Rationale of the Week | Reluctant to Start Metformin due to Side Effects
For last week’s practice question, we quizzed participants on a person’s concerns about metformin use & potential side effects. 41% of respondents chose the best answer. We want to clarify and share this important information, so you can pass it on to people living with diabetes and your colleagues, plus prepare for exam success!
Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer it below: Answer Question
Question: LS is reluctant to start on metformin because they heard it can cause diarrhea and kidney problems. You reassure LS that metformin doesn’t harm the kidneys and can actually improve gut health.
Based on the most recent evidence, which of the following is true?
Answer Choices:
- Hold metformin if the GFR is less than 45 and the person has an occasional alcoholic beverage.
- Metformin increases the growth of bacteria like Akkermansia muciniphila.
- Most people with metformin experience diarrhea, so make sure to increase fiber intake when starting.
- Start vitamin B12 therapy and iron supplements with initiation of metformin.
Getting to the Best Answer
Answer 1 is incorrect. 22.27% chose this answer. “Hold metformin if the GFR is less than 45 and the person has an occasional alcoholic beverage.” The guidelines state not to start metformin is the GFR is less than 45. But if someone is already on metformin their GFR drops below 45 we can continue it with caution and we might reduce the dose. We stop metformin if the GFR is less than 30. We don’t recommend metformin if someone is binge drinking due to the potential risk of lactic acidosis. An “occasional drink” would not reach the threshold to stop the metformin. Download Med PocketCards for more info.
Answer 2 is correct. 41.17% of you chose this answer. “Metformin increases the growth of bacteria like Akkermansia muciniphila.” Yes, this is the best answer. Metformin has been shown to increase gut bacterial diversity with a special nod to one of our favorite mucus protective bacteria known as “Akk”. This beneficial bacteria increase levels of butyrate and protects intestinal mucous lining, which helps to decrease inflammation. Cheers for AKK! Download Med PocketCards for more info.
Answer 3 is incorrect. About 19.51% of respondents chose this. “Most people with metformin experience diarrhea, so make sure to increase fiber intake when starting.” This is not accurate, since only a small percentage of people experience diarrhea. And, if they do, switching them to metformin extended release can decrease intestinal discomfort. Download Med PocketCards for more info.
Finally, Answer 4 is incorrect. 17.05% chose this answer. “Start vitamin B12 therapy and iron supplements with initiation of metformin.” Some, but not all individuals experience B12 deficiency on long term metformin therapy. We would only start B12 replacement therapy after confirming low B12 levels. Download Med PocketCards for more info.
We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!
Check out these upcoming class offerings!
All hours earned count toward your CDCES Accreditation Information
Sign up for Diabetes Blog Bytes – we post weekly Blog Bytes that are informative and FREE! Every week we post one exam practice Question of the Week and Rationale of the Week. Sign up below!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Diabetic Retinopathy: The Role of Diet in Prevention and Progression
Nutrition Intervention Can Protect Vision
by Christine Craig, MS, RD, CDCES
Recent research highlights the role of diet in preventing and slowing the progression of diabetes retinopathy, which is the leading cause of vision impairment among individuals with diabetes.
While glucose management is essential in reducing the risk of retinopathy, nutritional strategies that target reduced glycemic variability, blood pressure, inflammation, and oxidative stress significantly impact retinal health and vision.
In 2021, it was estimated that 26.43% of individuals with diabetes in the US have diabetic retinopathy, and 5.06% of individuals have vision-threatening diabetic retinopathy.1
Non-Proliferative and Proliferative Retinopathy
Clinically, diabetic retinopathy presents as non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR).
- NPDR occurs in the early stages when blood vessels in the retina weaken, and microaneurysms occur, but there is no new blood vessel growth.
- PDR is when there is a “proliferation” of new blood vessel growth in the retina, and these unstable vessels break and bleed into the vitreous, causing severe vision loss. PDR requires urgent and ongoing medical treatment.
Chronic hyperglycemia, dyslipidemia, nephropathy, and hypertension are factors that increase the risk of diabetic retinopathy.3 In type 1 diabetes, the DCCT and EDIC studies identified that higher mean HgbA1c is the strongest predictor of retinopathy progression. A 1% reduction in HgbA1c was associated with a 35% reduction in the risk of developing diabetic retinopathy.
