Vertex Pharmaceuticals just announced preliminary results from a trial that explores a new intervention to treat type 1 diabetes. The early results are very promising.

The first person with type 1 diabetes to receive this new stem-cell derived experimental therapy, had an 91% drop in their insulin needs. The person has lived with type 1 for over 40 years. After the intervention, they not only experienced a reduction in their insulin needs, their fasting C-peptide levels went from undetectable to 280. This dramatic C-peptide increase is a clinical indicator of stem-cell therapy success and endogenous insulin secretion.

These results are exciting and offer hope for a potential new treatment approach for type 1 diabetes.

VX-880 is a stem cell derived therapy that replaces damaged beta cells with healthy transplanted insulin producing cells in clinical trials. However, these new cells are at risk for attack by the body’s immune system, so immunosuppression therapy is currently required for stem-cell transplant success.

The future goal is to create a version of this treatment that doesn’t require immunosuppressive therapy. And Vertex, the makers of VX-880 are working on creating an encapsulated islet cell program that doesn’t initiate an autoimmune attack.

For more information and clinical trials, click this link.

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Resources for People Living with Type 1 Diabetes

Below is a list of helpful online resources for Type 1 Diabetes. They 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. Click here for a Type 1 Resource Handout to share with colleagues and people living with type 1 diabetes.

Click the links below to visit the website:

• Let’s fight Type 1 Together | American Diabetes Association (ADA)
• Mental Health Resources Directory | ADA
• Type 1 Diabetes Resources and Support | Juvenile Diabetes Research Foundation: Explore our informational guides or make a personal connection with someone experienced with type 1 diabetes (T1D). The JDRF community has you covered.
• Empowering Youth with Type 1 Diabetes |The Chris Dudley Foundation
• The National Institutes of Health Diabetes Resources | CDC
• The College Diabetes Network: Focuses Specifically on Young Adults with Diabetes | College Diabetes Network
• The Diabulimia Helpline: for Individuals Having Eating Problems
• Beyond Type 1 Diabetes
  • Type 1 Diabetes Online Community
  • Mental Health Resources website
• Connected in Motion: Peer-Based Sports & Outdoor Adventures for those with Type 1 (in U.S. and Canada) | Connected In Motion
• Diatribe: Library of Online Resources, Blog & Community Forums
• Diabetes Education: At times it might seem overwhelming, but you can thrive with diabetes, and a Diabetes Care and Education Specialist can help. Includes a link to find a diabetes program near you.

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“I just want to get rid of my diabetes”, is something I frequently hear when people are newly diagnosed with diabetes.

Can people with type 2 get rid of their diabetes? Well, not exactly, but a small percentage of people with type 2 can achieve normoglycemia, especially after metabolic surgery or significant weight loss. However, over time, blood sugars often rise again. That is why diabetes isn’t “cured” or fixed. Keep reading to learn the new standardized term and ongoing screening guidelines.

What is the right term to use when blood sugars normalize, even with type 2 diabetes?

A new consensus statement designed to answer this question was issued by the American Diabetes Association, the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK last month.

The 12-member panel recognized that we have no standard term to describe the phenomenon of prolonged normoglycemia in people previously diagnosed with type 2 diabetes, who are not using glucose-lowering medications.

Terms like “reversal”, “resolution”, or “cure”, are frequently used to describe this phenomenon and are sometimes are associated with unsubstantiated claims.

The new standardized term is “remission”.

Diabetes remission defined – A1c< 6.5% for at least 3 months after stopping glucose-lowering pharmacotherapy. This definition holds true whether attained by lifestyle changes, metabolic surgery, or other means,

When A1c is not a reliable marker of glycemic control (due to anemia, hemoglobinopathies, or others), fasting plasma glucose <126 mg/dL or estimated A1C <6.5% calculated from CGM values can be used.

With this standardized definition, researchers will be able to conduct studies and analyze medical records using standard terminology so they can accurately compare factors that help people with type 2 achieve remission and factors that influence remission duration.

