Lifestyle and Nutrition Strategies Across CKM Syndrome Stages
Cardiovascular-kidney-metabolic (CKM) syndrome represents the interconnected systems of adiposity, metabolic dysfunction, kidney disease, and cardiovascular disease. In 2023, the American Heart Association’s (AHA) advisory panel defined a spectrum of risk by defining five progressive stages.¹ These stages span from stage 0 (no CKM risk factors), stage 1 (excess or dysfunctional adiposity), stage 2 (metabolic risk factors and CKD), stage 3 (subclinical cardiovascular disease in CKM) and Stage 4 (clinical cardiovascular disease (CVD) in CKM). This staging system emphasizes the continuum of risk, the importance of assessment across the lifespan, and the value of early interventions. The AHA advisory emphasized systematic screening (1) across all stages and lifespans to identify risk early. It is predicted that in the US, almost 90% of the population meets stage 1 or higher. (2) In collaboration with the community and medical care teams addressing CKM requires consideration of genetics, behavior, environment, and social determinants of health alongside pharmacotherapy, lifestyle and nutrition interventions. As diabetes educators, we are already skilled in assessing many of the metrics included within the staging assessments, making us well-positioned to implement CKM-based risk interventions.
In June 2025, the Journal of the American College of Cardiology published an expert review of evidence-based lifestyle interventions for CKM syndrome.² Although few studies have examined dietary interventions specifically for CKM syndrome, existing research for metabolic, kidney, and cardiovascular disease ❤️ highlights a consensus of diet quality and whole-diet patterns over single-nutrient approaches. Stage 0 encourages youth interventions to promote health through healthy diet, activity, and multi-component education within schools. In Stage 1, the goal is to prevent the development of metabolic risk factors in individuals with excess or dysfunctional adiposity. While intentional weight loss of at least 5% provides significant cardiometabolic prevention benefits, adopting a heart-healthy diet and increasing physical activity can improve health even without weight loss.¹ Stage 2 is focused on metabolic and CKD risk reduction, with DASH and Mediterranean diets recommended alongside aerobic and resistance training to support glycemic management and reduced blood pressure, hypertriglyceridemia, and progression of CKD.¹ ² Concerns of subclinical CVD modify recommendations in Stage 3 to focus on interventions that can reduce non-calcified arterial plaques and CVD events; however, only one dietary study was included within the review. The DISCO-CT trial² found that a dietitian-led DASH dietary pattern significantly reduced non-calcified plaque in individuals with non-obstructive stenosis. Nutrition should also focus on kidney preservation through individualized protein goals, increased plant-based foods 🥦, and limited processed-food consumption. In addition, medication optimization and high-intensity exercise are recommended. Dietary strategies for individuals with established CVD, Stage 4, focus on improving recovery and secondary prevention. The Mediterranean and low-fat dietary patterns are supported by evidence to reduce the recurrence of cardiovascular events post MI and reduce myocardial ischemia and coronary artery disease progression, respectively. In stage 4, like all stages, evidence-based pharmacotherapy and coordinated care with multi-disciplinary teams complement lifestyle interventions. While more research is needed to tailor strategies to individual needs at each stage, we can see that these stages have many overlapping recommendations. We can use a whole-person, comprehensive assessment approach instead of focusing on dietary interventions that treat diseases in isolation.
Dietary patterns and lifestyle strategies can be implemented using a simplified, patient-centered approach. The DASH and Mediterranean diets both support CKM syndrome outcomes but have slight differences in food patterns. DASH emphasizes fruits, vegetables, whole grains, low-fat dairy, lean protein, and limits on sodium. The Mediterranean diet prioritizes plant-based foods, healthy fats like olive oil, moderate fish and poultry, and limited red meat, with a focus on flavor and traditional eating patterns rather than strict nutrient targets. Both dietary patterns emphasize micronutrient dense, antioxidant rich and high fiber foods. By using these evidence-based dietary patterns as a framework, diabetes educators can tailor nutrition and lifestyle strategies to an individual’s preferences, abilities, and cultural context as we know is recommended by the American Diabetes Association.³ Practical considerations to address diet quality include seeking opportunities to increase vegetables and fruits, whole grains and legumes, plant proteins, fish, and nuts and seeds, while minimizing red/processed meat consumption, added sugars, sodium, and ultra-processed foods.³
Optimizing CKM health requires a comprehensive and collaborative approach.¹ This includes recognizing the impact of social determinants of health, expanding education and access to pharmacotherapies, and filling critical research gaps. It also means strengthening care coordination among providers, offering better education for both professionals and the public, and focusing on factors to address dysfunctional adiposity as a key driver of CKM. Finally, building strong partnerships across health systems and communities will be essential to support at-risk communities and help people achieve healthy outcomes. Diabetes educators can serve as guides, assisting individuals to understand their risks, supporting behavior change, and ensuring evidence-based CKM strategies are translated into practical, sustainable care.
