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Re: [IPk] Pregnancy and diabetes: Woman's Hour tomorrow morning discusses la...

Hi Abi,

I should have been clearer: the foetal malnutrition thing I mentioned was 
more with regard to a hypocaloric diet. Here's what I was getting at: take 
your fit, healthy type 1 who already may eat fewer carbs than the average 
non-diabetic fit/healthy person. Then reduce the carbs further, without 
adding extra protein and fat for fear of causing excess weight gain in the 
pregnancy. Such a type 1 could wind up on a hypocaloric diet that is not 
good for her or the baby. Jovanovic would advocate a low-carb diet that 
takes into account the nutritional needs of the mother and the baby, not a 
diet that cuts out all carbs without regard to the total number of calories 
consumed. Does that make better sense?

The reasons for not putting a pregnant woman on a pump in 1996 aren't as 
powerful today...in 1996 only about 30,000 Americans had insulin pumps; 
today over 350,000 do. The technology has come a long way and the clinical 
evidence for the achievability of an A1C below 6 has been proved. If one 
could get to an A1C below 6 on Humulin R (or Actrapid) and isophane without 
frequent, severe hypos, then there'd be no reason to pump at all. The 
studies that Jovanovic and her colleagues have done in the past 12 years (it 
can take about a year after a manuscript has been submitted to get the book 
out, so the text of _The Diabetic Woman_ is not heavily influenced by the 
findings of the DCCT or the advent of rapid-acting insulin analogues) have 
shown that macrosomia is not a necessary fact of pregnancy in diabetes.

Here's a link to a study that Jovanovic did regarding Humalog use in 
gestational DM http://tinyurl.com/nequk

I think the reason for using a small dose of isophane may not be only 
because of the conventional/analogue thing. It is possible that the woman I 
knew who was Jovanovic's patient and took isophane at night was taking 
isophane primarily because Levemir was not available in the US at the time 
that she was pregnant. Levemir was launched late in the US because of some 
FDA quibbles regarding data from multiethnic studies (basically, the US FDA 
wanted Novo Nordisk to prove that Levemir was all right for Asians, blacks, 
Hispanics, etc., as most of the studies had been conducted on whites). I can 
find out pretty easily if Jovanovic has opinions about Levemir in 
pregnancy...will let you know what I find.

PS I have not forgotten about the request for scientific opinion regarding 
loss of hypo awareness and switching from animal to 'human' insulin. So far 
the researchers that I have talked to have pointed me to Stephanie Amiel's 
landmark study that showed that tighter control -->more frequent 
hypos-->hypo unawareness. But I have also found this very interesting 
article by Prof. Amiel:
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