By: Christine Craig, MS, RD, CDCES

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) are now recognized as high-risk health conditions for people living with diabetes.

Two out of three individuals with type 2 diabetes are affected by liver steatosis.¹ In May 2025, the American Diabetes Association (ADA) published a consensus report, which emphasized recommendations for early diagnosis, long-term monitoring, and highlighted lifestyle interventions as critical in preventing progression to cirrhosis.¹

In the past year, two medications have been approved for the treatment of MASH; however, lifestyle change remains at the foundation of treatment. These changes focus on improving dietary quality, increasing physical activity, promoting weight loss, and reducing sedentary behaviors.

Nutrition Therapy Approaches

Nutrition therapy, ideally guided by a registered dietitian nutritionist and reinforced by the entire diabetes care team, needs to be individualized to each person’s social, cultural, and financial needs.¹ Ivancovsky Wajcman et al. ² published a fascinating review of different country’s MASLD management guidelines summarizing recommended lifestyle interventions, their findings indicated many similarities with only a few differences.

Most groups recommended evidence-based eating patterns with the following themes:

• High in fiber and focused on whole food consumption, while reducing saturated fat, added sugars, and ultra-processed foods.¹
• Reduction of commercially produced fructose consumption was recommended as high fructose intake has been associated with greater fibrosis severity, independent of total calorie intake.
• A few guidelines specifically called out reduction/avoidance of regular soda consumption emphasizing that consuming more than four servings of regular sodas per week was associated with a 45% higher risk of developing MASLD. ³
• In contrast, coffee consumption, whether caffeinated or not, has been shown in meta-analyses to reduce MASLD risk when intake exceeds three cups per day. Guidelines suggested consumption of greater than 2-3 cups per day. (Can I get a whoot for my daily coffee habit). 
• Similar to the ADA Standards of Care for diabetes management, focusing on shifting towards water consumption and reducing the consumption of sugar-sweetened beverages has shown improved outcomes.

Other Recommended Eating Patterns &  Physical Activity

The Mediterranean diet eating pattern is recommended in the MASLD/MASH ADA consensus report as well as the EASL–EASD–EASO Clinical Practice Guidelines ¹,²,³ due to its relationship with improving diet quality and evidence of hepatic and cardiovascular health benefits, even without weight loss.

Other dietary patterns, such as the low-fat, low-carbohydrate, Dietary Approaches to Stop Hypertension, high protein, meal replacement, and intermittent fasting, have also been shown to be comparable strategies to improve steatosis due to weight loss.¹ 

In people with overweight and obesity, the magnitude of weight loss has been associated with improving glycemic management, insulin sensitivity, as well as histological improvements in MASH.¹ 

Weight reduction over 5% has been associated with reduced steatosis, and greater weight loss of 7-10% has been shown to reverse steatohepatitis and liver fibrosis.¹,²,³ However, it is recognized that achieving long-term weight reduction may be challenging.³

Avoidance of alcohol is recommended for individuals with moderate fibrosis, as even modest use may aggravate injury.

Physical Activity, Stress Reduction & Sleep

Physical activity, including aerobic and resistance training, has independent effects beyond weight loss: decreasing intrahepatic fat, improving cardiovascular risk, improving insulin sensitivity, and supporting weight‐loss maintenance. Guidelines generally recommend greater than or equal to 150 minutes per week of moderate intensity (or equivalent) and resistance activities 2-3 times per week, with greater benefit when increasing activity. 

However, reducing sedentary time and breaking up prolonged sitting bouts can be effective ways to reach this goal.¹,³ Emerging evidence highlights the importance of stress reduction, adequate sleep and treatment of sleep apnea, and management of comorbidities such as dyslipidemia and hypertension, due to their impact on liver steatosis, inflammation, and fibrosis.¹,² 

FDA-Approved Medications

Until recently, there were no FDA-approved medications specifically for MASH; treatment was either off-label or targeted at comorbidities such as weight reduction or lipid and glycemic management. However, in the past 2 years, two different medications have been released to address MASH. In March 2024, the FDA approved resmetirom (brand name Rezdiffra) for adults with noncirrhotic MASH to be prescribed in conjunction with lifestyle therapy. 4 In August 2025, the FDA approved semaglutide (brand name Wegovy) for the treatment of  MASH and moderate to advanced liver fibrosis. 5

MASLD and MASH

MASLD and MASH are high-risk health conditions for people with diabetes, with approximately 10-30% progressing to advanced liver disease, including cirrhosis.³ While new FDA-approved medications such as resmetirom and semaglutide offer promising options, lifestyle modification remains a cornerstone treatment.

