Why I Transformed my Approach to Diabetes Self-Management Education
When I was hired to be a part of the Embark Trial Team at UCSF, I felt confident in my approach to self-management education for people living with type 1 diabetes. After all, I had been providing diabetes care and education for over 20 years.
Little did I know that participating in this Trial would change my practice approach.
The Embark Trial, simply explained, was designed to evaluate if addressing diabetes distress and supporting an increased level of self-management confidence for people living with type 1 diabetes improved outcomes.
As part of the Embark Trial Team, I attended trainings which outlined the philosophy and novel approach of the intervention. The research team repeatedly emphasized that even though we were diabetes specialists, we were not to provide answers or solutions for the type 1 participants during the group classes or individual interventions. In addition, they taught us to use an innovative step-wise approach for glycemic management along with custom log sheets and strategies to address diabetes distress.
Putting this new approach to the test.
As part of the intervention team, I provided a group training and met individually with each participant for up to 30 minutes for about six sessions. During these sessions we would explore issues that they would like to address and guide them in problem solving.
For example, if a person with diabetes asked, “why are my blood sugars so high in the morning”, I couldn’t suggest to them that they probably needed to increase their basal insulin.
Instead, I encouraged them to draw on their own knowledge about their diabetes and ask, “Why do you think your blood sugars are elevated in the morning?”
Another example is I would ask participants to scroll through their insulin pumps to find their basal and bolus insulin settings. They would ask me, “how do I find those?”
Instead of providing step by step instructions, I encouraged participants to start looking through their pump settings to see if they could discover it themselves.
Guess what? Participants of all ages and backgrounds were able to figure it out without any hands-on instruction from the “fixer”.
Even though the coaching was provided over the phone and on zoom, with each accomplishment, I could feel them glowing with the pride of self-discovery.
The participants were gaining a sense of agency and mastery.
And I was transitioning from being a “Fixer” to becoming a “Coach”. It felt great.
To be honest, it took a lot of pressure off of me to be the “all knowing” diabetes professional. This approach freed me from feeling like a failure if I didn’t know all the ins and outs of insulin pumps, CGMs, carb counting ratios and more. It felt very collaborative and I felt more authentic.
More importantly, I was able to tap into the individuals expertise by REALLY listening, asking meaningful questions and helping them find solutions. It turns out that people with diabetes have a lot of expertise in themselves. Unfortunately too many times, during provider visits, even though they try to share their worries, concerns and emotions, they often aren’t really seen and heard.
The study also provided simple conversational tools that the diabetes specialists could use to help participants address their diabetes distress. We often feel stuck or not sure how to best help people struggling with the real life distress that comes with living with a chronic condition 24/7/365. The approach used in this study empowered me to try new approaches that really made a difference.
As diabetes health care professionals, we can’t know everything, but we can gain needed skills to help address distress and encourage individuals figure it out for themselves. Being a part of this study help me grow my “Coach” approach and let my “Fixer” know that it can relax, we will call upon it as needed.
Now, we are excited to share the tools and approaches used in this study with our community of diabetes health professionals.
We have reassembled the training team and created a resource binder of fantastic tools that we are excited to share this all with you in our ReVive 5 Diabetes Training Program. Join us to learn a step-wise, proven approach to address hidden barriers to diabetes self-management and glucose management.
Learn from the Experts that Constructed this Approach
Live Virtual Sessions Air June 17 & June 24th
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!
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 Week | To Prevent Hypo’s, JR Stopped Taking Bolus Insulin
Click Here to Test your Knowledge
JR is 26 years old with type 1 diabetes for over a decade. JR keeps missing appointments and when you finally get a hold of them on the phone, they start crying and say “I am afraid my blood sugars will go too low, so I stopped using my bolus insulin”. They explain that they were too embarrassed to come in and have their data downloaded. Based on this information, what would be the most helpful approach?
- Provide reassurance and recognize that JR is dealing with childhood trauma.
- Encourage JR to start using half their usual dose of bolus insulin to get started.
- Recognize JR’s effort to prevent low blood sugars and explore their feelings.
- Remind JR that all of the downloaded data and reports are confidential.
Click Here to Test your Knowledge
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.