A1c Testing still needed if in Remission?

Even if people are experiencing remission, they require continued glucose evaluation because hyperglycemia frequently recurs. People in remission who experience weight gain, are started on steroids or other medications like atypical antipsychotics or meds to treat HIV, may exhibit elevated blood glucose levels. In addition, stress from other forms of illness and the natural decline of beta-cell function over time can all lead to the recurrence of Type 2 diabetes. Testing of A1c or another measure of glycemic levels needs to be performed at least yearly.

Metabolic Memory – people in diabetes remission still experience complications.

Even after a remission, the classic complications of diabetes including retinopathy, nephropathy, neuropathy, and enhanced risk of cardiovascular disease can still occur due to metabolic memory.

Diabetes Care Consensus Report 2021

The metabolic memory or legacy effect is relevant in this setting. If a person with diabetes has a history of hyperglycemia, this metabolic memory can cause persisting harmful effects in various tissues. Even after remission, the classic complications of diabetes including retinopathy, nephropathy, neuropathy, and enhanced risk of cardiovascular disease can still occur. This is why it is important for people in diabetes remission to have regular retinal screening, tests of renal function, foot evaluation, and measurement of blood pressure and weight in addition to ongoing monitoring of A1c.

To read the complete article from Diabetes Care, Aug 2021, Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes.

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Are you preparing for the CDCES Exam?

Join us live on November 4th, for our FREE Webinar

Starting your journey to becoming a CDCES? We recommend watching our FREE Preparing for CDCES Exam Webinar!

This course will transform your test anxiety into calm self-confidence and test-taking readiness.

Webinar Topics

• Exam requirement updates for 2021.
• Exam eligibility and test format
• Strategies to succeed along with a review of study tips and test-taking tactics.
• We will review sample test questions and the reasoning behind choosing the right answers.
• Learn how to focus your time and prepare to take the CDCES Exam. We provide plenty of sample test questions and test-taking tips!

Can’t join us live?
Don’t worry, we will send you a link to the recorded version.

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What is a Certified Diabetes Care and Education Specialist?

Read More: What is a CDCES?

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Why become a CDCES?
Three Reasons from Coach Beverly

Read More: 3 Reasons to Become a CDCES

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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.

Eli Lilly and Company issues a voluntary nationwide recall of one lot of GLUCAGON® Emergency Kit due to Loss of Potency. Warning – A person with severe hypoglycemia who injects this faulty formulation will experience worsening hypoglycemia.

Eli Lilly and Company is voluntarily recalling lot D239382D, Expiration April 2022, of Glucagon Emergency Kit for Low Blood Sugar (Glucagon for Injection, 1 mg per vial; Diluent for Glucagon, 1 mL syringe).

Loss of Potency due to manufacturing process issue

The Eli Lilly injectable glucagon kit (pictured here), usually contains a syringe with diluent and a vial with powdered glucagon. The user needs to put the diluent into the vial with the powdered glucagon and reconstitute it before injecting it.

However, a product complaint from a user found that the vial of Glucagon was in liquid form instead of powder form. Associated with this useful product complaint, the patient who was given this glucagon vial content, experienced worsening hypoglycemia and also reported subsequent seizures.

The use of the liquid form of this product may fail to treat severe low blood sugar due to loss of potency.

It is well known that severe hypoglycemia in people with diabetes, if not promptly treated and reversed, can potentially cause adverse health consequences ranging from transient, minor complaints to neurological damage, seizures, and even death. Eli Lilly’s investigation indicates that the liquid in this Glucagon vial could be related to a problem with the manufacturing process.

Please help get the word out

The Eli Lilly Glucagon product is packaged in a kit containing 1mg of freeze-dried (lyophilized) product in a 3 mL vial and a pre-filled diluent syringe. The affected Glucagon Emergency Kit lot is D239382D and the expiration date is April 2022 (label expiry date: 04 2022). The lot number can be found on the label of the kit as well as the vial (refer to the complete FDA warning below). The lot was distributed nationwide to wholesalers and retailers.