As diabetes healthcare professionals, we are uniquely positioned to implement evidence-based strategies into the individualized care plan.

We can screen, educate, and empower individuals living with diabetes to take proactive steps that protect liver health, improve metabolic outcomes, and prevent progression to cirrhosis. Through nutrition and lifestyle therapy, pharmacotherapy, and incorporating broad strategies into DSMES services (¹) we can strengthen prevention and outcomes.

References

1. Cusi K, Abdelmalek MF, Apovian CM, et al. Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) in people with diabetes: the need for screening and early intervention. A consensus report of the American Diabetes Association. Diabetes Care.
   2025;48(7):1057-1082. doi:10.2337/dci24-0094
2. Ivancovsky Wajcman D, Byrne CJ, Dillon JF, et al. A narrative review of lifestyle management guidelines for metabolic dysfunction-associated steatotic liver disease. Hepatology. Published online August 15, 2024.doi:10.1097/HEP.0000000000001058
3. Tacke F, et al. EASL–EASD–EASO clinical practice guidelines on the management of metabolic dysfunction–associated steatotic liver disease (MASLD). J Hepatol. 2024;81(3):492-542.doi:10.1016/j.jhep.2024.05.010
4. US Food and Drug Administration. FDA approves first treatment for patients with liver scarring due to fatty liver disease. Published March 14, 2024. Accessed September 19, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-patients-liver-scarring-due-fatty-liver-disease
5. US Food and Drug Administration. FDA approves treatment for serious liver disease known
   as “MASH.” Published March 14, 2024. Accessed September 19, 2025. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-treatment-serious-liver-disease-known-mash

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By: Christine Craig, MS, RDN, CDCES

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: 

1. 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
2. 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
3. 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.  

Click here to Register

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 Services

Disclosures: 

Beverly Thomassian has no financial disclosures

Bio:

Author, Nurse, Educator, Clinician, and Innovator, Beverly has specialized in diabetes management for over twenty years. As president and founder of Diabetes Education Services, Beverly is dedicated to providing compassionate and evidence based diabetes education and improving the lives of those with diabetes.

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.

Dawn Desoto RD, CDCES, celebrates the fall and winter season with a collection of recipes that nourish and heal. Dazzle your taste-buds and energize your gut bacteria with this delicious and seasonal compilation.

Below are the following recipes:

• Stevia Pumpkin Puree Recipe
• Simple Baked Apples
• Poached Pears (Naturally Sugar-Free)
• Blueberry-Banana Overnight Oats
• Spinach Pomegranate Recipe

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Stevia Pumpkin Puree Recipe:

Choose a pie pumpkin and wash it’s exterior. Cut in half lengthwise and remove the seeds and pulp. Roast in your oven for about 45 minutes at 350 degrees F.

Simply peel away the skin from the flesh and toss the pumpkin pulp into your food processor or blender.

Ingredients:

• 1 unbaked 9-inch pie crust
• ½ teaspoon stevia powder
• 1 teaspoon cinnamon
• ½ teaspoon ginger
• ½ teaspoon nutmeg
• ¼ teaspoon salt
• 2 eggs 
• 1 ¾ cups pumpkin puree
• 1 cup low-fat evaporated milk. 

In a large bowl, whisk eggs and pumpkin puree together. Add the rest of the ingredients and whisk them together while slowly pouring in the evaporated milk.

Pour mixture into pie crust. Bake in the oven for 20 minutes at 390 degrees, reduce oven to 350 degrees and bake for another  45 – 60 minutes until inserted toothpick comes out clean. Store in the refrigerator overnight.

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Simple Baked Apples:

• 5 – 6 medium apples, peeled and cut into chunks
• 2 Tablespoons butter or coconut oil, melted
• 1 teaspoon cinnamon
• ½ cup chopped walnuts
• Preheat the oven to 350 degrees
• Place the apples in a medium baking dish

Mix the melted butter or coconut oil, walnuts, and cinnamon together and pour over the apples. Bake in the preheated oven until the apples are soft, about 20 – 30 minutes. Stir once during the baking.

