Novo Nordisk Senior Vice President of China Ron Christie Discusses the State of the Diabetes Epidemic in China
by joseph shivers, eric chang, and kelly close
Ron Christie doesn’t like to use the word “dominant,” so let’s just say his company, Novo Nordisk, is doing quite well in China. Amid an alarming rise in the prevalence of diabetes, Novo Nordisk has flourished, in part due to support for education and public awareness campaigns, as well as strong ties with local doctors (China has between 40,000 and 50,000 endocrinologists, compared to fewer than 4,000 in the US). In this interview, Mr. Christie shares his impressions on the current state of diabetes in the China, along with thoughts on the developing culture surrounding the disease.
Mr. Christie himself has considerable international experience. Previously, he was Novo Nordisk’s Vice President of International Operations Sub Sahara, which covered 50 independent African states. In 2003, he was transferred to China, which is on the front lines of the global diabetes epidemic. We were lucky enough to sit down with him in his Beijing office during our recent Chinese tour.
background on diabetes and obesity in china
Kelly Close: Mr. Christie, thank you again for taking time to meet with diaTribe. To start, I would love to get some of your impressions about the rise of diabetes in China.
Ron Christie: Thank you for coming to China to speak with us. What’s happened in China has essentially echoed what’s happened in the West. We’ve seen an increasing prevalence of type 2 diabetes, reflecting the massive movement of people to cities and changes with diet, less exercise, more vehicle transportation, etc. Studies that were done by China’s Centers for Disease Control from some years ago showed that if you’re living in a rural area, prevalence rates of diabetes were around 2%. Just by moving to a mid-size city, the rate of diabetes increases to 4%. Move to the biggest cities, it’s 6%. And if you look around Beijing and Shanghai, you see that prevalence of diabetes is now running as high as 10% or even higher.
Kelly: Wow. Although the rate of obesity in China is still nowhere near the rate in the US, correct?
Mr. Christie: Well, they have a different definition of obesity in China, so even people who are considered to be of appropriate BMI (Body Mass Index) in the West are considered overweight in China. However, there is not very much morbid obesity in China. It’s very unusual.
Kelly: I assume it’s likely that with more KFC’s and McDonald’s here as well as more motorized bikes and less exercise, people will continue to gain even more weight. The implications of this seem very worrying, if obesity is already a problem at a lower BMI. It makes me wonder if we’ve seen the extent of the problem.
Mr. Christie: I don’t think we can blame any particular type of food, but it’s just too much food and too little exercise. It’s the same problem facing all countries around the world. Urbanization and increased availability of food in general seem to be the problem here. And I agree with you – the biggest concern I have is for the next generation, as I don’t think we have seen the peak in obesity yet in China.
the government’s approach
Kelly: Can you shine some light on the government’s efforts to combat obesity in China?
Mr. Christie: The government and the schooling system are looking at things like increasing playtime and exercise for children. If you look out the window, you see a green and orange building. That is a school, and during the day, you’ll see kids running around. [Editor’s note – this is in the middle of Beijing, in the Chaoyang District section. It is quite urban.] So schools have exercise programs every day, and what we also know is that the schools and the government are running – for want of a better name – “fat camps,” so the children who are already obese can go to a holiday camp and really whittle down towards a normal weight. Although this isn’t happening everywhere, it shows that there is an intent and interest by the authorities.
Kelly: That’s very good to hear. I wish they could work collectively with our authorities in the US, although I suppose that is a bit much to hope, for now. Can you speak a bit about how Novo Nordisk approaches diabetes in China and about how it works with the government? I’ll bet the US could learn a great deal. Clearly there are many more people to help here. Are you more focused on helping people get appropriately diagnosed, or helping people who are diagnosed get appropriate treatment?
Mr. Christie: First of all, our belief is that we need to treat diabetes, not just sell insulin. You have to look at this issue from a holistic point of view, which means starting with trying to raise awareness. We also need to try to ensure that there are the right protocols, the right treatment, the right drugs available, etc. Insulin is one of those drugs, but obviously insulin is not the first line of treatment for type 2 diabetes. About 99.5% of people with diabetes here have type 2 diabetes, it seems, and there are very few patients with type 1 diabetes. So insulin often comes after diet, exercise, and other medications.