References:
- Ndumel, C, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation 2023:148 (20) https://doi.org/10.1161/CIR.0000000000001184
- Shahid, I, Philip, J, Avenatti, E. et al. Lifestyle Interventions in Cardiovascular-Kidney-Metabolic Syndrome JACC: Advances Expert Panel. JACC Adv. 2025 Jun, 4. https://doi.org/10.1016/j.jacadv.2025.101788
- American Diabetes Association Professional Practice Committee; 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S86–S127. https://doi.org/10.2337/dc25-S005
Live in San Diego
DiabetesEd Training Seminar
Join us live October 22nd – 23rd, 2025!
30+ CEs with Expanded Accreditation!
Join our expert team for engaging, interactive sessions that bring the ADA Standards of Care to life—covering medications, behavior change, technology, and more. Ideal for CDCES or BC-ADM exam prep, this course also includes a 4-hour Virtual Medical Nutrition Therapy Toolkit and bonus content that also meets CDCES renewal requirements.
Program Objectives:
Upon completion of this activity, participants should be able to:
- Describe the current ADA Standards for diagnosis, goals, and person-centered diabetes management across the lifespan.
- Demonstrate insulin pattern management and dosing strategies in clinical scenarios.
- Implement timely screening and risk reduction strategies for microvascular and cardiovascular complications.
- Incorporate behavior change techniques and medical nutrition therapy to support people with diabetes self-management and lifestyle adjustment.
Expert Faculty:
Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC-ADM, FADCES, FCCPCES
Beverly Thomassian, RN, MPH, CDCES, BC-ADM
Faculty Bios & Disclosures
Our expert team transforms complex diabetes science into clear, practical insights—keeping it real, engaging, and fun!
Program Faculty Disclosures:
Partners for Advancing Clinical Education (Partners) requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Partners policies. Others involved in the planning of this activity have no relevant financial relationships.
Faculy Bios & Disclosures:
Coach Beverly Thomassian RN, MPH, CDCES, BC-ADM – CEO of DiabetesEd ServicesDisclosures:
Beverly Thomassian has no financial disclosures
Bio:
Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC-ADM, FADCES, FCCPCES
Disclosures:
Dr. Diana Isaacs has the following relevant financial relationships:
- Consultant, advisor, and speaker for Abbot Labratories, Dexcom, Medtronic, Insulet, Lilly, Cequr, Sanofi, and Undermyfork
- Board member at Association for Diabetes Care and Education Specialists
Bio:
Diana Isaacs was awarded 2020 ADCES Diabetes Educator of the Year for her educational platform promoting the use of CGM for people with diabetes and other innovations. She serves in leadership roles for several pharmacies and diabetes organizations. She has numerous diabetes publications and research projects with a focus on medications, CGM and diabetes technology.
For the past three year, Dr. Isaacs has served as a contributing author for the 2023 ADA Standards of Care.
As the Program Coordinator and clinical pharmacist specialist in the Cleveland Clinic Diabetes Center, Dr. Isaacs brings a wealth of clinical knowledge combined with extensive research and speaking experience to this program.
Expanded Accreditation
Activity Start and End Date: 10/22/25 – 10/23/2025
Estimated time to complete the activity: 15 hours and 30 minutes
_____________________________________
Jointly provided by Partners for Advancing Clinical Education and Diabetes Education Services
Joint Accreditation Statement:
In support of improving patient care, this activity has been planned and implemented by Partners for Advancing Clinical Education (Partners) and Diabetes Education Services. Partners is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Education:
Partners designates this enduring material for a maximum of 15.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing Continuing Professional Development:
The maximum number of hours awarded for this Nursing Continuing Professional Development activity is 15.50 contact hours.
Pharmacy Continuing Education:
Partners designates this continuing education activity for 15.50 contact hour(s) (1.550 CEUs) of the Accreditation Council for Pharmacy Education.
(Universal Activity Number – JA4008073-9999-25-206-L01-P)
Type of Activity: Application
For Pharmacists: Upon successfully completing the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Dietitian Continuing Education:
This program offers 15.50 CPEUs for dietitians.
Interprofessional Continuing Education:
This activity was planned by and for the healthcare team, and learners will receive 15.50 Interprofessional Continuing Education (IPCE) credit for learning and change.
For additional information about the accreditation of this activity, please visit https://partnersed.com.
Question of the Week | Managing Overnight Hypoglycemia: Best Plan?