Contact Info for Consumers

Consumers in possession of Glucagon Emergency Kit lot D239382D should contact The Lilly Answers Center at 1-800-LILLYRX (1-800-545-5979) for return and replacement instructions for the product (hours of operation are Monday- Friday, 9AM – 7PM EST) and should contact their health care provider for guidance. Consumers should contact their physician or healthcare provider if they have experienced any problems that may be related to taking or using this product.

Lilly is notifying its distributors and customers by written communication and is arranging for the return and replacement of all recalled products. Wholesalers and Distributors with an existing inventory of Glucagon Emergency Kit lot D239382D should cease distribution and quarantine the product immediately.

Read complete FDA Announcement Here

FREE Glucagon PocketCards

There are now 4 different glucagon formulations to choose from.

This free card details the different formulations available, from the injectables to the nasal powder formulation.

The backside includes teaching and hypoglycemia prevention strategies, along with the different official levels of hypoglycemia (for your certification study preparation).

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Join us live on November 11th for the upcoming

Meritus Health’s Virtual Diabetes Conference

Diabetes in the 21st Century with Coach Beverly

Join us live on November 11th from 8:00 am to 4:00 pm for our Virtual Conference: Diabetes in the 21st Century | 6.5 CEs

This conference offers comprehensive presentations on care of a person with diabetes examining a variety of evidence-based topics to aid in the care of a person with diabetes.

Click here to download the program flyer.

Location: Virtual

Fees: No charge for Meritus Health Employees. $50.00 for Non-Meritus Health Participants Meritus Health Employees: Please register via Healthstream, using keyword search “21st Century” or by clicking here.

Cancellation Policy: If you must cancel, please notify Ruth Leizear by phone at 301-790-8619 or toll free at 888-803-1518.

Check-in: Check-in starts at 8:00 a.m., please log in 15 minutes prior to the first presentation

Accreditation: 

•  Registered Nurses: Nursing Education Department of Meritus Health is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
  6.5 ANCC Contact Hours will be awarded; No partial credit will be given.
• Dieticians: Approved for 6.5 CPE II for Registered Dietitians by the Commission on Dietetic Registration.

Click here to download the program flyer.

Instructor: Beverly Thomassian RN, MPH, CDCES, BC-ADM is a working educator and a nationally recognized diabetes expert.

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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.

We are so excited to announce our DiabetesEd Specialist Scholarship Recipients!

We received dozens of applications for our annual Making a Difference Scholarship and the Flower Scholarship gifted from an anonymous donor! It was a great personal joy for our team to read these scholarship applications. Each applicant is serving communities with a great need and going “above and beyond” to promote and provide accessible diabetes care and education. It is always a very difficult decision for all of the judges, and we read each application in careful detail considering the financial need, impact, volunteerism, and readiness to take the CDCES exam.

We greatly appreciate the good work of all the applicants and thank them for their service!

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This year we are offered 3 Scholarship Options for our Virtual DiabetesEd Specialist Conference, October 6-8, 2021.

Congratulations Chantel Wade, his year’s Flower Scholarship Recipient!

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Congratulations Keira McCrary, “Making a Difference Exemplar Scholarship” Recipient!

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Congratulations Logan Mumphrey, “Making a Difference Scholarship” Recipient!

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This year we are offered 3 Scholarship Options which include:

