The Just and Injust of Diabetes
It is rare when one meets a soul as wise, caring, and no nonsense as Dr. Lois Jovanovic. Her bio speaks to her public accomplishments; those who have been her patients, her colleagues, or in the circle of her dynamic “we can get this done” personality know we are blessed. Diabetes is an illness with far reaching lessons and warnings that we feel are well within our charter to make the world a more just place. Dr. Jovanovic is on the Advisory Board of The Justice Project and we offer this interview which took place at the Sansum Diabetes Research Institute in Santa Barbara, where she is the Chief Scientific Officer, with gratitude for her time.
Thank you to Homaira Zaman, who is an intern at SDRI and is starting medical school at Penn State, for her invaluable help recording and transcribing this interview.
The Justice Project
We have two ways to enjoy this interview, the first is with the audio file, and the second is the transcript available below. We look forward to hearing your feedback!
Audio Recording of Interview:
Transcript of Interview:
NB: From your perspective Dr. Jovanovic, what is the current state of the diabetes crisis in this country and/or globally?
LJ: I think it’s the increasing rate of obesity around the globe and we don’t know how to handle it; and I’m not talking about over-nutrition, I’m talking about obesity. It’s really the accrual of fat, and it’s going around the world due to the westernization of food in other countries. The truth is, the world is getting bigger and bigger – not taller, but bigger and bigger – so it really is the explosion of obesity that is a worldwide problem. And with obesity comes the other metabolic problems. Though it starts with obesity, it then deteriorates into glucose intolerance. Yes, people may present to a doctor with a heart attack or something and they define it as an elevated blood sugar, but it all started with being too big for your body.
NB: Are there certain populations that you think are most at risk?
LJ: There’s a genetic tendency to develop type 2 Diabetes. And it’s a survival gene. This survival gene actually is a compliment that says, “You were chosen never to lose weight so you could survive through starvation.” If you were chosen to not lose weight during times of starvation, then you were chosen to be the survivors. So it’s a survival gene. But we aren’t starving worldwide, so what happens is that you put the weight on and you can’t lose it; there’s a genetic tendency towards that. Yes, certain populations have a higher tendency towards it, and it’s the populations that have been starving, like the American Indians, who were hunter- gatherers and needed to make sure they had a supply of fat. Holocaust survivors are another group, because the way they could survive was to be able to starve and not die from starvation. Also, populations that really have no access to food – you can see it in India- when they finally have access to food, they end up getting a little overweight and all of a sudden you see an explosion of type 2 diabetes. And in the United States, you wouldn’t define them as fat, or overweight, but with their population, they are too big for the genetic tendency. And if they get type 2 diabetes, it’s because they were chosen to be the survivors. That’s actually a nice thing to find out you were chosen, but a family history sometimes can tell you what you have no idea about. You really need to do a blood sugar measurement and talk to the person. That’s what the problem is, they’re not doing blood sugars in large populations.
NB: What are the implications for pregnancy?
LJ: In utero, the major food supply is glucose. If the mother’s blood sugars are elevated just a little bit, the baby gets fat. The baby makes more insulin, and the more insulin baby makes, the more the baby needs blood sugar. The mother’s eating, the blood sugar is getting higher, it goes out to the baby, the baby makes a ton of insulin, and gets fatter and fatter and fatter. So now you’ve got a really fat baby and the obstetrician can’t get the kid out. You can understand that if the kid is too big to deliver, the obstetrician’s pulling the head, and the head could come off.
NB: That happens?
