Written by Monique Jackson, MSN, CFNP, WHCNP, CDCES

A new study finds that hemoglobinopathies may distort A1C accuracy for people of African descent living with diabetes.  

African Americans at risk for falsely low A1cs due to Hemoglobin Variants

Hemoglobin variants don’t increase the risk for diabetes, but it can affect the results of A1C tests.  African Americans Heterozygous for the common hemoglobin variant HbS may have, for any given level of mean glycemia, lower A1C by about 0.3% then those without the trait.  Another genetic variant, X-linked glucose-6-phosphate dehydrogenase G202A, carried by 11% of African Americans, was associated with a decrease in A1C of about 0.8% in homozygous men and 0.7% in homozygous women compared with those without the variant  (American Diabetes Association, Standards of Care in Diabetes-2021; 16). 

 Health care professionals often use A1C test results to guide decisions about diabetes care, such as changes to medication, meal plan, or physical activity routine to manage diabetes.  In those with certain hemoglobin variants, A1C is not accurate for diagnosing and managing diabetes.  Different tests that accurately reflect long term glucose levels are needed for early diagnosis and to provide needed medical management that prevents complications. 

Mismatch between Glucose and A1c –  My Clinical Finding

At my clinic, where I work as a Diabetes Nurse Specialist, an African American individual arrived with a high random glucose and mildly abnormal A1C.  Reviewing their lab work, I noticed that the random blood glucose was 300 mg/dl and the A1C was at approximately 7.0%.  When I converted the A1C to average blood glucose and compared with the elevated reading in the logs, the numbers did not match up. I realized that this individual had one of the hemoglobin variants (Sickle Cell anemia) HbS.   I ended up starting them on Metformin for blood sugar, Atorvastatin because of the guidelines that everyone with Diabetes should be on a statin, Aspirin to prevent heart attack, and Lisinopril for blood pressure control. 

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Without this clinical finding that the elevated blood sugars were not reflected in the A1c, this individual might not have been started on diabetes treatment, because of the false low A1C.

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A1C reflects glucose concentration from the past 2-3 months, but this relationship may differ between those with nutritional deficiencies, anemia, or genetic hemoglobinopathies, including the Sickle cell trait.

Since A1C measures the percentage of glycosylated hemoglobin, individuals who possess variants of hemoglobin can exhibit falsely low readings.  

Fructosamine testing, which evaluates albumin glycosylation for the past 2-3 weeks, may be a better measure to help people with diabetes monitor and manage their blood glucose levels in cases where the A1C test cannot be used and/or a short-term monitoring window is desired.    

Summary and Notes for the Future

It is important to consider the results of the A1C, fasting blood glucose, two-hour glucose tolerance test, random blood glucose, and or fructosamine when you are screening someone with diabetes who is diagnosed with a Hemoglobin variant.  

A1C testing on two different occasions to diagnose diabetes for those with Hbs variants is not recommended, because it will yield false low results.  To diagnose a person with diabetes and Hbs variants, the ADA recommends only plasma blood glucose criteria be used to diagnose diabetes.

More research is needed on the diagnoses of diabetes utilizing the A1C in populations with increased prevalence of Hbs variants.  In addition, we need research aimed toward providing more accurate tests for the diagnosis and management of conditions associated with increased red blood cells turnover, such as sickle cell disease, hemoglobinopathy variants, pregnancy (second and third trimester).  

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Welcome, Monique Jackson, MSN, CFNP, WHCNP, CDCES, our new Blog Content Writer!

We are so excited to introduce our newest DiabetesEd Specialist Blog Contributor, Monique Jackson, MSN, CFNP, WHNP, CDCES.

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We’ve Missed you!

Who should attend? Health care professionals interested in taking the CDCES (formerly known as CDE) or BC-ADM exam or those seeking a state of the art review of current diabetes care. We also invite those in looking for hours to renew or apply for the CDCES or BC-ADM exam.

Registration Fee: $599

Registration Fee includes:

• 2.5 Days: of critical information delivered by passionate speakers in an engaging and fun format!
  20+ CEs: earned at the Live Seminar (RDs earn 20 CEs while Nurses & CA Pharmacists earn 24 CEs)
  Bonus Online Courses, Earn 13 CEs: As a course attendee, you automatically receive a bonus online course bundle of 12 online courses valued at over $179. Coach Beverly carefully chose each of these courses based on student feedback on which content best helped them succeed at the CDCES Exam and in their clinical practice. You will be given instruction after you purchase the course on how to enroll in our Online University and get started!
• Physical Syllabus: One of the few courses out there which provides a physical, spiral-bound syllabus, with PowerPoint slides pictured inside to follow along with note-taking. Over 100 pages meant to help you follow along and review after!
• Additional: Healthy meal options for breakfast and lunch. CE certificates and a fun and engaging learning environment.