Eye Screening Guidelines
Screening is essential; 2019 data indicates that 64.8% of individuals with diabetes had completed an eye exam in the past 12 months.2
The ADA Standards of Care recommends that adults with type 1 diabetes be screened within five years of diagnosis and individuals with type 2 diabetes be screened at the time of diagnosis. followed by an annual screening. If the eyes are healthy on exam and glucose is within the target range, eye specialists can consider extending screening to every 2 years.3
Diet and Retinopathy Risk
An individual’s diet plays in important role in retinal health.
Research has associated the consumption of fatty fish, fruits, vegetables, and antioxidant-rich foods with a reduced risk of diabetic retinopathy.4
In contrast, dietary patterns that contribute to glucose elevation and increase advanced glycation end-products (AGEs) contribute to retinal inflammation and microvascular damage.4 Focus on dietary interventions that support glycemic, lipid and blood pressure management help reduce risks or slow profession of this condition.3
Just as in general diabetes management, no one diet pattern is recommended; however, there is some evidence for specific nutrients. Research on nutrients such as omega-3 fatty acids, fiber, lutein and zeaxanthin, Vitamin C, Vitamin E, and Zinc have shown positive association with lowering diabetic retinopathy risk.4 To meet these nutrient needs, whole food-based diets rich in vegetables, whole grains, legumes, lean proteins, and healthy fats may be considered.
The Dietary Inflammatory Index (DII)
The Dietary Inflammatory Index (DII) is a scoring system that measures the inflammatory potential of individual diets based on 45 parameters, including various macronutrients, micronutrients, and phytochemicals. Liu and colleagues5 found that a one-point increase in the DII score was associated with 38% increased odds of having diabetic retinopathy. Their research also noted the relationship between higher HbgA1c, duration of diabetes, and increased retinopathy risk. While the research used NHANES data, the small sample size and retrospective cross-sectional analysis limit the ability to conclude causation.
We can consider the benefits of increasing anti-inflammatory foods and decreasing inflammatory foods, but additional information is needed to implement direct recommendations.
Role of Diabetes Educators in Prevention
As Diabetes Care and Education Specialists (DCES), we can support the prevention of diabetic retinopathy by helping individuals manage glucose through dietary patterns to reduce risk and slow progression. Although barriers exist to adopting anti-inflammatory diets rich in whole foods, antioxidants, and essential nutrients, understanding the potential connection beyond glycemic management can guide additional nutrition interventions.
Programs that support retinal photography with remote reading can increase access to screening in areas lacking accessible services. Additionally, ensuring blood pressure, lipid and renal screening and management, understanding the role of physical activity, and long-term glucose management can support vision health. DCES can empower patients to make sustainable lifestyle changes that support retinal health through individualized counseling and interdisciplinary collaboration with eye care providers.
References:
- Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol.2023;141(8):747–754. doi:10.1001/jamaophthalmol.2023.2289
- Healthy People 2030 Data Report. Downloaded on October 18th 2024 from https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increase-proportion-adults-diabetes-who-have-yearly-eye-exam-d-04
- American Diabetes Association Professional Practice Committee; 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2024. Diabetes Care1 January 2024; 47 (Supplement_1): S231–S243. https://doi.org/10.2337/dc24-S012
- Bryl A, Mrugacz M, Falkowski M, Zorena K. The Effect of Diet and Lifestyle on the Course of Diabetic Retinopathy-A Review of the Literature. 2022 Mar 16;14(6):1252. doi: 10.3390/nu14061252. PMID: 35334909; PMCID: PMC8955064.
- Liu, R., Zhang, J., Gu, W. et al.Dietary Inflammatory Index and diabetic retinopathy risk in US adults: findings from NHANES (2005–2008). BMC Ophthalmol 24, 46 (2024). https://doi.org/10.1186/s12886-024-03303-1
Save the Date!!
Cyber Weekend Sale is Nov 29th – Dec 2nd
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The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Question of the Week | Best Action to Avoid Thanksgiving Post Meal Elevation?