Your client wants to discuss a concern about overnight hypoglycemia alerts on the CGM. These hypoglycemia alerts have been happening intermittently and only in the overnight hours. The client reports no changes in diet, activity, or insulin doses over the past 2 weeks. These events are asymptomatic, and the client reports that these episodes resolve rapidly before they can get to the kitchen to treat the hypoglycemic event. What is the best plan of action for this client?
- Advise the client to eat a high-carbohydrate snack before bed to avoid hypoglycemia.
- Advise the client to verify the asymptomatic hypoglycemia with a fingerstick blood
glucose reading and treat if hypoglycemia is verified. - Advise the client only to treat hypoglycemia if they are symptomatic.
- Advise the client to decrease their basal insulin dose.
ReVive 5 Diabetes Training Program: A Person-Centered Approach to Diabetes Distress & Glucose Management
Join us live on July 15th and July 22nd, 2025 at 9:00 am PST
6+ CEs with Expanded Accreditation!
Join experts Larry Fisher, Ph.D., ABPP, Susan Guzman, Ph.D., and Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM, for this transformative two-part training on the ReVive 5 framework—an evidence-based approach that integrates emotional well-being and glucose data into person-centered diabetes care.
Grounded in the results of the EMBARK Trial, this program emphasizes the urgent need to assess and address diabetes distress, now recognized in the ADA Standards of Care as a critical component of care. You’ll gain practical tools and strategies used in the trial to support emotional well-being, meet clinical standards, and empower individuals on their diabetes journey.
Program Objectives:
Upon completion of this activity, participants will be able to:
- Identify the key differences between diabetes distress and depression and explain their impact on self-care behaviors.
- Apply evidence-based communication strategies to respond to diabetes distress screening results.
- Demonstrate how to analyze glucose patterns using meter and sensor data.
- Utilize the ReVive 5-step approach to integrate emotional and glucose management into diabetes care.
Team of Experts:
ReVive 5 is taught by a team of 3 Interdisciplinary Experts:
Lawrence Fisher, Ph.D., ABPP
Professor Emeritus, UCSF
Susan Guzman, PhD
Beverly Thomassian, RN, MPH, CDCES, BC-ADM
CEO of DiabetesEd Services
Faculty Bios & Disclosures
Program Faculty Disclosures:
Partners for Advancing Clinical Education (Partners) requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Partners policies. Others involved in the planning of this activity have no relevant financial relationships.
Faculy Bios & Disclosures:
Lawrence Fisher, Ph.D., ABPP, Professor Emeritus, UCSF
- Consultant, advisor, and speaker for Eli Lilly
Speaker Interview:
Bio:
Dr. Fisher has been a professor in the Department of Family & Community Medicine at the University of California, San Francisco for over 25 years, and he is the Director of The Behavioral Diabetes Research Group at UCSF.
He has a Diplomate in Clinical Psychology from the American Board of Professional Psychology and is a former Associate Editor of Diabetes Care. He has conducted multiple cross-sectional and longitudinal NIH- and ADA-supported clinical research with adults with diabetes and their families.
His recent work focuses on diabetes distress and depression, disease management, and how adults and families struggle over time to manage chronic health conditions. He has won two major UCSF School of Medicine teaching awards, was nominated for the UCSF Postdoctoral Scholars Association Outstanding Mentorship Award, and has received a certificate from the American Psychological Association in “Recognition for Substantial Contributions to the Field of Family Psychology and Health.”
In 2012 he received the Richard Rubin Award from the American Diabetes Association. He maintains an active clinical practice at UCSF, has published over 190 peer-reviewed articles on diabetes and related topics, and frequently speaks to both professional and lay groups at local, national, and international meetings and workshops.
Susan Guzman, PhD
- Consultant, advisor, and speaker for Abbot Labratories and Embecta
Dr. Guzman is a clinical psychologist specializing in diabetes. In 2003, Dr. Guzman co-founded the Behavioral Diabetes Institute (BDI), the first non-profit organization devoted to the emotional and behavioral aspects of living with diabetes.
At BDI, she serves as the Director of Clinical Education, developing and leading programs for people with diabetes and healthcare professionals. She has helped develop and facilitate diabetes distress group interventions for two NIH-funded research studies for adults with type 1 diabetes.
Dr. Guzman is passionate about helping to change the conversations in diabetes away from shame, blame, and judgment to those based on facts, empathy, and engagement. She has been part of a joint ADA/ADCES effort to address problematic language and messages in diabetes.