Team of Experts: Our team of expert faculty has been fine-tuning this course for over 20 years and we know what you need to succeed! In addition to informative lectures, we also use group activities and case studies to highlight the essential knowledge, skills, and strategies needed to succeed in diabetes education today!  

IMPORTANT! Please review these COVID safety regulations before registering for this course>>

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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.

2021 ADA Standards include important changes that you won’t want to miss!

Diabetes nerds across the United States are staying up way past their bedtime to read the latest standards in diabetes! You can now revel in the updated ADA Standards in our CDCES Coach App. Dig into the latest diabetes care recommendations, while waiting for your Standards Booklet in the mail. 

Or you can join Coach Beverly for a virtual webinar that will walk you through these critical updates for your clinical practice and exam success. Join our ADA Standards Live Webinar on February 2nd at 11:30 am PST!

There are some exciting changes in the 2021 Standards.

Based on my review of this playbook for Diabetes Specialists, here are some of the highlights:

• There is a focused blending of science and person-centered care, with an intentional exploration of uncovering barriers and exploring social determinants of health.
• A new powerful acronym was released. CRN – which stands for Cost-Related Medication Nonadherence. ADA is working to raise awareness of cost as a barrier to care and encourage care providers to address cost issues on a regular basis. Especially with the current economic crisis, finances are more of a barrier than ever.
• More clarification about Latent Autoimmune Diabetes in Adults.
• Immunization clarification. Finally, I completely understand the vaccine guidelines, which are more comprehensive and detailed than ever. Thank you, ADA.
• Given the shaming associated with a diabetes diagnosis, a new section on “mindful self-compassion” is included in the Facilitating Behavior Change section.
• The medication management section just keeps getting better. This year’s version is more straightforward while incorporating the newest research findings in an algorithm that is easy to follow.
• OVER basalization made the headlines in the Pharmacologic Approaches to Hyperglycemia section.  Too much basal insulin is an issue that we encounter way too often. These guidelines help to clarify what is too much basal and offer possible solutions.
• Older adult guidelines include updates on glucose goals and prevention of hypoglycemia.

Want more details on the 2021 Standards?

Those are just some of the highlights, but there is so much more to discover. Please join Coach Beverly on February 2, 2021, at 11:30 am for her annual State of the Standards Live Webinar.

See complete Level 2 Standards of Care Webinar Schedule Here

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Join Coach Beverly on February 2, 2021, for her annual
Level 2 – Standards of Care Update!

This course is an essential review for anyone in the field of diabetes. This course summarizes the 2021 updates to the American Diabetes Association’s Standards of Medical Care in Diabetes and provides critical teaching points and content for health care professionals involved in diabetes care and education.

Earn 2.0 CEs and get ready to lead the charge to implement best care practices for the New Year. 

Topics Include:

• A review of changes and updates to the 2021 ADA Standards of Medical Care
• Identification of key elements of the position statement
• Discussion of how diabetes educators can apply this information in their clinical setting

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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.

Watch for FREE or purchase to earn CEs!

Perfect for those planning to take CDCES or seeking an update.

Coach Beverly is updating her Level 2 Standards of Care Intensive Courses.

The Women with Diabetes webinar is completed revised for 2020, with a focus on detecting and managing gestational diabetes and diabetes in pregnancy.

Medication Management includes important 2020 updates. We include a critical review of existing medications and instructions on how to use the ADA or AACE Algorithms as a roadmap in clinical practice.

We hope you can join us! Coach Beverly

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Women & Diabetes | Ready for Viewing

1.5 CEs | $29.00 or No CEs | Free

Women with diabetes are confronted with a variety of issues that require special attention, education, and understanding. This online course reviews those special needs while focusing on Gestational Diabetes and Pre-Existing Diabetes. Included are the most recent diagnostic criteria, management goals, and prevention of complications during pregnancy.

Topics include:

• Three issues that affect women with diabetes
• The unique attributes of pre-existing diabetes in pregnancy and gestational diabetes
• Diagnostic criteria and management goals for gestational diabetes
• Prevention measures to keep mother and baby healthy

View FREE recorded webinar (no CEs).