Poached Pears (Naturally Sugar-Free):

• 1 cup red wine
• 1 orange zest and juice
• 1 cinnamon stick
• 1-inch ginger root peeled
• 3 cloves whole
• 2 Conference pears, peeled, sliced in half, and core
• 1 Tablespoon sliced toasted almonds
• 2 Tablespoons thick plain Greek yogurt

Pour the wine into a small saucepan along with the orange zest and juice and all of the spices

Bring almost to a boil and add the pear halves. Turn down the heat and let the pears simmer gently for 20 – 30 minutes, or until they have slightly softened.  Carefully turn the pears over a few times throughout the cooking time to ensure they color evenly. When the pears are cooked remove them from the wine and place them on plates. Add a tablespoon of yogurt to each plate and sprinkle with toasted almonds.

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Blueberry-Banana Overnight Oats:

• ½ cup unsweetened coconut milk beverage
• ½ cup old-fashioned oats
• ½ TB chia seeds
• ½ banana
• 1 tsp maple syrup
• ½ cup blueberries
• 2 TB chopped walnuts
• 1/8 tsp cinnamon

Combine coconut milk, oats, chia, banana, maple syrup in a pint-sized jar and stir. Top with blueberries and coconut. Cover and refrigerate overnight. Heat up and sprinkle with walnuts and cinnamon in the morning.

285 calories, 6 gm protein,  57 gms carbohydrate, 7 gms fiber 6 gm fat

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Spinach Pomegranate Recipe:

To add more color into our diets, I am sharing my Spinach Pomegranate Salad recipe

• 10 oz bag of baby spinach leaves    
• ½ cup walnut pieces
• ¼ red onion sliced thin                     
• ½ cup crumbled feta cheese
• 1 pomegranate peeled and seeds separated                            
• 4 Tb Balsamic vinaigrette

Toss the spinach leaves with the rest of the ingredients.  Serves 4

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We hope you enjoy these delicious recipes!

Check out these upcoming class offerings!

Hyperglycemic Crisis Dec. 10th @11:30am PST

Assess Well Being Dec. 12th @ 11:30am PST

Meds MGMT for Type 2 Dec. 17 @ 11:30am PST

ADA Standards of Care Jan. 30 @ 11:30am PST

All hours earned count toward your CDCES Accreditation Information

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The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.

These treasured food and nutrition experts translate the science of nutrition into practical solutions for healthier living.

Some of my favorite people are RD/RDNs. I’ve been blessed to teach with many inspiring, kind, knowledgeable, and dynamic dietitians over a span of more than 20 years. RDN’s are trailblazers and advocates for improving the health of our communities through nutrition and are passionate about sharing their breadth of knowledge with their diabetes community and colleagues alike.

People with diabetes who meet with a Registered Dietitian Nutritionist (RD/RDN) can expect an A1C drop of 0.3% to 2.0%.

We are honored to highlight the significant impact RDNs have on individuals, communities, and society as a whole by promoting healthy eating habits, preventing disease, and improving our overall quality of life by encouraging us to eat a rainbow of foods filled with fiber and phytonutrients.

To celebrate Registered Dietitian Day, we are highlighting a leader in the field and the newest member of our DiabetesEd Team, Christine Craig.

Christine Craig, MS, RD, CDCES – Nutrition Content Expert and Contributor

We are excited to welcome our newest faculty member! Christine is a Registered Dietitian, Certified Diabetes Care and Education Specialist and a consultant dietitian. It is important to her that each person living with diabetes feels supported and empowered not only with information but an individualized approach for lifelong health. Winner of the 2023 Impact on Diabetes Award, she is a leader in the field of nutrition, technology, and diabetes care. She has served as a preceptor, lecturer, researcher, and is an active association board member. She has worked across health systems; within Diabetes Care Centers, Endocrinology clinics, Primary Care, Telemedicine Rural Health, and Virtual-First Primary Care. Currently she is owner of Nutrition for Daily Living, where it is her mission to increase access to compassionate and evidenced-based nutrition and diabetes care.

As an adventurer, travel, hiking and snow skiing are her favorite past-times. For Christine, having a moment to take in the landscape and beauty around us can re-energize and fuel a busy life.

Christine Craig, MS, RD, CDCES

Featured Articles by Christine 

• Plant Based Eating – What Approach is Best?
• Can Understanding Chronotype Help with Glucose Regulation?

Register for our Virtual Conference to enjoy a half-day presentation on Medical Nutrition Therapy!

