork or King's College perhaps.
Professor Jaspal Kooner: Indeed. So, uh, the South Asia Biobank is planning to collect stool samples eventually. So we are going to be looking at the gut microbiome, gut microbiome and to be able to put that, uh, as, uh, you know, one of the approaches of trying to answer these diseases. Uh, it's a very, very interesting area. As you know, the initial work on the gut microbiome was done in rats where you have obese rats, uh, lean rats, you can take, uh, the, uh, the microbiome from the lean rats, put it into the obese rats and vice versa. And after a period of time, the obese rats become lean, the lean rats become obese, uh, depending on, uh, their change of microbiome. And this work has been replicated at some level by Tim Spector and his colleagues, published a really nice paper in Nature Medicine a couple of years ago, um, in their twin studies at King's College. And, uh, we feel that for the Asian community and its prevalence of, of obesity, this is going to be an important thing to pursue. We're not doing it just yet. So people listening in don't have to come in with a stool sample. Uh, so our initial, our initial strategy is just to collect blood and urine samples, but you're quite right, it's the microbiome is a very important area, uh, to factor in and this is one of the substances that we'll be picking up in due course.
Dr Rupy: Brilliant. And, um, just to close, you've, you've been privy to a lot of this information, uh, about the, the risk profiles affecting South Asians. I'm very interested to know if you have any daily or weekly activities that you do on a personal level that protect you and, uh, promote cardiovascular health.
Professor Jaspal Kooner: Yeah, so Rupy, we are all in this together. Yeah, yeah. So, you know, uh, yes, I, I mean, you know, I do try to make time for my workouts in the morning. It's the only time I can do that, get up in the morning and, uh, you know, walk across to our little gym at the back and, uh, uh, do my stuff. And, uh, you're a lot leaner than I am at the moment, so you're doing probably more, more of it than I am. Uh, but actually, it's, it's a really, really important thing. I think until such point in time as we are able to bridge this gap of knowledge and we have personalised medicine either for the individual or for the population, it is paramount to be able to ensure that we deal with the risk factors optimally so that we can curb the burden of disease. So, you know, good, healthy diet, crucial, physical activity and maintaining optimal, uh, weight, crucial, treating blood pressure, treating cholesterol, uh, preventing diabetes, treating diabetes, crucial, stopping smoking, crucial, keeping alcohol intake down, crucial, plenty of good, fresh intake of vegetables and fruits, crucial. So until such point in time as we find this kind of personalised medicine approach, the message, I guess, you know, is get the basics right, deal with these important risk factors, because there are some studies which say if you deal with these important risk factors, you can drive risk down by two-thirds to 80% for the population. And so we will continue to pursue the reasons for the gap and, you know, we look forward to engagement from, you know, people listening in today, uh, but, you know, that should not prevent all of us to, to turn the screws on, move away from, uh, the kind of, uh, the thrust of just being healthy, but move away from being normal to actually optimally healthy. That's where it's at for Asians. If you've got a twofold excess risk of these diseases, you can't afford to be normal. You know, you can't afford to have a normal blood pressure. I mean, normal blood pressure of 140/90 is two times the risk of 110 over 70. So get ourselves into the optimal range for these risk factors to help drive the risk down. So that's what I, you know, that's the kind of here and now approach as opposed to the futuristic approach.
Dr Rupy: Brilliant. Prof, thank you so much for your time today. It's been a pleasure to chat to you. Uh, I hope you've enjoyed your first podcast experience and, uh, perhaps in the future I can, uh, I can donate my microbial samples as well when you start collecting those as part of the biobank. I'll be more than happy to come back again.
Professor Jaspal Kooner: Yeah, it won't be difficult. You could even post it to us.
Dr Rupy: Fab. That's great. That's great.