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Meds Management for Type 2 | Ready for Viewing

1.5 CE | $29.00 or No CEs | Free

Have you heard a novel insulin formulation was FDA approved this week? What is all the news about metformin? How do we know which diabetes medication to start or add next?

Join Coach Beverly RN, MPH, CDCES, BC-ADM for an intensive live course that weeds out fact from fiction while detailing the latest diabetes medications and management algorithms.

During this live stream webinar, we will discuss diabetes medication benefits, considerations and critical information to share with people with diabetes and providers.

Coach Beverly will highlight the key elements of the latest Medication Guidelines by AACE and ADA. We will explore clinical factors to consider when determining the best strategy to improve glucose management in people with type 2 diabetes and discuss new medications.

Topics include:

• Overview of classes and actions of diabetes medications
• Medication updates and new recommendations
• Using the ADA/AACE algorithms to improve diabetes care and outcomes

Watch FREE Recorded Webinar (No CEs)

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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.

Diabetes and Inclusivity – Strategies for Change

Click here to view our June Newsletter

Our community has faced many challenges in 2020. As a result of the pandemic, some health professionals have lost their positions or had jobs furloughed. We have shifted from in-person visits to telehealth. For those working on the front line, there is a real fear of being infected by COVID-19.

In our neighborhoods, we are witnessing many of our community members demanding a repair of social injustices. There is a recognition that worse health outcomes with COVID-19 and diabetes are often the result of longstanding social inequities in marginalized communities.

As diabetes advocates, we owe ourselves the time to reflect on how these inequities came to be and how we can contribute to their repair.

Certainly, as a community dedicated to health, we can stand up and acknowledge, address, and advocate to improve health equity for each person.

In this newsletter, we explore strategies to provide more inclusive diabetes care. From reflecting on the language we choose to how we set up and deliver our health care services. Let’s step back and take a new view from a different lens and see how we can be more welcoming to all people, but especially to those from marginalized communities.

We also celebrate the 2021 Medicare Cap on the monthly cost of insulin and share a warning on some brands of metformin. Lastly, we dive deep into two of our Questions of the Week and provide rationales.

Please consider joining Coach Beverly for her ADA Standard Intensive Live Stream Webinar Series (below). We invite you to join us for free as our guest. We want to make sure that everyone has access to this critical information.

Coach Beverly

Click here to view our June Newsletter

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Upcoming Live Streaming Webinar
Airs June 23, 2020 from 11:30 am to 12:30 pm (PST)

Our Level 2 Standards of Care Intensive Series is designed to engage students in deciphering and exploring the ADA Standards of Care from top to bottom. This straight forward program will provide you with information you can use in your clinical setting and also provides critical content for the diabetes educator exam.

Mastery of this content is critical to ensure certification exam success and to improve clinical outcomes.

Register for FREE live stream webinar (no CEs)

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Email Address Sign Me Up!

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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.

Diabetes Intensive with Dana Armstrong, RD, CDCES | Medical Nutrition Therapy + Meal Planning

Join Dana Armstrong, RD, CDCES, a trailblazer and thought leader, for a lively and intensive review of the latest in Medical Nutrition Therapy with immediate application to your clinical practice.

Dana combines the newest findings, her clinical experiences, plus the ADA Standards of Care into an action-packed presentation that will inform your practice while preparing for the certification exam.

Virtual MNT Course Dates:

Session 1 May 27 | Medical Nutrition Therapy Overview | Ready for Viewing!

Session 2 May 27| Meal Planning – How to Eat by the Numbers | Ready for Viewing!

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$69 | Earn 4.0 CEs

Course Description:  These two 2-hour courses review the latest national nutrition guidelines and provide strategies to translate this information to an individual living with diabetes.

Included is a discussion on different approaches to meal planning and the benefits and limitations of each. Dana will also review metabolic surgery, gastroparesis, and disordered eating.

She reviews nutrition approaches during pregnancy and for those living with chronic co-conditions. Dana also provides insights on how to support the transition to healthier eating using a “tasteful” approach.

Objectives:

1. Prioritize person-centered nutrition issues based on assessment and clinic data.
2. Explore national guidelines for medical nutrition therapy and how to individualize interventions from a person-centered perspective.
3. Describe the impact of micro and macronutrients on health.
4. List different meal planning approaches and the pros and cons of each.
5. Describe how to help people with diabetes to read labels and be thoughtful consumers.
6. State how to customize nutritional approaches in people living with complications of diabetes.