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.

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.

Group discounts are available!*

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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!

Recent Blog Bytes

• Download Free Diabetes Cheat Sheets!
• Question of the Week | What to Assess When Looking for PAD?
• January 2026 eNews
• Rationale of the Week | Teens’ A1C Climbs After Starting CGM
• Rationale of the Week | What Do New ADA Standards Say About Development of Type 2?

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and our CPEU courses have received Prior Approval* from the Commission of Dietetic Registration (CDR), Provider DI002. Since our CPEU courses received Prior approval* from the CDR, these CPEU courses satisfy the CE requirements for the CDCES /BC-ADM regardless of your profession! 

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.

We are thrilled to welcome our newest member of the Diabetes Education Services faculty and blog team. Winner of the 2023 Impact on Diabetes Award, Christine Craig, MS, RD, CDCES is a leader in the field of nutrition, technology, and diabetes care. Her years of expertise combined with her person-centered approach and work ethic, make her a perfect fit for our company. In addition to writing a monthly blog and question of the week, Christine will also be providing nutrition lectures as part of Diabetes Fundamentals and Boot Camp. We are excited to integrate her fresh perspective and breadth of knowledge into our courses and blog offerings.

On a personal note, Christine loves to adventure. Travel, hiking, and snow skiing are her favorite pastimes. For Christine, having a moment to take in the landscape and beauty around us can re-energize and fuel a busy life.

Learn more about Christine’s approach to diabetes and nutrition education in this brief interview and you can read more about Christine here. Welcome, Christine!

Interview Christine Craig, MS, RDN, CDCES

What advances in nutrition therapy are you excited to explore? 

Nutrition is a constantly evolving field that is both a science and an art; we know there is no one-size-fits-all approach. In the science of nutrition, I am excited by the emerging field of precision nutrition, which may give us better insight into an individual’s needs. Precision nutrition uses the complexity of genetics, metabolic profiles, individual microbiomes, wearables, lifestyle, and environmental exposures to better predict an individual’s nutrition needs. This science is still in the very early stages, but the ability to integrate precision nutrition with the art of nutrition has the potential to transform our approach to medical nutrition therapy.

How do you integrate social determinants of health when developing a diabetes management plan?

Developing a diabetes management plan involves finding out about the individual, asking questions, and not making assumptions that you know what is best for the person living with diabetes at that time. Life is complex and managing health can be complex. As a healthcare provider, we can’t always solve structural obstacles, which can feel overwhelming at times. We can, however, through shared decision-making, constant learning, and linking to community resources, develop a collaborative self-care plan that considers the individual’s social determinants of health.

What communication strategies do you find most effective when providing nutrition therapy?

As a dietitian and diabetes educator, I have worked across modalities of care including in-person visits, telehealth, chat-based message communication, and group classes. Like nutrition therapy, there is no one-size-fits-all approach; each person can respond differently to different style types. For me, what has always been effective is using non-judgmental language and open-ended questions. People want to feel heard; this opens the doors to trust and developing an effective nutrition plan.

What do you love most about being a diabetes nutrition specialist?

I love that diabetes care supports health throughout the lifespan, we care for individuals with diabetes over time and at different transition points in their lives.  I love that we can walk into work each day and present a breadth of options to support the person living with diabetes or our care teams. I love that I can talk diabetes tech in one moment, nutrition meal planning in the next, and then end my day reviewing coping strategies. This profession is never boring and I love bringing the latest research into my daily practice.

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!

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and our CPEU courses have received Prior Approval* from the Commission of Dietetic Registration (CDR), Provider DI002. Since our CPEU courses received Prior approval* from the CDR, these CPEU courses satisfy the CE requirements for the CDCES /BC-ADM regardless of your profession! 

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.

MR is frustrated that their morning glucose is almost always elevated. Since you have heard about the impact of “chronotype” on glucose, you ask them about eating patterns and explore whether they are early birds or night owls.

The 2024 American Diabetes Association (ADA) Standards of Care introduced the field of chrononutrition, the science of how our body’s 24-hour cycle (circadian rhythm), nutrition, and health interact. Growing evidence shows that factors, including when and type of food is eaten, hormones, genetics, exercise, sleep cycles, and a person’s daily light exposure, influence health and risk for metabolic disease.

A person’s chronotype is their body’s inclination to sleep at a particular time and rise at a certain time.