Indigenous Peoples’ Day | Remember – A Poem by Joy Harjo
To recognize Indigenous Peoples’ Day, we are honored to share a treasured poem by one of my favorite poets and writers, Joy Harjo. Plus, we also share an interactive map of Indigenous Lands (credit to NPR).
In 2019, Joy Harjo was recognized as the United States poet laureate and served three terms. Harjo is an internationally renowned performer and writer of the Muscogee (Creek) Nation.
She lives in Tulsa, Oklahoma and is the author of nine books of poetry, including the highly acclaimed An American Sunrise, several plays and children’s books, and two memoirs, Crazy Brave and Poet Warrior. Her many honors include the Ruth Lily Prize for Lifetime Achievement from the Poetry Foundation, the Academy of American Poets Wallace Stevens Award, two NEA fellowships, and a Guggenheim Fellowship.
You can learn more about Joy Harjo on her webpage, www.joyharjo.com.
Remember
Joy Harjo
Remember the sky that you were born under,
know each of the star’s stories.
Remember the moon, know who she is.
Remember the sun’s birth at dawn, that is the
strongest point of time. Remember sundown
and the giving away to night.
Remember your birth, how your mother struggled
to give you form and breath. You are evidence of
her life, and her mother’s, and hers.
Remember your father. He is your life, also.
Remember the earth whose skin you are:
red earth, black earth, yellow earth, white earth
brown earth, we are earth.
Remember the plants, trees, animal life who all have their
tribes, their families, their histories, too. Talk to them,
listen to them. They are alive poems.
Remember the wind. Remember her voice. She knows the
origin of this universe.
Remember you are all people and all people
are you.
Remember you are this universe and this
universe is you.
Remember all is in motion, is growing, is you.
Remember language comes from this.
Remember the dance language is, that life is.
Remember.
Which Indigenous lands are you on? This map will show you.
Indigenous Peoples’ Day is a time of reflection, recognition and celebration of the role Native people have played in U.S. history. One way to mark the day — and to learn about Indigenous history year-round — is to learn which Native lands you live on.
DiabetesEd Online University | Closed for Renovations Today, October 5th
DiabetesEd Online University is closed today to make the switch to our new platform.
We can’t wait to share our new look with you on Thursday, October 6th.
Students will be able to experience our New and Modernized learning platform starting Thursday! Since we will be busy setting up our new site, Bryanna and I may be delayed in answering emails and phone calls today. We appreciate your patience during this exciting renovation process.
Our main website and shopping cart will remain open.
We know for many of you, losing a day of progress can feel overwhelming and we appreciate your patience during this transition.
We invite you to use the following tools as part of your study plan while we make this transition.
• Free Webinars – This page offers some helpful info on test taking and other topics.
• CDCES Coach App – this app has a lot of great tools such as free quizzes that you can use to test your knowledge while the website is down.
• Cheat Sheets – We know that a great resource page full of accurate and helpful cheat sheets can save busy diabetes specialists time.
• Medication PocketCards – Download here to use as a study tool and resource.
However, with any move, there are some details that need to be wrapped up.
Other Important Info for University Students
If you are currently enrolled and active in DiabetesEd Online University for the past 1 year, you will be able to experience the new platform as soon as we make the switch in October. You will be prompted to create a new username and password as part of the process.
When we flip the switch over, you will notice a new fresh home page, more intuitive navigations, and some additional bells and whistles.
Still have questions? Please email us at [email protected] or chat with us at www.DiabtesEd.net.
More to come! We will be sending you ongoing communications to keep you posted on our progress and enhancements.
Thank you, Beverly and Bryanna
Question of the Week | Best approach for distress & DKA?
RJ is in the hospital for the 3rd time this year in DKA. You ask RJ to complete the diabetes distress survey tool and immediately recognize that RJ is experiencing high levels of diabetes distress.
When working with RJ to assess what is happening, which of the following approaches could be used as a conversational tool?
- Use closed-ended questions to create a safe space for the interaction.
- Keep your clinical reports and records handy to use for reference.
- Accept RJ’s current self-management regimen without judgement.
- Avoid use of too many feeling words because it might embarrass RJ.
Click Here to Test your Knowledge
Want to learn more about this question? Join our NEW
ReVive 5 Diabetes Training Program | 14 CEs
Whether you are a novice or an expert in providing diabetes care, we invite you to attend this exciting training program that provides the essential steps to address diabetes distress combined with an innovative approach to glucose management that will revolutionize your practice.
