Exclusive Interview from AACE Orlando
Steve Freed: Well, it’s a real honor to be here at AACE 2016 at Orlando. And to be with probably the most knowledgeable person when it comes to pregnancy and diabetes. I can’t imagine if I was to ask you, how many babies were you involved with, whether it was via the internet or just your own patients, it’s probably a wonderful feeling to know that you probably have 3 and a half million grandchildren, if each of those were your children. So you certainly have something to be proud of.
Dr. Jovanovic: Thank you, and actually I always kid to everybody that half of them are named Lois.
Steve Freed: You know and that’s terrific. Maybe we can start off with [you telling] us a little bit about yourself and your type of practice.
Dr. Jovanovic: Yes, I’m a consultant to obstetricians. Obstetricians know how to deliver a baby. They are excellent about getting the baby out quickly and making sure that the baby survives long enough to hand the baby to the pediatrician. But the obstetricians really don’t know how to take care of the diabetes correctly. And in fact they really almost push themselves to have a reason to deliver the woman early, because that means the woman would have a C-Section. If you have a normal baby, that means a woman can go all the way to term, which is about 40 weeks and go through labor and delivery and usually that takes 3 or 4 days so actually it’s harder for the obstetrician if you have a normal pregnancy. So, indeed, you can have a normal pregnancy with diabetes if you normalize the blood-glucose.
You see, sugar crosses the placenta freely, and the baby gets fat from too much sugar. The baby gets fatter and fatter and fatter and the baby makes too much insulin. Too much insulin really does cause the baby to be hungry when the baby is born. So it’s an irritable baby and so the mothers continue to feed the baby right after the baby is born because the baby has hyperinsulinemia. So you see it’s not just a fat baby when it’s born, it’s a fat baby who also is an irritable baby, because the baby’s always hungry. So the mother feeds the baby and feeds the baby, a fat baby is a fat toddler, is a fat teenager, is a next generation of type 2 diabetes. So you can cure the problem by making the blood-sugar normal in utero.
So now I have to tell you what I mean by a normal blood-sugar. A normal blood sugar is a blood sugar that stays less than 90 milligrams per deciliter all the time, even after the meal. That means the mother has to know what her blood sugar is all the time. So she needs to measure her blood sugar before she eats and one hour after she eats. And if indeed the blood sugar after she eats is too high, she needs to do something to quickly normalize the blood-glucose, otherwise that sugar is going to stimulate the baby’s pancreas. In addition mothers need to know that if they stay away from carbohydrates, they can eat anything they want, because carbohydrate becomes sugar, and indeed they can eat tons of protein, it’s not the calories that get to the baby it’s only sugar. So I always say please, please, please, cut out all the carbohydrates but you can eat a whole cow if you want to, because a cow doesn’t have any sugar in its protein and its meat. So it’s easy to follow the diet, you just take away carbohydrate.
Steve Freed: So, that’s interesting, because I would have to say that most obstetricians are going to turn it over to a dietitian and the dietitian is going give them maybe 50-60% of their calories as carbohydrates because that’s what the ADA says.
Dr. Jovanovic: Exactly.
Steve Freed: So, how many healthy babies have you helped to deliver?
Dr. Jovanovic: Well, you know I don’t deliver them, I just stand there in the labor and delivery room and glean all over that the kid is perfectly healthy. But the truth is probably millions of babies are normal because of our protocols. We’ve written books on how do you do it? How do you make the blood sugar normal? And just walking around here, I have people from all faiths and walks of life come up to me and thank me for writing the protocols because they work in every country in the world. And all you have to do is take away the carbo. For instance the people that are here from India say, you know it’s really really hard to take away rice from our patients. And I say to them, well so don’t take away the rice, just start insulin and let them eat anything they want. Just start insulin. They said that’s what they do. The women become depressed if you take away rice. Now in Mexico the women become depressed if you take away tortillas. So they have their choice of eating the tortillas and taking insulin or not eating the tortillas. Women usually choose insulin rather than take away the carbohydrate. It doesn’t matter how you normalize the blood-glucose as long as the blood-glucose is normal. But the truth is the only safe and efficacious medicine in pregnancy is insulin. You can’t use pills, so women have their choice of carbohydrate restriction or insulin. It’s that easy.
Steve Freed: As soon as you start insulin, it brings up other issues. How much insulin? Basal, bolus? What should the dose be? Because isn’t too much insulin is going to cause problems in pregnancy also?
Dr. Jovanovic: Nope, absolutely not, absolutely not, women love to eat so actually they take extra insulin so their blood sugar will be slightly lower so they can eat something sweet. Women during pregnancy have a reason to take good care of themselves. There’s no such thing as too much insulin. There’s enough insulin to normalize the blood glucose. And in fact the truth is, insulin doesn’t cross the placenta. So all you have to worry about is making blood sugar normal so the baby is normal. Too much insulin just makes the mother hungry if her blood sugar gets low. The only complications of insulin are if a woman who takes her injection, doesn’t eat, and gets into a car. So we have absolutely strict guidelines. You are not allowed to get into a car unless your blood sugar is above 120. Because then you’ll have room to fall if you’re in a long traffic line and you know your blood-sugar is dropping. You have a lot of room to fall from a blood-sugar above 120 to a blood sugar that is still safe. So the truth is you have to eat before you drive if you’ve taken your insulin.
Steve Freed: So insulin doesn’t play havoc, or maybe, does the requirement for insulin go up because you’re carrying another human being?
Dr. Jovanovic: Oh absolutely, and there are formulas, that’s what I’m trying to tell you, there are protocols, all you have to do is follow the directions like a cookbook. It’s 0.7 units per kilogram per day, present pregnant weight, in the first trimester, 0.8 units per kilogram per day in the second trimester, and 0.9 to 1 unit per kilogram per day in the third trimester. And yes you divide it so that half is basal and half is bolus. Now the half basal, we now have an insulin that is FDA approved in pregnancy, insulin detemir, because in the olden days all we had was NPH. So the insulin detemir you take twice a day, but is half of the total insulin requirement. They take half of the total insulin requirement as basal (detemir) and give 1/3 of the detemir dose in the morning and 2/3 at night because the dawn phenomenon is potentiated in pregnancy. So now you’ve got the basal taken care of. The meal time bolus in only two insulins that are proved to be efficacious in pregnancy by the FDA: insulin aspart and insulin lispro, so you take those before each and every bite of food. If you don’t eat, you don’t have to take the rapid-acting and if you do eat you have to take the rapid-acting. So yes if women want to eat 10 meals a day, they’re taking 10 injections of rapid-acting, they don’t want to eat at all is fine with me.
Steve Freed: So why isn’t this information really made available to most of the medical community? Because as I said before, I keep getting questions myself with Dr. Bernstein, you know, I’m pregnant, how safe is it? Because people think even with young children. They say I have a 3 year, my doctor says… he won’t talk to me if I say I won’t go on a low-carbohydrate diet, and yet we’re seeing an epidemic of kids that are obese. Certainly it increases their risk as they get older for so many other different diseases. We’re seeing an epidemic of this right now?
Dr. Jovanovic: You know you should tell Dr. Bernstein to talk to the grandmas, it’s the grandma’s fault. Grandmas think fat children are healthy and unless you can change the philosophy of the grandma — because a grandma is of course affecting the family and most of these families have a grandma that lives or is nearby. And she thinks it’s good for the baby or the child to eat and eat. That’s the way you show love, you show love by feeding people. So to get to the grandma probably is the way to solve the problem. We have to change the family structure so that the thought [is] that a lean, healthy child is good for the family, and the role model usually is the grandma.