Coach Beverly Thomassian RN, MPH, CDCES, BC-ADMBeverly Thomassian has no financial disclosures
Speaker Interview:
Bio:
Expanded Accreditation
Activity Start and End Date: 7/15/2025 to 7/22/2027
Estimated time to complete the activity: 6 hours and 15 minutes
Jointly provided by Partners for Advancing Clinical Education and Diabetes Education Services
Joint Accreditation Statement:
In support of improving patient care, this activity has been planned and implemented by Partners for Advancing Clinical Education (Partners) and Diabetes Education Services. Partners is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Education:
Partners designates this enduring material for a maximum of 6.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing Continuing Professional Development:
The maximum number of hours awarded for this Nursing Continuing Professional Development activity is 6.25 contact hours.
Pharmacy Continuing Education:
Partners designates this continuing education activity for 6.25 contact hour(s) (.625] CEUs) of the Accreditation Council for Pharmacy Education.
(Universal Activity Number – UAN JA4008073-9999-25-198-H01-P)
Type of Activity: Application
For Pharmacists: Upon successfully completing the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Dietitian Continuing Education:
This program offers 6.25 CPEUs for dietitians.
Interprofessional Continuing Education:
This activity was planned by and for the healthcare team, and learners will receive 6.25 Interprofessional Continuing Education (IPCE) credit for learning and change.
Disclosure of Unlabeled Use:
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer:
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Instructions for Credit
Participation in this self-study activity should be completed in approximately 6 hours and 15 minutes. To successfully complete this activity and receive CE credit, learners must follow these steps during the period from 7/15/2025 to 7/22/2027.
- Review the objectives and disclosures
- Study the educational content in Online University
- After review of content, a module within the course in the Online University will list a link to Partners for Advancing Clinical Education’s website
- Visit Partners for Advancing Clinical Education website listed in course in the Online University
- Complete the activity evaluation through Partners for Advancing Clinical Education website
For additional information about the accreditation of this activity, please visit https://partnersed.com.
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.
Rationale of the Week | Current Hormone Therapy Guidance in T2D
For last week’s practice question, our special guest expert Jill Schramm, DNP, FNP-C, BC-ADM, CDCES quizzed us on Current Hormone Therapy Guidance for people with T2D. 57% 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: Which statement accurately reflects current guidelines on hormone therapy (HT) in postmenopausal women with type 2 diabetes?
Answer Choices:
- Oral estrogen is preferred over transdermal forms due to better metabolic outcomes.
- Progesterone levels increase post-menopause, exacerbating insulin resistance.
- Transdermal estrogen may improve insulin sensitivity and carries a lower thrombotic risk compared to oral
estrogen. - Testosterone levels rise during menopause, leading to increased central adiposity.
Getting to the Best Answer
Answer 1 is incorrect. 10% chose this answer, “Oral estrogen is preferred over transdermal forms due to better metabolic outcomes.” Oral estrogen undergoes first-pass hepatic metabolism, which can negatively influence clotting factors. Transdermal estrogen bypasses the liver and is generally favored in women with cardiometabolic risk, such as those with type 2 diabetes.
Reference: The Menopause Society, 2022; American Diabetes Association (ADA) Standards of Care in Diabetes; 2025.
Answer 2 is incorrect. 16% of you chose this answer, “Progesterone levels increase post-menopause, exacerbating insulin resistance.” Progesterone levels actually decrease after menopause due to ovarian senescence. There is no physiological increase in progesterone levels that would worsen insulin resistance during the postmenopausal years.
Reference: The Menopause Society, 2022.
Answer 3 is correct. About 57% of respondents chose this, “Transdermal estrogen may improve insulin sensitivity and carries a lower thrombotic risk compared to oral estrogen.” GREAT JOB. This is the best answer and aligns with current guidelines. Transdermal estrogen has been shown to improve insulin sensitivity and does not increase hepatic production of clotting factors the way oral estrogen does. As a result, it is associated with a lower risk of venous thromboembolism, making it a safer option for postmenopausal women with metabolic concerns such as type 2 diabetes.
Reference: The Menopause Society (formerly NAMS), 2022 Position Statement
Finally, Answer 4 is incorrect. 14% chose this answer, “Testosterone levels rise during menopause, leading to increased central adiposity.“Testosterone levels generally decline with age and menopause, although the ratio of testosterone to estrogen may shift due to declining estrogen. While visceral adiposity does tend to increase in menopause, it is more directly related to estrogen deficiency rather than a surge in testosterone.
Reference: The Menopause Society, 2022.
Thanks to Jill Schramm, DNP, FNP-C, BC-ADM, CDCES for her providing us with these terrific insights into menopause. Join her presentation on August 27th to learn more! See info below. 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?
