Exclusive Interview from AACE Orlando
Steve Freed: So let’s talk about a little bit different topic and that is prediabetes. There’s probably 100 million in this country alone with prediabetes. The whole idea is to prevent them from going to diabetes. But once you become pregnant, you’re gestational diabetes and you give birth, the diabetes goes away. Those women are really at risk dramatically for getting type 2 diabetes. So what do you do?
Dr. Jovanovic: 10% per year, so that means in 5 years, they are going to have type 2 diabetes. 10% per year. I insist that they have some sort of blood test every 6 months, because it’s 10% per year. 50% of those women will get type 2 diabetes. It’s even higher in other countries. But they have to be told that even though the diabetes seems to be gone now, 10% per year will get diabetes. So what I tell them to do is to keep their sugar monitor and every once in a while check themselves. Who needs to go to a laboratory? Just check themselves. They’ll know full well if they’ve eaten something sugary and sweet and they test their blood sugar and it’s 200. They have diabetes now. They don’t have to wait until the doctor makes the diagnosis. So the best advice is to keep the machine, go to the drug store make sure they have fresh reagent strips. So when they check their sugar after eating something really disastrous, that is absolutely wonderful that their blood sugar’s normal, they don’t have diabetes. If their blood sugar’s is elevated they have diabetes. It’s that simple.
Steve Freed: So the situation like that, when do you tell them to monitor their blood sugars? Fasting when they wake up in the morning? Or postprandial?
Dr. Jovanovic: No, after they’ve eaten something disgusting. Because the diabetes has gone away but the way you make the diagnosis of diabetes is with a glucose tolerance test. It’s not necessarily with the fasting. It’s after you eat. And the women will know that if they’ve eaten something really sweet and their blood sugar is normal they don’t have diabetes. No need to waste the sticks on fasting.
Steve Freed: It’s funny that you say that, because, I can ask 1,000 people, when does your doctor tell you to check your blood sugars? Not for type 1s, type 2s.
Dr. Jovanovic: Before breakfast, before lunch, before dinner, before bed.
Steve Freed: But if they only have prediabetes, the doctors, and the doctor is monitoring them. They still are told fasting.
Dr. Jovanovic: Because the doctor is sending to them to the laboratory to look at lipids too. And the tier for normal lipids is based on a fasting blood sugar. They’re looking at other tests that depend that you haven’t eaten something. But if you’re just looking at sugar and you want to know whether the patient has hyperglycemia, they really should be sending the patient to the lab after breakfast.
Steve Freed: Because even when you go for a physical. You don’t have diabetes. The doctor’s always going to tell you don’t eat anything we want to check your triglycerides. And the report comes back and their blood sugar’s 94, no mention of diabetes. You don’t have diabetes so why mention anything and the patient goes home. You go out have a big pizza and some French fries and the blood sugar’s 275.
Dr. Jovanovic: Now you understand I can’t change the world, but we really shouldn’t send patients to the lab fasting. We should change the norms for lipids and tell patients to go to the lab an hour after breakfast so that we can see their worst glucose control. Their worst triglycerides. We want to see how bad it is, not how good it is.
Steve Freed: Then why is it the medical community doesn’t understand that? I mean, maybe the standard should be… there should be a standard for when a person should take a blood test to diagnose prediabetes or diabetes.
Dr. Jovanovic: So you tell your other doctors you interview, they have to say that, and they have to convince their laboratory to change the lab, because it’s a laboratory specific direction, the patients are given about when to show up, how long to fast. So you can change your community in your laboratory by telling your laboratory to do that. You have control over your own community. Now, yes, they send the blood test out to some diagnostic lab, but as far as preparation for the test, it’s an individualized community philosophy.
Steve Freed: So when you, and by the way, I think I’ve read that because we only check fasting blood sugars in the physical, that we miss about 25% of the people that actually have diabetes.
Dr. Jovanovic: Of course, but how would you even know that?
Steve Freed: So, in looking at the bigger picture, where do you think we are as far as knowledge and having healthy babies? Because that’s really a critical question that they need better care. I mean, we’re not seeing people being told that their A1C should be 5.3 at least from my perspective.
Dr. Jovanovic: No, but we need Centers of Excellence. Because the truth is not every obstetrician or endocrinologist needs to know about diabetes and pregnancy, we have to set up Centers of Excellence. And we have to have transportation to allow the women to get to a Center of Excellence. And they have to be scattered, at least throughout the United States. So that in a community there’s not more than 100 miles that you have to travel to get to see someone who knows about diabetes and pregnancy to tell the local doc what to do. So you have to have networking and you have to have the opportunity, but you can’t just say oh the only place that it has a good Center of Excellence is in New York or in Los Angeles. You really need local communities to have Centers of Excellence in diabetes and pregnancy. And that’s what we need to do. It’d be wonderful if AACE took on the responsibility making sure the doctors at least know where the Centers of Excellence are, so that they can refer their patients so that doc in the Center can talk back to them. And then they can do the rest of the care.
Steve Freed: One of the things that you said, that still I can’t get out of my mind is the A1C of 5.3. So you actually, especially for type 1s, but even type 2s, you basically tell them they should not get pregnant until they can reach that number.
Dr. Jovanovic: I don’t… I just tell them the risk, the baby could die, they could have an abortion, and actually that wouldn’t be bad news, because that meant the baby was so malformed that they were lucky that they lost the baby rather than have a monster. But if they really want a healthy baby, usually women have only two chances to have a healthy baby, especially with type 1 diabetes. They’re told they have two healthy kids, that’s great. So the truth is, it’s a window of opportunity to teach them how to restrict carbohydrate, how to take their insulin, how to go to the doc, how to get their blood sugars in better and better control. And then boom, they have permission to get pregnant. I mean we’re talking about a short period of time you have to have tight control.
Steve Freed: But it’s very difficult for people to get their blood sugars down. Because, mostly, because of nutrition.
Dr. Jovanovic: Thus we’re back to the same question.
Steve Freed: And how important is physical activity?
Dr. Jovanovic: Actually it’s probably not that important because pregnant women are young and healthy. But the truth is pregnancy has its own risk factors on the heart, and certainly there are cardiologists that will tell women that they’ve got a heart defect, they shouldn’t get pregnant. That’s a whole different question. Exercise, we’ve done the research on exercise, using exercise as a treatment modality, but exercise ends up bouncing the uterus and increases the risk for spontaneous abortion. So the truth is, it really many times obstetricians will say lie down, just relax your uterus is contracting and therefore pregnancy really isn’t the time you should start to exercise, and if you’re trying to get pregnant, it could be a reason you’re not getting pregnant is because you’re exercising so much that your body is stressed and stress hormones don’t let you ovulate. It’s not that I’m against exercise, it’s just the right time in your life to think that you’re going to become a marathon runner.