1. Flower Scholarship valued at $1000 for a diabetes nurse educator who comes from an under-served community and is providing care and education to communities that lack access to Diabetes Specialists and health care resources. The nurse applicant taking their CDCES exam within a year. The donor of this scholarship is generously providing funds to cover course registration plus enrollment in our Ultimate Online Bundle, Diabetes Educator Course 2021 Syllabus Hard Copy – over 100 pages, ADA 2021 Standards of Care Book DiabetesEd Services highlighters, PocketCard and Pen.
2. Making a Difference Exemplar Scholarship valued at $1000 for a diabetes educator who exemplifies advocacy and compassionate care in their community and is pursuing their CDCES. This top-tier scholarship provides funds to cover course registration plus enrollment in our Ultimate Online Bundle, Diabetes Educator Course 2021 Syllabus Hard Copy – over 100 pages, ADA 2021 Standards of Care Book DiabetesEd Services highlighters, PocketCard and Pen.
3. Making a Difference Scholarship valued at $900 for a diabetes educator who exemplifies advocacy and compassionate care in their community and is pursuing their CDCES. This scholarship provides funds to cover course registration plus enrollment in our Ultimate Online Bundle.

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The goal of these scholarships are three-fold:

1. To support U.S. health care professionals who are going above and beyond to improve diabetes care in their community; and
2. To support applicants’ effort to become a Certified Diabetes Care and Education Specialist (CDCES) and
3. To provide financial assistance with the DiabetesEd Course registration fee and or sleeping rooms

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As a child, LR lived with neglect and mistreatment by their parents. Escaping home as a teenager, LR couch surfed at friends but finally ending up living in their car. At the age of 23, LR showed up at our local community clinic with dysregulation, depression, and anxiety coupled with a new diagnosis of type 2 diabetes and elevated triglycerides. LR had limited access to healthy food and carried a BMI of over 35.

After a few months of getting comfortable with the clinic staff, our counselor asked LR to complete the Adverse Childhood Experiences (ACE) screening assessment. After LR finished checking off their adverse childhood experiences, they looked up with tears and said, “I scored a 9 out of 10”.

Adverse Childhood Experiences (ACEs) are common. At least two-thirds of people living in the U.S. have experienced one ACE and over 15% have experienced 4 or more.

Furthermore, a dose-response relationship exists: as the number of adverse experiences increases so does the risk of problems from childhood through adulthood.

These childhood traumas can lead to toxic stress which, over time, can change the biology of our bodiy.

People with elevated ACE scores are more likely to experience a variety of mental health issues, which is not surprising given their painful, confusing, and unsafe childhoods. Based on sound research by the CDC and Kaiser, they are also more likely to suffer from physical diseases, like heart attack and stroke, diabetes, and cancer. They are more likely to break bones and experience unintended pregnancies.

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Join Coach Beverly at an Upcoming Webinar

The Impact of Adverse Childhood Experiences on Health: A Personal Story of Resilience and Hope with Coach Beverly

ADCES National Virtual Meeting – Ready for Viewing
California Coordinating ADCES Chapter – September 30, 2021 at 4:45pm PST
Diabetes Ed Services Webinars – airs October 27th at 11:30 am PST

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Toxic Stress Affects us at the Cellular Level

Research shows that ACEs can lead to a cycle of toxic stress and cellular inflammation. This heightened adrenal-mediated “flight or fight” response over time, can lead to neuroendocrine dysregulation, altered immune response, affect DNA packaging and activate epigenetic tags that can alter genetic makeup.

The CDC Morbidity and Mortality Weekly 2019 report tell us that preventing ACEs could reduce:

• 21 million cases of depression
• 1.9 million cases of heart disease
• 2.5 million cases of excess weight

The first Surgeon General of California, Nadine Burke Harris, MD, MPH, has made it her mission to increase awareness, identify and address ACEs with parents, children, and adults so that we can break the cycle.

Health care professionals at risk for ACEs
People who enter healing professions may be experiencing toxic stress from childhood or current trauma. They may be dealing with burnout, fear, or feelings of deep pain with their past coupled with all the intensity of providing care during the COVID pandemic. This chronic and toxic stress can lead to dysregulation while impairing our ability to cope and care for others. You are not alone.

My own personal journey of experiencing childhood trauma and holding myself together until I ended up in the hospital, has compelled me to share my story with you. And offer a message of hope.