When we consider a person’s chronotype, we realize that it’s not just “what” individuals eat that impacts metabolic health. Could “when” they eat and their chronotype be just as crucial for glucose regulation? Can we leverage this information to suggest modifications in the type of nutrients consumed throughout the day to support improved glycemia?

Insights from Shift work

We have learned the association between circadian rhythm disruptions and metabolic disorders from people who perform shift work. Working in shift work and having type 2 diabetes is associated with increased A1c, neuropathy, and decreased psychological well-being.¹ Glucose metabolism and tolerance follow a circadian rhythm throughout the day. Hormones, such as insulin and cortisol, cycle daily and regulate insulin sensitivity and glucose metabolism changes. Research suggests when food intake is out of sync with the daily cycle, this can reduce glucose tolerance and increase the risk of metabolic diseases such as type 2 diabetes, obesity, and cardiovascular disease.

“Meal timing and food nutrient components (chrononutrition) play an important role in regulating the circadian clock, enhancing metabolic health, and reducing the risk of type 2 diabetes.” ²

Time of Meal and Glucose Response

Post-prandial glucose response is affected by what and how much we eat and can vary based on the time of day the meal is consumed. Meal timing can affect type 2 diabetes, so it is important to consider timing in addition to composition alone. In a 2020 review article by Henry et al., they reported several different studies completed in individuals with type 2 diabetes and healthy subjects. These studies suggested both morning and late-night eating can contribute to the greatest glucose excursions. Eating after 8 pm was independently associated with an increase in A1C levels. Consuming more than a third of daily calories late in the evening led to higher post-meal glucose excursions and reduced morning glucose tolerance compared to other times of day. And a study of individuals with type 2 diabetes showed higher post-meal glucose trends after morning meals verses identical meals consumed throughout the day. These small studies suggest that modifying when a meal is consumed could reduce glycemia and the risk of diabetes. However, more extensive studies are needed to support causation and associate it with a person’s genetics and true chronotype. 

Macronutrient meal composition

Macronutrient meal composition and the time of day consumed may also play a role in chrononutrition. Whether it is a variation of calories consumed or manipulating different macronutrients from meal to meal, the relationship between food type and timing could affect glucose metabolism. Changes in insulin sensitivity throughout the day can affect post-meal glucose in response to varying carbohydrate quantity, quality, and rate of digestion. Davis et. Al, 2019 found that increased protein and lower carbohydrates at dinner meals reduce night post-prandial glucose compared to standard meals. 

The key nutrition recommendations from the 2024 ADA Standards of Care are focused on individualizing eating patterns, meal plans, and dietary approaches. Research continues to evolve in this field, and there is much more to understand and validate. Most of the articles regarding chrononutrition referenced in the ADA Standards of Care are specific for type 2 diabetes, but we know circadian cycles and metabolism also play a role in type 1 diabetes. More research is needed to improve our understanding of why nutrients consumed at different times of day have differing effects, how this relates to the individual’s circadian biomarkers and genetics, and how it interplays with psychological factors that drive sleep cycles.

Take home messages

There is much to learn, but are there practical approaches we could consider implementing now? Yes! We can start by:

• Individualizing our recommendations, reviewing meal timing and composition with individuals with diabetes.
• Encourage clients to experiment with modifying macronutrient distribution at different times of the day instead of using a “each meal looking the same” approach.
• Continue to stay abreast of new evidence that highlights research findings in this area.

Blog contributed by nutrition expert Christine Craig, MS, RDN, CDCES

References:

1. American Diabetes Association Professional Practice Committee; 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S77–S110. https://doi.org/10.2337/dc24-S005
2. Henry, C.J., Kaur, B. & Quek, R.Y.C. Chrononutrition in the management of diabetes. Nutr. Diabetes 10, 6 (2020). https://doi.org/10.1038/s41387-020-0109-6
3. Chrononutrition: Timing of meals matters for your health. Downloaded on January 13^th, 2024 from https://www.nhlbi.nih.gov/news/2023/chrononutrition-timing-meals-matters-your-health.
4. Davis R, Bonham M, Nugo K, Huggins C. Glycaemic response at night is improved after eating a high protein meal compared with a standard meal: A cross-over study. Clinical Nutrition. 35, 5 (2019) https://doi.org/10.1016/j.clnu.2019.06.014

Want to learn more about the latest in MNT and Diabetes Care?