Join us live on August 27th for our
Level 5: Hot Flashes & Hyperglycemia: What Clinicians Need to Know
Join us live on August 27th, 2025, at 11:30 am PST to watch our brand new webinar, Hot Flashes & Hyperglycemia: What Clinicians Need to Know by Dr. Jill Schramm, DNP, FNP-C, BC-ADM, CDCES
The intersection of menopause and diabetes is often underrecognized in clinical care, yet people with diabetes in menopausal transition face unique metabolic, hormonal, and lifestyle changes that can significantly impact glycemic control. This session explores the physiological shifts of menopause, the implications for insulin resistance, and evidence-based strategies for individualized care. Attendees will leave with practical guidance on hormone therapy, lifestyle management, and education tools to improve outcomes for people with diabetes navigating both diabetes and the menopausal transition.
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.
Beyond Blood Glucose: Empowering Health Through a Holistic Lens
In today’s fast-paced, tech-forward medical world, we’ve made incredible strides in diabetes management—continuous glucose monitors, automated insulin delivery systems, and smart dosing algorithms. But amidst this progress, something vital is often overlooked: the person behind the diagnosis.
That’s where holistic care comes in.
What Is Holistic Care?
“Holistic” has become a bit of a buzzword lately—often evoking images of spa treatments, essential oils, or acupuncture needles. But at its core, holistic care is much simpler and more profound. It means supporting the whole person—not just a diagnosis or set of symptoms. It’s about understanding the interconnectedness of body, mind, environment, and lifestyle, and recognizing that true healing requires addressing all of these layers.
In holistic care, we recognize the body’s innate ability to heal itself when given the right conditions—adequate rest, nourishment, connection, and movement. Rather than just reacting to symptoms, holistic practitioners aim to restore balance and strengthen the body’s foundation, from the ground up.
In many cases, the healthcare system we work in tends to focus on disease management rather than actual health and healing. Managing symptoms, prescribing medications, and performing procedures are often necessary—and can be life-saving—but they’re just one part of the picture. Holistic care does not replace conventional medicine, it complements it by focusing on the why behind the symptoms and empowering people living with diabetes to take an active role in their well-being.
Why Approach Diabetes Holistically?
The simple truth? It doesn’t work any other way. Real health care has to be holistic—because human beings are holistic. We’re not just blood glucose readings or lab values; we’re a complex blend of body, mind, emotions, thoughts, and even spirit. When we focus only on the numbers, we risk overlooking 99% of the person sitting in front of us.
Diabetes care, in particular, is uniquely suited to a holistic approach. It’s a condition shaped not just by biology, but by lifestyle, environment, sleep, stress, and social factors—many of which can’t be solved with medication alone. And while innovations in technology and therapeutics are incredible tools, they often become expensive “Band-Aids” unless they’re paired with strategies that build health from the inside out.
What Does Taking a Holistic Approach Look Like?
Holistic care doesn’t mean ditching science or abandoning evidence-based practice. It simply means zooming out—expanding our perspective and staying open to the full context of a person’s life. For practitioners, it’s often more of a mindset shift than a change in tools. Thinking holistically invites us to pause and ask deeper questions like:
🩺 What does this person’s body need to heal, not just manage blood glucose?
🌿 What’s happening in their lifestyle, stress levels, relationships, or environment that might be influencing their blood glucose?
🧠 Are we supporting the health of the whole person, not just treating the symptom?
🍎 Does this person have access to nutritious food or safe spaces to exercise?
🧳 Are they carrying the weight of adverse childhood experiences (ACEs)?
🪞 Is this person’s mindset or beliefs about their health holding them back from improving?
The goal isn’t to replace conventional tools—but to strengthen the foundation beneath them. As practitioners, these questions help us connect the dots between physiology, psychology, and lived experience—especially when working with marginalized populations disproportionately affected by diabetes and its complications.
It’s Not All or Nothing
Some healthcare professionals hesitate to embrace holistic care because it feels like a totally different world—outside the bounds of what we were taught in school or what we have time to address in a 20-minute visit. But this doesn’t have to be an all-or-nothing shift.
You don’t need fancy certifications or to leave your clinic to practice holistically. You can integrate holistic thinking into your everyday work with individuals by listening more deeply, validating lived experiences, and supporting foundational lifestyle changes—even in small ways.
And if that still feels out of reach? Let me remind you: there is a holistic practitioner inside of you. Whether you’re just beginning to explore this space or have been weaving in integrative tools for years, simply being curious about the whole person already puts you on the path.
A Call to Expand Our Perspective
As diabetes professionals, we have an opportunity—and a responsibility—to widen our scope. Learning the tenets of holistic care doesn’t just help us become more well-rounded clinicians; it helps us better understand the people we serve. Exploring other modalities, understanding root-cause approaches, and appreciating the interconnectedness of body and mind allows us to offer more personalized, compassionate, and effective care.
As a CDCES who splits time between a busy endocrinology clinic and holistic practice myself, I’ve seen firsthand the difference this integrated lens makes. When we treat the person, not just the pancreas, outcomes improve—and so does quality of life.