“ReVive 5” breathes new life into our relationship with diabetes, bringing a fresh perspective to both the person with with diabetes and the provider.
By addressing old habits that no longer serve us, we have the opportunity to create a new life tool kit toolkit in partnership with the person living with diabetes.
The ReVive 5 program is built on sound research and will revolutionize your approach to diabetes self-management education.
Join our Team of Experts | Starts Nov 1st, 14 CEs
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
Training Program Includes:
- 14.0 CEs – Includes the 4 Session ReVive Training Program, Certificate and 5 FREE bonus courses to supplement content
(Four 1.5 hour training sessions (6.0 CEs) plus Five bonus courses worth 9.0 CEs) - Quarterly 1 hour follow-up sessions with an expert -dates to be announced
- A comprehensive set of assessment tools, educational materials, log sheets and resources.
Don’t worry if you can’t make it live. Your registration guarantees access to the recorded version in the Online University.
All hours earned count toward your CDCES Accreditation Information
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!
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.
Coach Bev’s 7 Takeaways | New ADA/EASD Type 2 Management Guidelines
The content of this newly published guideline is thoughtful, person-centered, and offers a clear clinical path for the management of type 2 diabetes. I tip my hat to the authors in gratitude for their dedication and vision.
Besides having lots of attractive infographics and a fantastic summary of the research, this guideline offers evidence-based strategies to get glucose to the goal with an emphasis on taking a person-centered approach to pharmacologic and lifestyle interventions. We invite you to enjoy a detailed review by joining our webinar or reading this brief summary of the findings that impressed me most.
- Metformin doesn’t have to be the initial therapy.
This medication has enjoyed the number one seat in the ADA guidelines for over a decade. And for good reason. In addition to being low cost ($4 a month), it does not cause low blood sugar or weight gain and it lowers A1C by 1-2% points. Although it lowers LDL cholesterol, it is not officially recognized as a cardiovascular risk-lowering medication.
The guidelines state, that in addition to lifestyle interventions if there is a history of CV disease, heart failure, or kidney disease, we need to turn our gaze elsewhere and consider an SGLT-2 Inhibitor or a GLP-1 Receptor Agonist.
- Embrace Diabetes Self Management Education (DSMES) as being as important as other aspects of care, including pharmacotherapy.
This endorsement of the significance of DSMES in improving outcomes and quality of life in people living with diabetes is powerful. Research has demonstrated that people with diabetes who receive DSMES, including counseling by an RD/RDN, experience an A1C drop of 1-2%. In addition, they are less likely to be hospitalized, engage in more preventive behaviors, and know when to reach out for help. They go on to say that DSMES needs to offer on an ongoing basis, using a variety of delivery approaches, and should be accessible in all communities. - If GFR is 20 or greater and the UACR is 30mg/g or more, start SGLT-2 Inhibitors.
It doesn’t get much bolder than that statement. There is the fine print, that recognizes that clinicians can use their discretion and judgment, but the data is clear. The use of SGLT-2 slows the progression of kidney disease and can delay the need for dialysis. Even if glucose levels are at target, in the presence of renal failure, starting an SGLT-2 is indicated. Since the leading cause of death for those with kidney disease is CV events, if SGLT-2 can’t be tolerated for clinical reasons, using a GLP-1 with CV benefits would be the second choice. - In the presence of heart failure, start an SGLT-2 Inhibitor.
All four of the available SGLT-2 Inhibitors are effective “glucoretics” helping rid the body of excess sugar and fluid. This action has a significant impact on improving not only glucose levels but decreasing fluid overload thereby improving cardiac function. This class of medication is so effective at treating heart failure, that 2 of the 4 SGLT-2 meds are indicated to treat heart failure even in the absence of diabetes. - Weight loss Goals Intensified
Traditionally, in the recommendations, weight loss targets range from 5-7% for people with diabetes. However, these new guidelines suggest we aim for at least 5-10% weight loss with even better outcomes if people can lose 10-15% or more significant weight loss can lead to diabetes remission, improved metabolic profiles, and fewer complications. In the past, achieving these targets was usually linked to very low-calorie diets or metabolic surgery. However, with higher doses of the GLP-1 RA and the Dual GLP GIP Agonist, Tirzepatide, we have additional tools in our toolkit to get the job done.