Join us for our upcoming 2024 Boot Camp Series

Airs live February 13th – March 19th, 2024, at 11:30 am PT

Class Topics & Webinar Dates:

• February 13, 2024 – Boot Camp 1: Diabetes | Not Just Hyperglycemia | 1.75 CEs 
• February 15, 2024 – Boot Camp 2: Standards of Care & Cardiovascular Goals | 1.8 CEs
• February 20, 2024 – Boot Camp 3: Meds for Type 2 | What you need to know | 1.75 CEs 
• February 22, 2024 – Boot Camp 4: Insulin Therapy | Basal/Bolus to Pattern Management | 1.75 CEs
• February 27, 2024 – Boot Camp 5: Insulin Intensive & Risk Reduction | 1.75 CEs 
• February 29, 2024 – Boot Camp 6: Medical Nutrition Therapy | 1.75 CEs 
• March 12, 2024 – Boot Camp 7: Microvascular Complications & Exercise | 1.75 CEs
• March 14, 2024 – Boot Camp 8: Coping & Behavior Change | 1.75 CEs 
• March 19, 2024 – Boot Camp 9: Test-Taking Coach Session (48 Questions) | No CE 

Intended Audience: This library of critical information is designed for individuals or groups of diabetes specialists, including RNs, RDs, Pharmacists, Nurse Practitioners, Clinical Nurse Specialists, Physician Assistants, and other health care providers interested in staying up to date on current practices of care for people with diabetes and preparing for the BC-ADM or the CDCES certification Exam.

Can’t make it live? No worries. We will send post the recorded version to the Online University within 24 hours of the broadcast

Instructor: Beverly Thomassian RN, MPH, CDCES, has been Board Certified in Advanced Diabetes Management for over 20 years. She is an Associate Clinical Professor at UCSF, a working educator, and a nationally recognized diabetes expert. She has a Master’s Degree in Public Health from UCLA, with a focus on behavioral health and education.

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and our CPEU courses have received Prior Approval* from the Commission of Dietetic Registration (CDR), Provider DI002. Since our CPEU courses received Prior approval* from the CDR, these CPEU courses satisfy the CE requirements for the CDCES /BC-ADM regardless of your profession! 

The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.

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JR lives with type 1 diabetes and is excited to eat a stack of blueberry pancakes with a new type of maple syrup sweetened with allulose. The syrup label reads that there are 28 grams of carbs in 2 Tablespoons of Zero Sugar Maple syrup. JR adds up the total carbs in the pancakes and syrup, and takes 6 units of bolus insulin (4 for the pancakes and 2 units for the syrup). Within a half hour, JR realizes their blood sugar is dropping fast and grabs some glucose tabs to treat the sudden low. Trying to figure out what went wrong, JR double confirms the nutrition in the pancakes and then takes a closer look at the Maple Syrup label.

Is the Maple Syrup to blame for the Unexpected Low Blood Sugar?

Looking at the label, JR confirms that there are 28 gm of carbs per serving of this unique maple syrup and 26 of those carb grams come from Allulose. Allulose is a low-calorie sugar that is Generally Recognized As Safe (GRAS) approved by the FDA in 2022. Allulose is considered a rare sugar found naturally in figs, raisins, wheat, maple syrup, and molasses or it can be commercially produced and added to foods. It’s roughly 70% as sweet as sugar and it tastes very similar. Allulose is hardly digested or absorbed, so it provides very few calories – approximately 0.4 calories per gram, compared with 4 calories per gram in table sugar.

Because very little of ingested allulose is absorbed, the impact on post-meal glucose levels is negligible.

Allulose labeling Can Cause Confusion for People Matching Insulin to Carbs

In 2019, US Food and Drug Administration (FDA) issued guidance, allowing food manufacturers to exclude allulose from total and added sugar counts on Nutrition and Supplement Facts labels. Like sugar alcohols and dietary fiber, allulose still counts towards total carbohydrates on the nutrition label.

The fact that allulose hardly raises blood sugar may lead people who match insulin to carbs to take more insulin than needed.  

FDA Labeling Rule for allulose:

• Not included in “Total Sugars” or ”Added Sugars”

• Included in Total Carbohydrates

• Calories calculated with 0.4 kcals/gram

• Must be in the ingredient list

Take home message for People Counting Carbs for Accurate Insulin Dosing

Look on labels to see if allulose is listed under carbohydrates or included in the ingredient list. If it is, subtract allulose carbs from the total carbs to get an accurate carbohydrate measurement.