JR is excited about enjoying Thanksgiving with family but is a little worried about post-Thanksgiving meal blood sugar elevations. JR takes 1 unit bolus insulin for every 10 gms of carb, with a correction factor of 1 unit for every 50 points above 120, plus 23 units of basal insulin at night. For Thanksgiving JR plans to eat:
- 1 cup of mashed potatoes
- Spoonful of green beans
- Gravy
- 1 Roll with lots of butter
- ½ cup of sweet potatoes
- Turkey leg
- A glass of white wine
If JR’s blood Sugar is 173 before the meal, what is the best approach?
- Decrease carbs by half and increase intake of high fiber vegetables.
- Take about 7-8 units bolus insulin before the meal.
- Increase basal the night before to prevent post meal elevation.
- Take bolus insulin after meal based on blood sugar response.
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Register for these FREE courses today!
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All hours earned count toward your CDCES Accreditation Information
Sign up for Diabetes Blog Bytes – we post weekly Blog Bytes that are informative and FREE! Every week we post one exam practice Question of the Week and Rationale of the Week. Sign up below!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Free Webinars | Revitalize your DSME and Prepare for BC-ADM Exam
November is Diabetes Awareness Month, and there’s no better way to expand your knowledge than by attending one of the many free webinars hosted by Diabetes Education Services. These webinars provide essential insights that can help you stay informed and empowered in your journey to becoming a Diabetes Educator.
This month, join Coach Beverly—a trusted expert in diabetes education—as she leads a series of engaging and informative webinars. With her wealth of experience and passion for helping others, Coach Beverly will guide you through topics ranging from the basics of diabetes to more advanced management strategies. Don’t miss these valuable opportunities to learn from one of the top educators in the field. Be sure to register for the upcoming sessions and make the most of Diabetes Awareness Month!
To celebrate 25 years as the CEO of Diabetes Education Services and 30 years of specializing in diabetes, I am excited to offer my ADCES presentation, Strategies to Revitalize your Diabetes Program or Business.
If you are starting a diabetes self-management program or want to revitalize your current practice, we invite you to join this one-hour webinar full of practical tips on advocating for the best health care in a variety of practice settings.
Starting your journey to becoming a BC-ADM?
Register for our FREE Preparing for BC-ADM Exam Webinar!
Interested in learning more about Board Certification in Advanced Diabetes Management?
This webinar will answer your questions.
Why Attend These Webinars?
Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and our Level 4 | The Impact of Adverse Childhood Experiences on Health awards 1.0 CPEUs in accordance with the Commission on Dietetic Registration’s CPEU Prior Approval Program.
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Celebrate National Diabetes Month with DiabetesEd Services: T-shirt & Diabetes Book Giveaway!*🎉
How You Can Participate:
Share your plans and activities for National Diabetes Month by Submitting the activities form by November 29th. Tell us what you’re doing to spread awareness, provide education, or advocate for diabetes prevention and management. Your ideas have the power to motivate others to take action, and we’d love to amplify your voice by sharing your initiatives on our social media channels or website.
Let’s Work Together to Make a Difference
As we celebrate National Diabetes Month, we have the opportunity to inspire change, build stronger communities, and help individuals affected by diabetes lead healthier lives. Whether you’re just starting your diabetes education journey or have been in the field for years, your contributions are vital to improving diabetes care. By sharing your plans and participating in our giveaway, you’re helping to spread the word and create a more informed, supportive environment for everyone impacted by diabetes.
We can’t wait to hear from you and see how you’re making a difference this National Diabetes Month. Together, we can create a lasting impact!
Submit your Diabetes Ed Awareness activity by Nov 29th and enter to win—we look forward to celebrating your efforts with you! 💙
Sign up for Diabetes Blog Bytes – we post weekly Blog Bytes that are informative and FREE! Every week we post one exam practice Question of the Week and Rationale of the Week. Sign up below!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Happy World Diabetes Day – We are Celebrating!
I love November because we get to celebrate National Diabetes Month and World Diabetes Day on November 14th, which is Dr. Banting’s Birthday. Plus…
This year is the 103rd birthday year of the discovery of insulin!
Over one hundred years ago, two researchers kick-started the production of insulin, making it available for worldwide use and saving millions of lives. Now, that’s a real cause for celebration. The discovery of insulin by Banting, Best, and team was no easy feat. They encountered resistance, setbacks, and failures.
Dr. Banting secured space to test out his theory at the University of Toronto during a hot summer in 1921.