Coach Beverly

As I work on healing and integrating the different aspects of myself, I now feel more attuned to others who have weathered and survived childhood trauma. This awareness has significantly changed the way I hear what people with diabetes are saying and interpret what they are doing. For example, knowing that LR had a very high ACE score, I was able to adjust my expectations and focus on behavior changes that support self-care and self-regulation. When LR doesn’t take their diabetes medications for a few weeks, I provide gentle strength-based coaching to help LR get back on track. I make sure LR knows that they are safe sharing the truth of their story, no matter what.

In your hospital setting, do you have a person who keeps getting readmitted to the hospital in a diabetes crisis? In your outpatient setting, do you experience frequent no-shows or situations where people aren’t able to make changes in self-care? Maybe, they are struggling with the emotional impact of toxic stress.

Adults who have experienced trauma as children may exhibit the following behaviors:

• Missing appointments
• Not taking meds as prescribed
• Not adopting new lifestyle changes

As Diabetes Care and Education Specialists, if we recognize these behaviors as a response to dysregulation due to toxic stress, we can provide a therapeutic response to start the healing process.

Helpful provider responses when you suspect that participants are not engaging in care due to childhood trauma and toxic stress:

1. Refrain from harsh language or judgement
2. Be curious, ask open ended questions
3. Provide the ACE screening tool to start the conversation
4. Encourage collaboration using a person centered approach
5. Identify mental health resources in you community

Diabetes Care and Education Specialists recognize that the mind and body are a deeply connected, dynamic, and powerful force when they are working together in harmony. When trauma and toxic stress are not recognized or treated, there can be devastating health consequences. We can make a difference in preventing, recognizing, and helping people heal from adverse childhood experiences.

Want to learn more about the ACEs and Healing?

Join Coach Beverly at an Upcoming Webinar

The Impact of Adverse Childhood Experiences on Health:
A Personal Story of Resilience and Hope with Coach Beverly

ADCES National Virtual Meeting – Ready for Viewing
California Coordinating ADCES Chapter – September 30, 2021 at 4:45pm PST
Diabetes Ed Services Webinars – airs October 27th at 11:30 am PST

Resources

ACE Resource Network

ACE Screening Tool and Resilience Inventory

Becoming ACE-Aware Training Program

Nadine Burke Harris, MD TED Talk on How Childhood Trauma affects health

NPR Article – Take the ACE Score and Learn what it does and doesn’t mean

Trauma-Informed Care Fact Sheet

Why should I care about my number?

CDC Vital Signs – Impact of ACES

CDC Mortality and Morbidity Weekly Report on ACEs – 2019

What happened to you? Conversations on Trauma, Resilience, and Healing – authors Oprah Winfrey and Bruce D. Perry, M.D., Ph.D.

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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.

Click here to read our full August 2021 newsletter.

Featured Blogs

• DiabetesEd Scholarship Recipients
• 3 Reasons to Recognize and Address Trauma
• Hidden Barriers to Type 1 Technology Use
• Rationale of the Week
• Question of the Week

Upcoming Events & Resources

• Summer Sale – 15% OFF Online Courses – Use Code SUMMER15 During Checkout
• Prep for CDCES Exam FREE Webinar, Aug 5th
• Setting up a Successful Diabetes Program
• Microvascular Disease and Risk Reduction
• Free Resources Catalog

I felt pretty discouraged reading through the New England Journal of Medicine (NEJM) summary of the state of diabetes treatment and control in the U.S. from 1999-2018. We have stalled in improving diabetes outcomes in spite of exciting new therapies and dazzling technologies.

Based on this “Diabetes Report Card” for the U.S it seems pretty clear that changes in our care delivery system are urgently needed. First, let me share the data, then we consider how Diabetes Care Specialists (you and me) can drive the improvement arrow in the right direction.

The data summarized below is extracted from the National Health and Nutrition Examination Survey (NHANES) which assesses national trends in diabetes care and outcomes for the past decade.

Summary of the major findings of the Diabetes ABC’s.  A1C, Blood Pressure and Cholesterol.  
Data is compared from the 2007 -2010 period to the 2015-2018 time period.