For other people, allulose may be a sweet-tasting alternative to sugar that provides few calories and doesn’t raise blood sugar.

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Included in this bundle is:

• Level 1 focuses on the fundamentals and introduces each topic area for the exam.
• Level 2 deep dives into the ADA Standards of Care, 
• Level 3 AKA Boot Camp is a more accelerated level that focuses on test simulation for finding the best answer to get you to the finish line of your study path.
• Technology Toolkit which gives information on pumps, sensors, and calculations,
• Test Taking Toolkit includes over 220 practice questions for test simulation plus a webinar where Coach Beverly provides test-taking tips based on her experience taking the certification exam six times. 
• ADCES Review Guide for the Diabetes Care and Education Specialist Exam – 6th Edition – The ADCES Review Guide is a fantastic independent study tool and comprehensive resource for the Diabetes Care and Education Specialist Exam. This book includes 475+ multiple-choice questions and strategies for preparing for and taking the exam with an answer key with rationales for all questions! 
• Medication PocketCard – Our four-sided medication accordion Pocketcards were designed by Coach Beverly Thomassian to assist in clinical practice and exam preparation.
• Tote Bag

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In a recent study published in Circulation, large, multisite produce prescription programs were associated with significant improvements in fruit and vegetable intake, food security, and health status for adults and children. At the conclusion of the food prescription program, participants experienced clinically relevant improvements in A1C, blood pressure, and body weight.

However, for this food-is-medicine strategy to work, it’s clear that the people will need long-term support.

The idea of food as medicine dates back to the ancient Greek doctor Hippocrates, and this new study adds to the evidence that a diet full of fruits and vegetables can help improve heart health.

Researchers evaluated the impact of “produce prescriptions,” which provide free fruits and vegetables to people with diet-related diseases including diabetes, obesity, and hypertension. The study included nearly 4,000 people in 12 states who struggle to afford healthy food. They received vouchers, averaging $63 a month, for up to 10 months, which could be redeemed for produce at retail stores or farmers markets, depending on the location.

Many people with diabetes struggle not only with food insecurity but also with nutrition insecurity. Improving nutrition security is about providing the right food to prevent or decrease the prevalence of chronic conditions like diabetes, heart disease and hypertension.

By providing adults with hypertension with access to healthy fruits and vegetables using a prescription program, this study demonstrated a systolic blood pressure decrease of 8 mm Hg and diastolic blood pressure decrease of about 5 mm Hg. In addition, among people with diabetes, A1C levels also declined significantly, by about 0.6 percent.

“Anything that lowers hemoglobin A1C and improves blood pressure control is beneficial,” says Dr. Dariush Mozaffarian, a cardiologist and professor at the Friedman School of Nutrition at Tufts University, where the research was conducted. The challenge is to maintain these reductions. 

The research clearly indicates that food prescription programs are an effective strategy to improve health outcomes, but long-term funding for these programs is difficult to secure.

More research is needed to establish which individuals and communities will most benefit from which food assistance programs. Options include medically tailored meals, produce prescriptions, and community-based programs. The ultimate goal is to get to a place where these programs cover long-term benefits for people who need them most.

Resources and Related Articles

Wholesome Wave – partnering with community organizations to provide the right food to people at risk.

White House Conference on Hunger, Nutrition and Health

7 Ideas to Eat Healthier in the U.S.

Medically Prescribed Meals

Want to learn more about how nutrition can support people living with diabetes?

Join us LIVE in San Diego for our DiabetesEd Training Conference with Ashley LaBrier MS, RD, CDCES as she reviews MNT & Meal Planning

Two Registration Options

Join Coach Beverly and Team for two and a half days of knowledge-sharing, fun, networking, games with prizes, and “aha” moments in beautiful San Diego. 

You don’t want to miss this one-of-a-kind learning opportunity. Get away from all those daily responsibilities and immerse yourself in a fun and intensive conference with plenty of networking opportunities.    

Attendees will leave this conference with new tools and a more complete understanding of the latest advances in diabetes care, from medications to technology to Medical Nutrition Therapy! 

Bring your colleagues and enjoy our friend discount.

Our team expertly translates the complex science of diabetes into understandable terms while keeping it real, practical, and fun. 

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 

All hours earned count toward your CDCES Accreditation Information

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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.