Along with his colleague, Charles Best, and a bare-bones lab, they conducted dozens of experiments on dogs. Marjorie (dog 408) lived for 70 days without a pancreas due to receiving life-saving insulin injections.
This success was replicated in other experimental dogs and ultimately provided the first step toward producing insulin from pig and cow pancreases.
In 1922, children with type 1 diabetes started receiving early doses of this newly available life-saving hormone. Leonard Thompson, was the first recipient in January 1922, followed by many thereafter. Here is a heartbreaking then uplifting photo of J.L., who after 2 months of receiving insulin, transformed into a healthy young boy.
To learn more about the Discovery of Insulin and download historical slides Click here!
We are Celebrating Diabetes Month with Free Webinars and Giveaways (plus 30% off Sale on December 2nd)
For the month of November & December:
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Join or View our 3 FREE webinars
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Share Your Action to raise Diabetes Awareness to Win a FREE Carb Counting Book or TShirt
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Cyber Monday Sale – 30% off Online Courses on December
Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!
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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
Rationale of the Week | Diabetes Risk with Statin Use
For last week’s practice question, we quizzed participants on concerns with diabetes risk and statin use. 95% of respondents chose the best answer. We want to clarify and share this important information, so you can pass it on to people living with diabetes and your colleagues, plus prepare for exam success!
Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer it below: Answer Question
Question: LC is a 49-year-old living with type 2 diabetes and reports during their appointment they have stopped their statin because of concern over risk of type 2 diabetes incidence with statin use.
Using the ADA Standards of Care as a guide, what would be the best response to LC concerns?
Answer Choices:
- Your concern is valid, but restarting the statin is mandatory. Everyone with type 2 diabetes should be on one without exception.
- While statins may slightly increase the risk of type 2 diabetes, their benefits in preventing cardiovascular events outweigh the risks for most people. Let’s talk about your personal risks and explore if continuing a statin is right for you.
- Stopping your statin was a good idea. There are other medications that don’t carry any risk of increasing diabetes incidence.
- We can focus solely on lifestyle changes to manage both your cholesterol and diabetes.
Getting to the Best Answer
Answer 1 is incorrect. 1.40% chose this answer. “Your concern is valid, but restarting the statin is mandatory. Everyone with type 2 diabetes should be on one without exception.” Although statins are recommended for most people with diabetes, especially those over 40, the ADA emphasizes individualized care. There may be specific cases where statin use is not appropriate. Mandatory recommendations fail to consider individual preferences and circumstances, which are central to person-centered care.
Answer 2 is correct. 95.21% of you chose this answer. GREAT JOB! “While statins may slightly increase the risk of type 2 diabetes, their benefits in preventing cardiovascular events outweigh the risks for most people. Let’s talk about your personal risks and explore if continuing a statin is right for you.” This response acknowledges LC’s concern while addressing the evidence-based benefits of statin therapy for cardiovascular disease prevention. Statins are generally recommended for people with diabetes because cardiovascular protection outweighs the slight increase in diabetes incidence. This option promotes person-centered care by encouraging a collaborative approach.
Answer 3 is incorrect. About 0.40% of respondents chose this. Stopping your statin was a good idea. “There are other medications that don’t carry any risk of increasing diabetes incidence.” This response is misleading and may not be the best recommendation for LC. The ADA recommends considering the individual’s cardiovascular risk profile, not discontinuing statins simply because of concerns about diabetes incidence.
Finally, Answer 4 is incorrect. 2.99% chose this answer. “We can focus solely on lifestyle changes to manage both your cholesterol and diabetes.” Discontinuing statins without clinical justification could increase LC’s risk of cardiovascular events. The ADA recommends a combination of lifestyle changes and pharmacotherapy, when appropriate, for optimal outcomes.
We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!
Want to learn more about this question?
Live & On-Demand Viewing
FREE Webinars this November!!
Why Attend These Webinars?
Instructor: Beverly Thomassian RN, MPH, CDCES, BC-ADM is a working educator who has passed her CDCES Exam 7 times. She is a nationally recognized diabetes expert for over 25 years.
Sign up for Diabetes Blog Bytes – we post weekly Blog Bytes that are informative and FREE! Every week we post one exam practice Question of the Week and Rationale of the Week. Sign up below!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
National Diabetes Month – Resources
November kicks off National Diabetes Month
According to the latest CDC Data, over 16% of Americans are living with diabetes and 38% have prediabetes. This means about half of our communities are living with hyperglycemia.