Reaching A1c Target of less than 7%?

• The percentage of people with diabetes and an A1c of less than 7%, declined from:
  • 57.4% in 2007-2010 to
  • 50.5% in 2015 to 2018

Coach Bev’s Report Card Comment: Blood glucose levels trended up.  GRADE C-

Reaching LDL target of less than 130 mg/dL?

• The percentage of people with diabetes and an LDL of less than 130 leveled off, with slight movement in the right direction.
  • 52.3% in 2007-2010 to
  • 55.7% in 2015 to 2018

Coach Bev’s Report Card Comment: Lipid levels improved slightly.  GRADE B-

Reaching blood pressure goal of less than 140/90 mm Hg?

What are the barriers and how can Diabetes Care and Education Specialists help improve the grade?

The year 1999 got off to a good start with improved diabetes control but stalled and declined as the decade moved forward. There are several possible reasons as cited by the authors.

Sluggish initiation of first-line therapies. In 2015–2018, only 56.3% of adults with diabetes were using statins, 59.5% were using metformin, and 60.3% were using an ACE inhibitor or ARB.

These results are consistent with those of previous studies and point to clinical inertia as a potential culprit.

In addition, achieving glycemic and blood-pressure control often entails the use of multiple agents. However, the study found that only 60.6% of participants with an A1C level of 7% or higher and 52.8% of those with a blood pressure of 140/90 mm Hg or higher were treated with more than one glucose-lowering or blood-pressure-lowering medication, respectively.  

Coach Beverly suggested action: Diabetes Care and Education Specialists can continue to raise awareness of the ADA Standards of Care for Diabetes and advocate for initiating first-line and add-on therapies in their work settings. Plus, we can encourage a streamlined referral process to facilitate participant access to DSMES and to RD/RDN for initial and ongoing lifestyle and nutrition counseling.

Care Gaps for Young People, Ethnic Groups and Uninsured Populations

The study found that younger people, Mexican Americans, and persons without health insurance were more likely to be untreated when risk-factor targets were not achieved. These gaps are especially magnified in under-resourced areas.

In addition, given that the rates of diabetes-related complications are higher in people of color and uninsured populations and that type 2 diabetes discovered in young adulthood have a more aggressive clinical course than diabetes, immediate action is required to improve outcomes.

Coach Beverly suggested action: Diabetes Care and Education Specialists continue to take a leadership role in intentional and unrelenting outreach to provide DSMES and MNT to under-resourced communities using novel and evidenced-based approaches. Since prediabetes rates are also higher in many of these communities, establishing easily accessed Diabetes Prevention Programs and networking with community health workers and leaders can contribute to improved health outcomes.

Medications are too expensive for many people

Even though we have a slew of new and highly effective classes of diabetes medications, they are out of the financial reach for many. As patents expire and the medications are available as generics, access and affordability will increase. In the meantime, a realistic approach to providing affordable diabetes treatment is needed.

Coach Beverly suggested action:

Diabetes Care and Education Specialists can help craft a medication plan that is realistic and affordable. For people with no insurance or large co-pays, consider using available generic diabetes medications. These medications often cost $10 or less for a 3-month prescription. They include: metformin, sulfonylureas, and pioglitazone. In addition, Walmart offers Reli-On insulins including Regular, NPH, and 70/30 insulin for $25 a vial. There are also online resources like GoodRx.com that help people find discounts on their usual medications and the different pharmaceutical companies also offer discount programs based on need.

See Insulin Cost Savings Guide for an abundance of resources and useful links.

In conclusion, Diabetes Care and Specialists are perfectly positioned to influence health delivery systems and advocate for best clinical practices. We can be catalysts for establishing DPP and DSMES programs in under-resourced communities and advocate for access to affordable medications and technologies to help participants reach their targets for A1C, Blood Pressure, and Cholesterol while improving quality of life.

With a concentrated effort, maybe our next report card will be a little bit better!

With hope, Coach Beverly

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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.