6. The placement of Tirzepatide (Mounjaro)
In the new ADA/EASD Algorithm, there are 2 hierarchies of medication effectiveness, glucose, and weight impact. As its trade name suggests, tirzepatide is at the top of the mountain of both lists (along with semaglutide) for its glucose-lowering properties and weight loss efficacy. This medication was studied in people with diabetes (Surpass) and people without diabetes (Surmount).
In the diabetes group, at the highest dose, A1C dropped by over 2% and people experienced a 10% or greater weight loss. In the non—diabetes group, people experienced up to 20% weight loss. This medication is currently only approved for people with diabetes, but don’t be surprised if we see it on the market as a weight loss intervention for people without diabetes in the near future.
7. Keep it person-centered and Address Social Determinants of Health. The last version of the guidelines recognizes that we have to consider the needs, values, and goals of the individual PATIENT. In this newer version, they ditched the word “PATIENT” and finally replaced it with the term “PERSON”. This consensus statement also recognizes the importance of considering inequities in access to diabetes care and resources. They offer a comprehensive list of all of the social determinants of health to consider when providing care.
There is so much more to this article. I hope I have inspired you to read the complete ADA/EASD Consensus document or join our webinar on December 1st to learn more.
Meds for Type 2 Update; New ADA/EASD Consensus Statement
Level 2 | 1.25 CEs
Airs live on Wednesday, December 1st at 11:30 am PST
Plan on joining this exciting webinar that walks participants through the newly released, “Management of Hyperglycemia in Type 2 Consensus Report by the ADA and EASD”. These updated guidelines will be incorporated into the 2023 ADA Standards of Care, but you can get a early sneak peak by joining Coach Beverly on December 1st, 2022. She will highlight the revised guidelines with a focus on new elements and exciting changes on how we approach medication management for type 2 diabetes. Together, we will explore clinical factors to consider when determining the best strategy to improve glucose management in people with type 2 diabetes and other co-conditions. There will be a special focus on cardiovascular risk reduction and renal protection and addressing clinical inertia.
Objectives:
- Describe the role of Diabetes Care and Education Specialists in advocating for optimal therapeutic approaches.
- Discuss the application of the new ADA/EASD Guidelines to improve glucose and reduce CV and renal risk.
- List strategies to initiate and adjust oral and injectable therapy using a person-centered approach
Intended Audience: A great course for health care professionals seeking evidence-based information that improves the quality of life and outcomes.
Don’t worry if you can’t make it live. Your registration guarantees access to the recorded version in the Online University.
All hours earned count toward your CDCES Accreditation Information
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!
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 | Best action before starting tirzepatide (Mounjaro)?
For last week’s practice question, we quizzed test takers on the best action before starting Tirzepatide (Mounjaro). 67% 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:
AR is 36 years old with type 2 diabetes and a BMI of over 40. Current A1C 7.9%, UACR less than 30, and GFR more than 60. Current diabetes medications include metformin, sitagliptin, and empagliflozin at maximum doses. AR is prescribed the new dual incretin tirzepatide (Mounjaro) to help improve glucose levels and support weight loss.
Before starting tirzepatide (Mounjaro), what action do you recommend to the provider?
Answer Choices:
- Repeat the UACR and GFR to verify kidney function.
- Stop the sitagliptin.
- Decrease metformin dose to prevent hypoglycemia.
- Evaluate thyroid function.
Getting to the Best Answer
Answer 1 is incorrect. 11.31% chose this answer, “Repeat the UACR and GFR to verify kidney function.” This is not the best answer because JR has great kidney function, evidenced by a normal UACR and GFR. So we do not need to recheck kidney function before starting this new dual incretin tirzepatide (Mounjaro).
Answer 2 is correct. 67.43% of you chose this answer, “Stop the sitagliptin.” YES, this is the best answer. The American Diabetes Association (ADA) and American Association of Clinical Endocrinologists recommend against combination therapy with a DPP4-inhibitor and a GLP-1 RA due to the lack of evidence that this strategy is beneficial. Initial research combining the two classes, reflect a negligible glucose lowering effect when GLP-1’s and DPP-4’s are combined. Given the approximate average wholesale price for the DPP-4 inhibitor of $434 and GLP-1 RA of $887, using both simultaneously is not cost effective or clinically beneficial.
