California Pacific Currents 2004
Saleh Adi: Building a Home for Pediatric Diabetes Care
Saleh Adi, MD, is very glad to have a place he calls home. Married, with a three-year-old daughter, he has settled happily into dual roles as a researcher and a pediatric endocrinologist at California Pacific’s Center for Diabetes Services. This is good news not only for him and his family, but for his colleagues and patients, who are fiercely loyal.
But stability was not always a defining trait of Dr. Adi’s life. As a child, he and the rest of his family followed his schoolteacher father from job to job throughout the Middle East. Born in Syria, he moved to Algeria at age nine, then returned to Syria for four years, then headed for the United Arab Emirates. He went to medical school back in Syria, completed his compulsory military service, and cast a young man’s desirous eye on the western horizon. A buddy from medical school got him a volunteer job as a research assistant at San Francisco’s VA hospital in 1988, so he applied for a visa, caught a plane, and moved into a shared household in San Francisco’s Haight-Ashbury.
The job was supposed to last six months, but his employers were so impressed with his work that they kept him around for three years. During that time Dr. Adi passed the qualifying exams to practice medicine in the United States, arranged for a fellowship in pediatric endocrinology at the University of California, San Francisco, and hasn’t looked back. If he sounds focused it’s because he is, but in the best possible way—quietly, with a disarming, self-deprecating sense of humor and a clear appreciation for the wider world and his contribution to it.
“This was my choice from halfway through medical school,” he admits. “I was either going to become a pediatric endocrinologist or do something besides medicine. I wouldn’t want to do anything other than pediatrics, and endocrinology made the most sense because I love basic science, and endocrinology is all about physiology, biochemistry, and molecular biology.”
Dr. Adi has arranged his schedule so he can spend half his time providing clinical care and half doing research. Somehow he seems to come up with a third half to spend with his wife and daughter, which may not hold up as arithmetic but equals a full, well-rounded life.
Stephen Rosenthal, MD, whom Dr. Adi describes as his mentor, interviewed him for a UCSF fellowship in 1994. Dr. Rosenthal’s laboratory was investigating the puzzling and complex properties of hormones called insulin-like growth factors (IGF-I and IGF-II), which promote differentiation and growth in cells—the process by which immature cells “decide” whether to proliferate by dividing or to mature individually into “grown-up” cells.
“During the interview process we really hit it off, so I invited him to join our lab,” Dr. Rosenthal says. “He took things to the next level, by identifying parts of the gene responsible for these opposite effects [proliferation or maturation], and by clarifying how they happen. He made significant advances in our understanding of these processes.”
The research holds promise for understanding and treating muscle-wasting syndromes or degenerative muscle diseases, according to Dr. Rosenthal, but his praise isn’t limited to Dr. Adi’s capabilities as a researcher. “He’s an outstanding scientist and clinician,” he says. “But Saleh also has great ethics. There’s no compromise in his integrity; he’s an extremely nice man—someone I feel fortunate to call both a colleague and a friend.” At the California Pacific Medical Center Research Institute, Dr. Adi continues to investigate the molecular mechanisms and signaling pathways involved in skeletal muscle differentiation and the effects of insulin-like growth factors on this process. Muscles contain dormant precursor cells known as myoblasts, which are similar to stem cells. They can be spurred by injury to “wake up,” multiply, and form new muscle fibers, he explains. Although the genes responsible for directing the process of myoblast differentiation have been identified, how these genes are activated remains a mystery that Dr. Adi hopes to solve.
“This research could potentially lead to treatments for many genetic conditions,” Dr. Adi says. “We could harvest these precursor muscle cells from human patients, grow them in culture, and engineer them to carry genes that the patient may be missing, so they could be put back in to deliver those genes without being rejected. Once these cells are delivered back into the patient, they can be directed to differentiate into mature muscle fibers that can integrate into the existing muscle tissues where they can survive for years. But to do that well we need a lot of these cells, so we first need to understand how these processes of growth, survival, and differentiation are regulated in order for us to control them after we put them back in.” The research relates to Dr. Adi’s clinical work in that it could potentially lead to treatments for type 1 diabetes, in which the patient’s pancreatic beta cells stop producing the insulin that allows the body to make energy out of glucose. Transplantation of beta cells doesn’t work without concurrent suppression of both the rejection and autoimmune responses, but engineering the patient’s own myoblasts to function as insulin-producing cells would at least address the rejection issue. In the meantime, Dr. Adi treats his pediatric diabetes patients through the Center for Diabetes Services, which helps both adult and pediatric patients control their diabetes.