LJ: Unfortunately, there’s a doctor who actually brags that actually happened to him. What happens is that the head gets out and the shoulders get stuck. There’s no solution to this problem short of ripping the mother completely open, pulling apart the bones, and delivering the baby alive – or pulling and pulling and pulling. As you pull too much, you end up stretching the nerves in the shoulder, and the baby can actually have nerve damage. It’s called Erb’s palsy or shoulder dystocia. They pull and pull to try and get the shoulder down and usually they can get half the body out and turn the body. That’s what obstetricians are taught – how to get a big baby out of a mother who’s had shoulders sticking in the delivery wall. So yes, there’s more difficulty in delivery, but even if you got the kid out by C-section, the kid’s now a fat baby, and is going to be a fat toddler, a fat teen, and the next generation of type 2 diabetes, depending on how you define it. You are going to be seeing more and more type 2 diabetes in children because the babies are born too big.
NB: Born to a mother that’s taking in too much glucose.
LJ: Right. Well, her blood sugar is too high. Doesn’t matter how it got high, could be either she’s eating or she has undiagnosed diabetes, or she likes tons of carbs, doesn’t matter. The baby sees the mother’s blood sugars, the baby makes insulin, and the baby gets fatter and fatter.
NB: You’ve done some excellent research in the research institute here about osteopenia. Can you tell me a little bit about that?
LJ: Well, osteopenia is a problem secondary to calcium deposits. And it’s interfered by excess sugar; just like sugaring hemoglobin, it’s sugaring a protein, and the calcium doesn’t deposit, so that the bones get thin with longstanding diabetes, either with type 1 or type 2. The research we’ve done here is with a mouse model with type 1 diabetes, and the mice start to get thinning of bone, and they get a hip fracture and start to limp, and it’s really clear that their blood sugars are high. Here in the Institute, we’ve actually documented that thin bone and broken hips in the mice are related to glucose. And the question becomes whether we can treat the glucose and therefore prevent loss of bone, and therefore hip fracture, and death and dying. That may also extrapolate to humans. And the truth is that you’ve got a perfect mouse model in this Institute about having hyperglycemia, thin bones, and leading to hip fracture.
NB: And, of course, people who suffer from hip fracture or weak bones become bedridden, and subject to all the pulmonary diseases that follow.
LJ: Absolutely, bedridden and no exercise, pain, need for pain medicine, and nursing homes. The whole family’s involved. And the costs are enormous.
NB: This leads to the next question. Please talk to us about the cross consequences of diabetes, economically.
LJ: Well, it’s cheaper if everybody dies, that’s for sure.
NB: Because they –
LJ: They don’t need hospitalization, they don’t need care. Dead is dead, doesn’t need care. It’s really the high cost of somebody having a heart attack, ending up in the emergency room and being in intensive care around the clock. They may need blood vessel surgery or tubes put in, and they probably will be in intensive care, which is a huge cost – and somebody needs to pay the hospital.
NB: So it’s exacerbated by diabetes?
LJ: Absolutely, vessel disease is sugar coating the vessels. The vessels get smaller and smaller and you have a heart attack. Atherosclerosis really is diabetes all over the place. It’s getting the blood vessels thinner and thinner, cholesterol, plaque, and all of a sudden they close and somebody starts to feel the pain of no blood supply, or they experience a stroke first and therefore they’re dependent on family for taking care of them. Then the family says, “We can’t do this,” and puts them in a nursing home, and who pays for that? It’s a terrible thing to say, but it would be easier if everybody died first from a vascular accident than having them survive and being dependent on the rest of the economy to take care of them.
NB: What is a social justice consequence of diabetes? Because what we see is that the hospitalization of somebody means that somebody’s wife finds herself living in the hospital is in hallway, or that somebody’s children are ignored or have to stop their lives and be a caretaker. Could you talk a little bit about this?
LJ: There are some children that really have no after-school life because they have to be home at a certain time to take care of another family member, so that the significant other can then go to work. Children learn early on that Grandpa was a burden, always a burden – I have to be home if Grandpa needs something, and Grandpa needs help up the stairs – it’s a terrible burden to children, and they end up thinking, “there’s no way that I want diabetes” – that’s true, but they’re not taught how to help themselves. And then they go to school and the school nurse says to the mother that the kid’s getting a little fat, but the mother’s not home to take care of the kid, and all they have at home are candy bars. We start to hear the social and economic consequences when the mother can’t be home to cook because she’s working, and therefore she leaves Grandma or Grandpa with the kid, and the only food she can put in the refrigerator is really cheap – and what’s cheap? Carbs are cheap. The truth is, it’s cheaper to eat carbo, and the kids stop complaining they’re hungry.