Kelly: Would you say the larger problem is awareness or what the patients are doing once they are diagnosed?
Mr. Christie: I think it’s both. Still far too many people are unaware that they have diabetes and even amongst those that are diagnosed many don’t seek treatment or stop their treatment. Our estimates are that 60% of people are undiagnosed and some 30% are untreated. This means we have an enormous amount of work to do in China to improve this situation.
novel drugs and who can afford them
Kelly: The introduction of GLP-1 analogs (e.g., Byetta, Victoza) in the last five years has been quite exciting in the US and EU. On an exciting note, Novo Nordisk’s Victoza was recommended for approval in China last March, ahead of all forecasts, and we understand you expect to launch soon [Editor’s note – it just launched in Beijing]. What are your expectations for this class here?
Mr. Christie: I think the GLP-1s will be available for those people who can afford them, but they won’t be universal for quite some time. Overall, it’s very hard to predict. It depends on when they update the national drug list (official list of drugs reimbursed by the government). They did it in 1998, 2004, and 2009. So the next update is probably four years or so away. Before that, we typically find we can get many provinces giving limited access to a drug and limited reimbursement. So we’ll start to see the drug being used over the first few years, but it’ll probably be five years before it becomes widely available.
Kelly: I see. But the fact that Victoza could become widely available in China is also quite striking, even if it doesn’t happen for some time. How big is the population that can afford to pay for its own drugs?
Mr. Christie: That’s a really difficult question. In terms of the number of people, there are obviously a lot of wealthy people in China. We have seen in the past that drugs that are not reimbursed and privately paid for can still reach significant sales over time.
Kelly: How have DPP-4 inhibitors (e.g., Januvia, Onglyza) done in China?
Mr. Christie: They have been out for a year, but the product really hasn’t taken off. I think doctors in China are pretty well informed about drugs, and I haven’t heard any good doctors tell me that their experience with DPP-4 inhibitors has been particularly novel.
Kelly: Do you think concerns about effectiveness are the reason doctors haven’t encouraged greater use of DPP-4 inhibitors?
Mr. Christie: I can’t say. Obviously doctors don’t see an advantage to rapidly switch patients to DPP-4 inhibitors. I think they feel that they get enough control with the existing products, and so why use something different? There’s a different philosophy in China, I think. In the US, there can be a lot of hype around launching new drugs. You have a situation with ready reimbursement in Europe and in the US, so doctors can immediately start to use a new product, especially with a lot of hype.
Mr. Christie: Compared to the west, China is much more circumspect. First of all, physicians in China have suspicions about how new products will work for Chinese patients. Second, there isn’t reimbursement for new products for years, so if a patient is not wealthy, access will be limited. The delayed launch of products makes them less subject to hype. Even the government has a degree of suspicion about the need for new drugs and the value of new drugs.
human insulin preferred, but underused
Kelly: Is there a delay to start insulin treatment in China, similar to in the US?
Mr. Christie: We have been doing some studies, but whatever the number is, there should be more people on insulin. In China it depends where you are, as the use of insulin varies around the country. Many doctors believe in very early use of insulin for three to six months, and then a withdrawal of treatment. But in that period, teach people diet and exercise, and if they stick to it then maybe they can withdraw all treatment for a long period. If you look at the markets, it is 50/50 – in terms of value, 50% insulin, 50% oral therapies, which is quite high compared to other countries.
Kelly: That’s really interesting. I didn’t realize that there was also the view that very early insulin use was positive – that makes a lot of sense to me because from a patient perspective, it’s great to get people on it and then see how easy it is. Broadly speaking, is it mostly regular human insulin?
Mr. Christie: Yes, mostly human insulin. Analogs are only about 46% of the sales, and about 27% of the volume. Human insulin is used widely because it’s cheaper. It’s on the essential drug list and available throughout the country.
Kelly: We understand premixed insulin is fairly common in China. Could you discuss the importance of premixed insulin?
Mr. Christie: About 70% of people here use premix. Some people in the early stages might just take a basal treatment, but later they take premix twice a day, and you might also get type 2 patients who are taking one shot a day plus an oral. That’s very common. Some provinces use a lot of modern insulins, while others don’t use them. For instance in Beijing and Shanghai, they’re not reimbursed by the government, but other provinces reimburse them very well.