“I believe in intensive management, especially in type 1 diabetes,” Dr. Adi remarks. In type 1 patients, intensive management means careful monitoring of diet and blood glucose, multiple daily insulin injections or use of an insulin pump, and regular measurement of glycohemoglobin A1C, which reveals the patient’s degree of blood glucose control over the previous three-month period.
“Although the incidence of type 1 diabetes has stayed about the same, type 2 is rising astro-nomically due to childhood obesity and lack of exercise,” Dr. Adi says. “So we have to address that as well, and luckily we have a lot of tools.”
In type 2 diabetes, which was formerly called “adult-onset diabetes,” there is no autoimmune response that destroys the beta cells; instead, the patient’s body grows resistant to the insulin it produces, and the beta cells are eventually exhausted by trying to compensate. The first course of action is to control metabolism with diet and exercise; antidiabetic drugs and ultimately insulin may be added if needed.
In the diabetes clinic, Dr. Adi has reserved one day a week for pediatric patients. “I work with the staff there, and they’re wonderful. They’ve been doing this for a couple of decades, as diabetes educators and nurses, nutritionists, social workers, and counselors. I couldn’t do it without them. The biggest challenge I face is time.” Dr. Adi makes himself available to his pediatric patients and their parents 24 hours a day, seven days a week. They take him up on it, paging him, calling his cell, or ringing him at home.
“We look at patients’ blood sugar at least once a week and make frequent adjustments in diet and insulin dosages,” he explains. And although high blood sugar (hyperglycemia) is the defining characteristic of diabetes, once patients start taking insulin, the more immediate concern is the opposite—hypoglycemia—which is particularly pernicious in the young.
“Hypoglycemia is the one thing we have to avoid at any cost,” Dr. Adi says. “This is especially true in children younger than five, because of its effect on brain development and cognitive function.” The challenge, then, is to get the children’s blood sugar levels as close to the normal range as possible without increasing their hypoglycemia risk.
One Last, Sobering Journey…
Although Dr. Adi initially began practicing at California Pacific in 1999, in late 2001 he was offered a job as an assistant professor of pediatrics at Johns Hopkins University School of Medicine. He took it and got a fresh perspective on his West Coast life. He and his wife moved to Baltimore and immediately encountered a stunning cultural divide.
“I am an Arab and my wife is Chinese-American,” Dr. Adi says. “When we tried to buy a house in several upper-middle-class neighborhoods, we were bluntly encouraged to look elsewhere. We finally ended up living way out of town, a long commute from work, and my daughter would have been the only Asian kid
in her school.”
It was the kind of appalling discrimination those who live in the Bay Area consider a thing of the past. After less than three years, they happily moved back “home,” and it appears that his wandering is done. He shrugs off the experience with characteristic good humor. “We didn’t like the crab in Maryland,” he laughs. “Dungeness is much better. And after being here for fifteen years, I missed going to the farmer’s market and hearing seven different languages spoken.”
…and a Welcome Return
Mindy Schwartz, RN, the supervisor at the Center for Diabetes Services, is one of Dr. Adi’s biggest boosters. “We were so happy when he came here a few years ago,” she says. “When he left to go to Johns Hopkins, we had to close the pediatric clinic; we didn’t want anyone but him. Now that he’s back we’ve reopened, and many of his patients have returned.”
“He’s really wonderful with the patients and their families,” Schwartz says. “He’s gentle, but he’s firm. We have a lot of scared parents, and he has a way of making them comfortable and encouraging them to follow his guidelines. We’re very happy to have him back.”
Dr. Adi says that his goal is simply to grow the program in order to help as many patients as possible. “We want to build it, not only in terms of the number of patients, but in the number of physicians and staff,” he says. “The care we provide—both medical and supportive, in terms of ancillary services—far exceeds that available at many other institutions. I like the opportunity to be here and have the freedom to do state-of-the-art research and clinical practice. We want to establish one of the best pediatric diabetes centers around.”
It’s pretty clear that this is likely to happen, for Saleh Adi is a man of his word.