Holistic care isn’t about abandoning what works—it’s about expanding what’s possible.
If you’re interested in gaining a deeper understanding of holistic care—its core principles, supporting modalities, and how it can complement your clinical work—I’d love to see you at my upcoming webinar Beyond Blood Glucose: Empowering Health Through a Holistic Lens on July 24th. Whether you’re curious about this approach or ready to begin integrating it into your practice, this session will offer valuable insight and practical tools. Hope to see you there!
Advance With Purpose & Deepen Your Impact
Join us live on July 24th, 2025, at 11:30 am PST to watch our brand new webinar, Beyond Blood Glucose: Empowering Health Through a Holistic Lens by Nick Kundrat, BS, CEP, CDCES, LMT
Despite the rise of cutting-edge diabetes technologies and therapeutics, many people with diabetes still struggle with fatigue, blood glucose swings, and burnout. Why? Because we’re often so focused on managing diabetes itself that we often forget to take care of the human being who lives with it.
Join Nick Kundrat, CDCES and Integrative Health Practitioner, for an engaging webinar where he simplifies the often-misunderstood world of holistic health. You’ll learn practical, accessible strategies to begin thinking more holistically and discover simple, effective tools that enhance conventional care and empower people with diabetes to thrive—physically, emotionally, and spiritually.
Drawing from over two decades of lived experience with type 1 diabetes and years of supporting clients in both clinical and holistic settings, Nick offers a unique perspective on diabetes care focused on the whole person. Through reconnecting with the foundational elements of health, which are often overlooked in conventional diabetes care, Nick aims to equip you with actionable strategies to help people with diabetes restore their energy, support their bodies, and thrive beyond diabetes.
Course topics:
-
Understanding the Holistic Mindset:
Explore what it means to think holistically in diabetes care and how adopting this mindset can transform your approach to supporting people with diabetes beyond blood glucose and lab values. -
Foundations of Health: Back to Basics:
Discover simple, low-cost, high-impact strategies rooted in foundational health principles that are vital to improving people with diabetes’ energy, resilience, and overall well-being. -
Evaluating Popular Holistic Approaches:
Gain insight into common holistic methods and modalities—what’s effective, what’s overhyped, and how to integrate complementary therapies safely alongside conventional care.
Question of the Week | Diabetes Burnout Despite BG in Target?
Jada, a 29-year-old with type 1 diabetes, tells you she’s feeling burned out and emotionally drained, despite maintaining a time in range above 70% for the past several months. She says, “I’m doing everything right, but I’m exhausted and don’t feel like myself lately.” You review her CGM data and see no major red flags. She denies any recent illnesses or major changes in insulin needs. What is the most appropriate next step?
- Celebrate her strong glucose metrics and encourage her to stick with the same plan, reassuring her that she’s doing well.
- Recommend scheduling an appointment with her endocrinologist to reevaluate her insulin doses and technology settings.
- Acknowledge her experience and assess for emotional burnout, stressors, or imbalances in her lifestyle that could be contributing to her fatigue.
- Increase the frequency of data sharing and remote monitoring to help identify subtle trends and reduce her self-management burden.
Want to learn more about this question?
Join us live on July 24th for
Level 5: Beyond Blood Glucose: Empowering Health Through a Holistic Lens
Join us live on July 24th, 2025, at 11:30 am PST to watch our brand new webinar, Beyond Blood Glucose: Empowering Health Through a Holistic Lens by Nick Kundrat, BS, CEP, CDCES, LMT
Despite the rise of cutting-edge diabetes technologies and therapeutics, many people with diabetes still struggle with fatigue, blood glucose swings, and burnout. Why? Because we’re often so focused on managing diabetes itself that we often forget to take care of the human being who lives with it.
Join Nick Kundrat, BS, CEP, CDCES, LMT and Integrative Health Practitioner, for an engaging webinar where he simplifies the often-misunderstood world of holistic health. You’ll learn practical, accessible strategies to begin thinking more holistically and discover simple, effective tools that enhance conventional care and empower people with diabetes to thrive—physically, emotionally, and spiritually.
Drawing from over two decades of lived experience with type 1 diabetes and years of supporting clients in both clinical and holistic settings, Nick offers a unique perspective on diabetes care focused on the whole person. Through reconnecting with the foundational elements of health, which are often overlooked in conventional diabetes care, Nick aims to equip you with actionable strategies to help people with diabetes restore their energy, support their bodies, and thrive beyond diabetes.
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.