NB: Right, right up to the time that it breaks you financially because you’re hospitalized, or the people around you.
LJ: Or they disown you. And then it becomes our taxpayers’ problem. What do you do with an old man who doesn’t have a home, and the nursing homes are all full, and the man ends up staying in the hospital for months because there is nowhere to put them? What are you going to do?
NB: Is that endemic across this country now?
LJ: Yes. I have to say, that anywhere you go, you find that the biggest hospital deficit is because there’s an old person there who can’t be placed. The social workers can’t find an open nursing home, or they’re moved to Bakersfield from San Diego and the family will never be able to come and visit, so the hospital has to keep them. So when the social workers say that there are no openings in nursing homes, the hospital ends up babysitting someone who’s a vegetable.
NB: Talk to me about, from what you perceive, what do you forecast in the field of diabetes?
LJ: I think diabetes is going to become a reportable disease. And therefore, you have to tell the state you live in that you have diabetes and it will be absolutely a law that you have to treat anybody with diabetes. It costs too much not to diagnose and not to treat the diabetes. That’s what’s going to happen, sort of like syphilis – syphilis is a reportable disease. If diabetes were a reportable disease, if the doctor saw an elevated blood sugar, then the doctor could report you that you have diabetes, and the state is obligated to take care of you.
NB: And try to put the brakes on it sooner.
NB: What do you think are the recent best advances?
LJ: I think insulin’s gotten easier to give. Pills are expensive. If doctors have the ability to give insulin without being scared, then the patient can eat whatever they want. If you can give somebody insulin, and they can inject themselves, then you can allow them to have dietary discretion. The doctors are afraid of insulin – it’s not the patients.
NB: Why are they afraid?
LJ: They’re afraid because they don’t know how to use it, and God forbid their patient has a car accident due to hypoglycemia. The truth is, they’re scared to start it because they don’t have the nurses to teach it, and they think that the patient may think it’s hard – all that’s true, but the barrier to insulin is the doctors, not the patient. You have to make it very easy so the doctors can prescribe it.
NB: And that’s happened – it’s becoming easier to use, you think?
LJ: It is easier, but doctors haven’t increased their pattern of behavior.
LJ: They are not educated. Pharmaceutical companies have no money, and are unable to teach doctors how easy it is.
NB: Is it also because pharmaceutical companies find it more profitable to –
LJ: No. Not at all. They would love insulin to be cheaper so more people would prescribe it. But if people don’t prescribe it, they have to pay for the costs of developing the insulin. The truth is, some insulins are really expensive, and pharmaceutical companies would love doctors to prescribe it. It’s actually cheaper to give insulin.
NB: Do you think that’s going to be the greatest advance in the next couple of years?
LJ: It’s the younger doctors. Coming out of medical schools, they use it.
NB: You’re on the advisory board of The Justice Project and I’ve got a bio for you, and I know you’ve been given all these awards and honors across time. Of all these honors and awards you’ve received, what is the most meaningful to you and why?
LJ: It’s the March of Dimes award. The March of Dimes truly identified that diabetes in pregnancy should be their chosen focus. I’ve received the international March of Dimes award, and it’s really for work in pregnancy. And there only have been five recipients across time. Just recently, the March of Dimes asked the previous recipients to name somebody that they would like to honor, and I have asked everybody to give me names so I can offer names to The March of Dimes, but there aren’t a whole lot of people who have focused on pregnancy and prevention of malformations.
NB: Thank you Dr. Jovanovic. Thank you for your rare talents, your time, and your caring.