Speaker Bio for Dana Armstrong, RD, CDCES

We are thrilled to welcome our guest speaker, Dana Armstrong, who will be joining our Virtual and Live Courses!

Dana received her degree in nutrition and dietetics from the University of California, Davis, and completed her internship in dietetics at the University of Nebraska Medical Center in Omaha. Dana is the Medical Clinic Director of The Diabetes Center/Salinas Valley Medical Clinic. She provides leadership for the Department of Diabetes Services and ensures coordination and integration of an effective system-wide Diabetes Center of Excellence across the organization for optimum patient care and collaboration of services.  Having a child with diabetes, she combines her professional knowledge with personal experience and understanding.

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These sessions are also included in our Virtual Conference.
Click here to enroll in the entire program.

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!

Email Address Sign Me Up!

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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.

This time of year is always exciting as the new ADA Standards of Care are released.

The 2020 version incorporates these 2019 Living Standard Updates, along with a lot of additional information that impacts our practice.

Want more details on the 2020 Standards?

Those are just some of the highlights,but there is so much more to discover. Please join Coach Beverly on January 21st at 11:30 for her annual State of the Standards Live Webinar.

Save money buy purchasing the full Level 1 Bundle and join us for all of Level 1 as we update this month: see full schedule here.

For more information read our January News Updates – Now Available!

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Email Address Sign Me Up!

Standards of Care Section 9 – Pharmacologic Approaches to Glycemic Treatment

Insulin Therapy for Type 1
This updated version of Meds Management includes more detailed information on insulin therapy for Type 1s. They note that the Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with multiple daily injections or insulin pump therapy reduced A1C and was associated with improved long-term outcomes. The study used short-acting and intermediate-acting human insulins. Since DCCT, rapid-acting and long-acting insulin analogs have been developed. These analogs are associated with less hypoglycemia, less weight gain, and lower A1C than human insulins in people with type 1 diabetes.

Type 2 Management Strategies – Pharmacologic Therapy of Type 2 Diabetes – 2019

Pharmacologic Approaches to Glycemic Treatment 2019.  This hyperglycemia road map details strategies to achieve glucose control for both Type 1 and Type 2 Diabetes. Section 9 of Standards of Care, January 2019.

Step 1 –

According to the ADA 2019 Standards, section 9, Metformin therapy should be started along with lifestyle management at diagnosis of type 2 Diabetes (unless contraindicated). Metformin is effective, safe, inexpensive and may reduce risk of CV events and death. If contraindicated, see figure 9.1 for alternatives.

Step 2

If A1c target is not achieved after 3 months, consider metformin and any one of the six preferred treatment options based on drug specific effects and patient factors. These factors include cardiovascular disease (ASCVD), congestive heart failure (CHF) or Chronic Kidney Disease (CKD). Plus, preventing hypoglycemia, weight gain and making sure medications are affordable.

If the patient has ASCVD, CHF or CKD, consider adding a second agent with evidence of cardiovascular risk reduction (based on drug specific effects and patient factors).

Medications indicated to improve CVD, CHF and CKD outcomes include:

• SGLT-2 Inhibitors – empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga)
• GLP-1 Receptor Agonist – liraglutide (Victoza), semaglutide (Ozempic)

Step 3

If A1c target is still not achieved after 3 months, combine metformin plus two other agents for a three-drug combination. Drug choice should be based on avoidance of side effects such as hypoglycemia, weight gain, cost, and individual preference.

Step 4  

If A1c target is still not achieved after 3 months, add combination injectable therapy to the three-drug combination.

For all steps, consider including medications with evidence of CV risk reduction, based on drug specific effects and patient factors.

Medication Therapy Based on A1c

• Upon initial diagnosis of type 2, most can consider monotherapy
• If A1c is greater than or equal to 1.5% above target, consider dual therapy
• If A1c is greater or equal to 10%, or if BG 300 or more, or pt is markedly symptomatic (polyuria/polydipsia), consider insulin and injectable therapy.

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Want to learn more about this topic?

• Meds Management Update Ready for On Demand Viewing!
• Join our Standards of Care Webinar – Jan 21, 2020
• Download our FREE Medication PocketCards (Or order any quantity with FREE shipping!)
• Download CDE Coach App – FREE

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