Gut to the Butt Webinar – Join for FREE & Earn CE | June 25th
Save the Date for an Advancements in Diabetes Webinar
From the Gut to the Butt – Exploring the GI System
Wednesday, June 25, 2025 3 pm Eastern
(2 pm Central | 1 pm Mountain | 12 pm Pacific | 11 am Alaska)
This session offers 1 hour of CME/CE/CPEU/CPE
Presented by:
Beverly Thomassian, RN, MPH, CDCES, BC-ADM
President, Diabetes Education Services
Diabetes Nurse Specialist, Colusa Indian Health
Information about the webinar presentation:
This webinar is designed to encourage health care professionals to explore digestive co-conditions
associated with diabetes and take actions to prevent and address disorders of the GI system.
Participants will gain a more in-depth understanding of the interrelationship between glucose levels,
insulin resistance and the role of the liver, pancreas, and intestinal tract in overall health.
Join at:
Link: https://hhs-ihs.webex.com/hhs-ihs/j.php?MTID=m9eb2bbefe1c03867eefeb4634b5c3b7f
Webinar Number & Access Code: 2825 648 4919
Webinar Password: qPZt6bGCu77 (77986242 when dialing from a phone or video system)
Join by Phone: 1-415-527-5035
Download Information Flyer Here
Notes:
• Advancements in Diabetes webinars use the Webex platform; if you have difficulty joining, please visit Webex help.
• If joining from a browser, please use Microsoft Edge or Google Chrome.
• Be sure to join the session about 5 minutes before the start time.
• Registration is not required.
• There is no cost for participation in the webinar.
For additional information, please contact the Division of Diabetes at [email protected].
Rationale of the Week | T1D and Artificial Sweeteners: Safe Limits
For last week’s practice question, we quizzed participants on T1D and Artificial Sweeteners: Safe Limits. 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: Sam is a 28-year-old with type 1 diabetes who reports drinking six diet sodas per day, believing they help manage blood sugar. Sam asks if this is safe or if they should reduce consumption. What would be an appropriate response based on the 2025 ADA Standards of Care?
Answer Choices:
- You should avoid diet soda and all non-nutritive sweeteners because they’re linked to cancer and heart disease.
- Diet sodas are completely safe, so there’s no reason to change your intake.
- While non-nutritive sweeteners are FDA-approved, let’s discuss your current intake, concerns, and whether unsweetened beverages may be a better option.
- Switch to natural sugars like honey or agave syrup since they are healthier than artificial sweeteners.
Getting to the Best Answer
Answer 1 is incorrect. 1% chose this answer, “You should avoid diet soda and all non-nutritive sweeteners because they’re linked to cancer and heart disease.” While concerns about non-nutritive sweeteners (NNS) exist, especially aspartame and erythritol, the ADA and FDA consider approved sweeteners safe and within acceptable daily intake levels. Blanket avoidance is not person-centered nor based on current evidence.
Answer 2 is incorrect. 1% of you chose this answer, “Diet sodas are completely safe, so there’s no reason to change your intake.” Although NNS are considered safe by the FDA, the ADA recommends moderation. It supports reducing the total intake of sweetened beverages and those with NNS, encouraging water and unsweetened options where possible.
Answer 3 is correct. About 95% of respondents chose this – GREAT JOB! “While non-nutritive sweeteners are FDA-approved, let’s discuss your current intake, concerns, and whether unsweetened beverages may be a better option.” The 2025 ADA Standards of Care support a person-centered approach and recognize that FDA-approved non-nutritive sweeteners (NNS) are safe when used in moderation. This answer allows for a discussion tailored to Sam’s health goals, type of sweetener consumed and specific concerns. While water is the preferred beverage, using NNS to replace sugar-sweetened drinks may be an option to reduce overall calorie and carbohydrate intake.
Finally, Answer 4 is incorrect. 1% chose this answer, “Switch to natural sugars like honey or agave syrup since they are healthier than artificial sweeteners.” Natural sugars like honey and agave, although considered natural, are a form of added sugar that can negatively affect blood glucose. There is no specific guidance for the amount of added sugar within the diet, but the ADA Standards of Care recommends minimizing all forms of added sugar while also considering an individual’s nutrition plan.
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 holistic care from our guest expert, Nick Kundrat?
Join us live on July 24th for Beyond Blood Glucose: Empowering Health Through a Holistic Lens
Join us live on July 24th, 2025, at 11:30 am PST to watch our brand new webinar, Beyond Blood Glucose: Empowering Health Through a Holistic Lens by Nick Kundrat, BS, CEP, CDCES, LMT
Despite the rise of cutting-edge diabetes technologies and therapeutics, many people with diabetes still struggle with fatigue, blood glucose swings, and burnout. Why? Because we’re often so focused on managing diabetes itself that we often forget to take care of the human being who lives with it.