Advocacy and education play essential roles in diabetes care and prevention. By equipping individuals with knowledge about diabetes management, healthy lifestyle choices, and preventative measures, we empower them to take ownership of their health and inspire change within their communities.
Community-centered education can be incredibly powerful—when people feel informed and supported, they’re more likely to make meaningful changes and encourage others to do the same. This creates a ripple effect, fostering healthier communities and potentially reducing the prevalence of diabetes over time.
We have put together a list of FREE Webinars and diabetes resources in English and Spanish to share with people living with prediabetes and diabetes. Thank you for your advocacy and belief that we can make a difference.
FREE Webinars to Celebrate National Diabetes Month
- From the Gut to the Butt- Exploring the GI System, Ready for On-Demand Viewing
- Prep for CDCES – Ready for On-Demand Viewing
- Revitalizing Diabetes Program Nov 14th
- Prep for BC-ADM- Nov 20th
Websites that offer FREE handouts & info on diabetes
ADA’s Diabetes Food Hub – English and Spanish! Web site filled with information on healthy eating and an abundance of delicious recipes.
ADA Resources in Spanish – this newly opened information hub is perfect for those who prefer to learn and read in Spanish.
ADA’s FREE Life with Diabetes Program: ADA’s program includes six digital, printable journeys to teach how to live well with diabetes; a monthly e-newsletter with tips, stories, and more resources; six free issues of the Diabetes Forecast® magazine; access to an online community and local events. (The program is available in both English and Spanish).
ADA’s Risk Quiz: 60-second online risk assessment for type 2 diabetes. ADA created a self-assessment and a version to fill out the assessment for others. There’s also a printable version in English & Spanish that can be distributed to help ascertain risk. This is a great first step in helping individuals consider coming in for an appointment
CDC Diabetes Prevention Program Curricula and Handouts This site offers excellent resources for those interested in offering Diabetes Prevention Education in English and Spanish.
Inclusive Care Handout for LGBTQ Individuals – this handout provides helpful language and strategies to create connections with this underserved at risk community.
National Diabetes Education Program is an online library of resources compiled by the NDEP to help provide accurate information and support for people living with prediabetes and diabetes.
Spanish Language Resources: language can be a barrier to adequate and quality care. ADCES has created a number of free downloads for people with diabetes and prediabetes, which have been translated into Spanish.
Type 1 Diabetes Resource Page – Includes is a list of helpful online resources for Type 1 Diabetes. It include sites for national organizations like the American Diabetes Association (ADA), sites for diabetes interest groups, and other participant organizations that provide helpful diabetes tips and opportunities to join online groups.
Tech Resources
DiabetesWisePro for Clinicians A non-biased web site for health care professionals that has a quick tool to access insurance coverage information, how to order devices, what to include and where to go for support.
DiabetesWise A non-biased website that helps people with diabetes learn about different diabetes devices and determine the best match for their needs
Insulin Cost Savings Toolkit Resource Page – An ADCES complete listing of low cost insulin options and resources.
Technology Cost Savings Resource Page – An ADCES listing of websites and information to obtain pumps and sensors for a lower cost.
DiabetesEd FREE Resource Catalog
See Full Free Resource Catalog
Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!
[yikes-mailchimp form=”1″]Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
Question of the Week | Reluctant to Start Metformin due to Side Effects
LS is reluctant to start on metformin because they heard it can cause diarrhea and kidney problems. You reassure LS that metformin doesn’t harm the kidneys and can actually improve gut health.
Based on the most recent evidence, which of the following is true?
- Hold metformin if the GFR is less than 45 and the person has an occasional alcoholic beverage.
- Metformin increases the growth of bacteria like Akkermansia muciniphila.
- Most people with metformin experience diarrhea, so make sure to increase fiber intake when starting.
- Start vitamin B12 therapy and iron supplements with initiation of metformin.
Want to learn more?
Check out our Free Webinars for the month of November.
All hours earned count toward your CDCES Accreditation Information
Sign up for Diabetes Blog Bytes – we post weekly Blog Bytes that are informative and FREE! Every week we post one exam practice Question of the Week and Rationale of the Week. Sign up below!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
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