Answer 3 is incorrect. 4.4.% of respondents chose this answer, “Decrease metformin dose to prevent hypoglycemia.” No need to decrease the metformin dose, since JR is not on any medication class that will cause hypoglycemia.
Finally, Answer 4 is incorrect. 16.82% chose this answer, “Evaluate thyroid function.” This class of medication is not recommended for any person with a history of medullary thyroid tumor. However, we don’t need to draw a TSH to see if this medication is safe, we would simply do a careful history to see if there is a family history of medullary thyroid tumor.
Thank you so much for reading this “Rationale of the Week”. You can download our Medication PocketCard below, for more information.
New Injectable – “TwinCretin” on Printed PocketCards
We have just added this novel, first in class, dual incretin hormone therapy, Tirzepatide (Mounjaro), to our printed version of our Diabetes Medication PocketCard.
This new twin therapy includes not only a GLP-1 Receptor Agonist, but also a Glucose-dependent insulinotropic polypeptide (GIP), which magnifies the therapeutic effectiveness. The SURPASS studies indicate that study participants experienced an A1C drop of up to 2.5% and weight loss of up to 10kg or more.
Want to learn more about Diabetes Medications?
New Tubeless Insulin Delivery System Approved for Toddlers
The FDA just authorized the Insulet Omnipod 5 tubeless insulin delivery system for pediatrics with type 1 diabetes starting as young as age 2. This remarkable moment marks the availability of the world’s first tubeless, wearable insulin delivery system for toddlers.
The Omnipod 5 received FDA approval earlier this year for integration with the Dexcom G6 continuous glucose monitor for adults and kids with type 1, but Insulet also petitioned the FDA to approve this technology for toddlers.
First Tubeless Hybrid Closed Loop System
This first tubeless hybrid closed loop system to receive FDA authorization includes the Omnipod 5, Dexcom G6 CGM and a phone app or controller to manage insulin delivery and monitor glucose levels. The Omnipod holds three days worth of insulin in a pod delivery device without the need for tubing, which can be helpful for active toddlers. No calibration or fingersticks are required.
As a hybrid loop system, the Omnipod and Dexcom are continuously data sharing, so most of the insulin delivery is automated. However, users can make needed adjustments, deliver bolus insulin and easily share data with the smartphone app or Ominpod 5 Controller.
Promising Outcome Data
Based on a study presented at the annual ADA Scientific Session, children with type 1 diabetes experienced a drop in A1C levels from a baseline of 7.4% to 6.9% and they remained at this improved A1C level for one year into the study. Time in range also increased from 57% at baseline to 68% after using the Omnipod 5 for three months. In addition, there were no reported cases of DKA or severe hypoglycemia. For more information on the latest in insulin pumps and CGMs, please join our Virtual Conference with technology expert Diana Issacs. In addition to explaining the technology, she provides an awesome “show and tell”.
Lila Grace Moss wears Omnipod on Runway
On a related note, I would like to give recognition to the courageous Lila Grace Moss, who lives with type 1 diabetes. On a recent runway show, she did not shy away from wearing her Omnipod as she modeled the latest fashion styles with camera’s clicking and hundreds of audience members.
Social media took note and many instagram followers thanked Lila for her bold and brave statement.
Thanks Lila!
Want to learn more about Technology and Diabetes Care? Join us for our
Virtual DiabetesEd Training Conference
30+ CEs
Airs October 12-14th, 2022
Join us LIVE for this Virtual Training Conference and enjoy a sense of community!
Whether you are new to diabetes or a seasoned expert, you’ll benefit from this virtual conference with the latest research plus critical content that you can immediately apply to your clinical practice.
Download Course Flyer | Download Schedule
If you are seeking a state-of-the-art review of current diabetes care, this course is for you. Our team has been fine-tuning this course for over fifteen years, and we know what you need. This program can also be a great addition to your CDCES or BC-ADM exam study plan.
Team of expert faculty includes:
- Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES – Educator of the Year, 2020
- Coach Beverly Thomassian, RN, MPH, CDCES, BC-ADM
- Ashley LaBrier, MS, RD, CDCES, Diabetes Program Coordinator
Two Registration Options
Don’t worry if you can’t make it live. Your registration guarantees access to the recorded version in the Online University.
All hours earned count toward your CDCES Accreditation Information
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!
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.
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