Join Nick Kundrat, BS, CEP, CDCES, LMT and Integrative Health Practitioner, for an engaging webinar where he simplifies the often-misunderstood world of holistic health. You’ll learn practical, accessible strategies to begin thinking more holistically and discover simple, effective tools that enhance conventional care and empower people with diabetes to thrive—physically, emotionally, and spiritually.
Drawing from over two decades of lived experience with type 1 diabetes and years of supporting clients in both clinical and holistic settings, Nick offers a unique perspective on diabetes care focused on the whole person. Through reconnecting with the foundational elements of health, which are often overlooked in conventional diabetes care, Nick aims to equip you with actionable strategies to help people with diabetes restore their energy, support their bodies, and thrive beyond diabetes.
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How Landing in the Wrong Place Can Help You Find Your Way
There are moments in life when you realize that even the wrong place can point you in the right direction. Looking back, I see now how one of the most emotionally wrenching chapters of my early nursing career became the impetus that guided me toward the work I was meant to do.
By my mid-twenties, I traded the heat of the San Fernando Valley for the ocean breezes of Venice Beach, California, and landed a position at UCLA Medical Center. My personal life was still bumpy, scarred by childhood wounds, unhealthy relationships, and a brush with death, but I was holding it together professionally. I had graduated nursing school, said goodbye to my job at Ying’s Kitchen, and proudly put on my white uniform and nursing cap each day. On the outside, I looked like I had it figured out. But inside, I felt like I was splitting in two.
You might know the feeling, where the version of you who shows up to work, strong and composed, is different from the one who goes home at night, aching for something more stable, more real, more whole. That was me.
My first day at UCLA placed me on the head, neck, and urology floor, and nothing could have prepared me for the heartbreak I would witness. Patients recovering from disfiguring cancer surgeries. People breathing through tracheostomies. The physical and emotional pain in those rooms was hard to hold. I often cried in my car after work, feeling helpless, overwhelmed, and unsure if I had what it took to stay in this profession.
And then came Midori
She had a “shrinking trachea,” the specialists said—something inoperable that would slowly close off her airway. One evening, we walked the hospital halls together, her IV pole trailing beside us. We paused at the window on the sixth floor, looking out over the glittering city. I put my arm around her small frame.
“I hope to go home and spend a few weeks with my family and friends,” she said quietly. Then, turning to me: “These last two days have been the most important days of my life. I am grateful that you have helped me through them.”
We stood in silence, tears spilling freely. In the reflection of that hospital window, I saw two women: one nearing the end of her life, and one just beginning to understand hers. I will never forget Midori—or the string of 100 colorful paper cranes her family had hung from the ceiling, symbols of courage, strength, and hope. That moment moved me so deeply, I wrote a short story called “The Paper Crane,” which was later published in the American Journal of Nursing.
Not every story was as heartbreaking. Some were filled with hope. I saw patients with diabetes transform after kidney transplants—skin glowing, energy restored, lives renewed. That sixth floor gave me a front-row seat to human resilience. And it sparked a realization: I didn’t just want to help people recover. I wanted to help them avoid suffering in the first place.
That’s when everything began to shift.
Sometimes, the “Wrong Place” Is Really a Doorway
The emotional toll of working on that unit was heavy—but it was also clarifying. It showed me what I could handle, what I needed to heal, and most importantly, what I felt called to do next. I wasn’t meant to stay in acute care. I was meant to move toward prevention, education, and empowering people to take charge of their health.
I applied to the Master’s in Public Health program at UCLA and was accepted in 1987. But before diving into graduate school, I knew I needed a break—and something inside me longed for an adventure, something that would shake me free from old patterns and reconnect me with purpose.
I reached out to David Werner, author of Where There Is No Doctor, who had started a clinic in rural Mexico. He told me, “Fly into Mazatlán, catch a bus to the town of Ajoya, and ask for Lupe. She’ll rent you a room for $6 a night, breakfast included.”
So I packed a suitcase full of medical supplies and hope—and boarded the plane.
An Invitation to You
Maybe you’ve landed in the “wrong place” too. A job that drains you. A relationship that confuses you. A season of life where you feel off-course, uncertain, or lost. I want to tell you: those moments aren’t wasted. They might just be redirecting you toward something more aligned, more meaningful, more you.
We don’t always recognize turning points when we’re living them. But trust that every tear, every doubt, every step forward—no matter how shaky—is shaping something vital.
Wherever you are on your path, keep going. And don’t be afraid to listen when your heart asks for something different.
Because sometimes, it’s the wrong place that helps you find your way home.
Coach Beverly is kicking off the launch of her first book, “Healing Through Connection for Health Care Professionals.”
This deeply personal book invites you into the pivotal moments that shaped her career and calling. She will post a new story each month so you can access the behind-the-scenes stories of struggle, growth, and hope that fueled her passion for transforming diabetes care.
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