Kelly: And do people mostly use blood glucose monitoring to guide their insulin intake? I’ve heard that a lot of people here take 10 units in the morning and something like four units at night?
Mr. Christie: The people who don’t measure are patients with type 2 diabetes, so they’re taking a very simple regimen, which is very safe probably. However, they’re probably undertreated. We have programs ourselves, and we’d gladly cooperate with suppliers of equipment to get them to the patients. The problem is that the strips are not reimbursed.
patients not stigmatized
Kelly: Is there a big stigma in China for having diabetes and using insulin? In the US, having type 2 diabetes can be so stigmatizing that many perceive it as a character flaw – that is what one of our favorite and most highly respected educators, Virginia Valentine says. We can’t find a single person of the 525 people in Congress in the US who will openly say they have diabetes, as an example – we’re going to be doing more work on this but to date, there is not anyone in national politics besides Mike Huckabee who is willing to openly admit they have it.
Mr. Christie: I don’t think there’s much of a public stigma attached to diabetes here in China. On the other hand, politicians usually won’t admit to having it. Occasionally, however, I see provincial people who openly admit they have diabetes. And I’ve been in discussions with government people in various positions who have said, “You don’t have to explain your products to me because I use insulin.” This is a major difference compared to the US and much of the rest of the world.
Kelly: How much time do doctors have to spend with patients? This time allotment has been declining for a long time in the US, but what kind of time pressure are doctors under in China? What impact does this have on them?
Mr. Christie: That is also a major problem here in China, but mainly due to the sheer number of patients who tend to all want to go to the same famous hospitals. There is definitely insufficient time for doctors to comfortably see all of these patients. Lines are very long in the hospitals, and doctors need to work long hours to attend to everyone. Nonetheless, doctors are highly respected for their individual efforts in combating diabetes.
promoting diabetes awareness
Kelly: What kinds of awareness programs is Novo Nordisk involved in?
Mr. Christie: We do extensive work educating doctors throughout China. We run educational programs for maybe 50,000 doctors every year. We also do a lot of public awareness, and we’re being successful because the doctors have been supporting the patients. We also have a patients’ club called NovoCare Club where we provide written information four times a year. There are more than 600,000 members in it.
Kelly: Wow. Do you send the 600,000 people a newsletter through the mail?
Mr. Christie: Yes, through the mail, six times a year. We also have a website and a hotline where people can phone in. We have a group of semi-retired doctors who work for us. We have maybe a dozen doctors every day sitting downstairs on the next floor below us, and they answer all the queries. I need to check my latest numbers, but it used to be – I think – 10,000 calls a month.
Kelly: Who else supplies insulin in China?
Mr. Christie: For insulin, there are the main international competitors, like Eli Lilly and sanofi; but there are also local producers of human insulins and animal insulins, so there are a number of players in China. A lot of animal insulin is used here. Because of affordability, local producers of animal insulin still probably have 20% of the total volume market, but for human insulin and modern insulins, the local producers probably only have about 5% or 6%.
why novo nordisk flourishes in china
Kelly: Why has Novo Nordisk done so well compared to the others in China?
Mr. Christie: The doctors believe in us because we consistently work in diabetes. We provide support to the country, we have a huge number of employees here – more than 3,000 people – and we have a lot of investments while also bringing a lot of technology and knowledge to the country. We’re good corporate citizens, put it that way. China is Novo Nordisk’s second biggest diabetes market in terms of value.
Kelly: Is that right? How big is that?
Mr. Christie: It’s on the order of $1 billion in annual sales.
Kelly: Of the 3,000 people that work here, what percentage is from China?
Mr. Christie: 99.9%. Just about everybody. In the commercial organization I’m the only one who’s not ethnically Chinese or born in China. They might be Chinese from other countries as well, but most people are native Chinese.
Kelly: Do you think your job overseeing China is much harder than that of the other people at Novo Nordisk or the other leaders at the company?
Mr. Christie: Our job is quite different. I think our job is more fun in China because we actually get much more involved, and a lot of the things that we do, you probably wouldn’t be able to do elsewhere. We have a bigger role to play here, and with that comes a lot of responsibility. It’s a real privilege.
Kelly: And, it’s been a real privilege speaking with you. Thank you so much for all you are doing for people with diabetes across the planet and in China.