Rationale of the Week | RD feels overwhelmed by all this sensor data. Best action?
For last week’s practice question, we quizzed participants on actions to help address stress during data monitoring. 87% of respondents chose the best answer. We want to clarify and share this important information, so you can pass it on to people living with diabetes and your colleagues, plus prepare for exam success!
Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer it below: Answer Question
Question: RD is 82 years old, on basal insulin with bolus insulin at breakfast and dinner if need. RD just started using a sensor to track their daily blood sugars. After using the sensor for a few weeks, they share that they are feeling anxious and don’t know what to do with all this information. They even took extra bolus insulin yesterday to try and get blood sugars down. RD’s time in range is over 70%.
Which of the following is the most appropriate intervention?
Answer Choices:
- Refer RD to a mental health provider who specializes in diabetes.
- Reassure RD that their time is range is on target and they are not at risk of complications.
- Suggest that RD stops using a sensor and resumes using a glucose meter.
- Explore feelings of anxiety associated with the data and glucose levels.
Getting to the Best Answer
Answer 1 is incorrect. 1.83% chose this answer. “Refer RD to a mental health provider who specializes in diabetes.” RD is having an understandable response to the abundance of info provided by their new CGM and is experiencing diabetes distress. Based on the information provided, their anxiety doesn’t warrant a referral to a mental health specialist.
Answer 2 is incorrect. 6.26% of you chose this answer. “Reassure RD that their time is range is on target and they are not at risk of complications.” Although it is important to reassure RD that they have a time in range greater than 70%, it is important to acknowledge their feelings and explore strategies to address to diabetes distress.
Answer 3 is incorrect. About 4.43% of respondents chose this. “Suggest that RD stops using a sensor and resumes using a glucose meter.” Since RD has only been using the sensor for a few weeks, we wouldn’t want to suggest giving it up just yet. In addition, we want to learn more about what RD is experiencing and the issues that are increasing their anxiety and help with problem solving.
Finally, Answer 4 is correct. 87.48% chose this answer. “Explore feelings of anxiety associated with the data and glucose levels.” YES. GREAT JOB! This is the best person-centered answer that encourages RD to share their feelings so we can help with problem solving and evaluate the best approach for this individual.
We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!
Want to learn more about this question?
Unlock insights for managing diabetes distress with the experts!
Join us live on June 17 & 24, 2024 for our
ReVive 5 Diabetes Training Program:
The 2024 ADA Standards of Care now recommends annual screening for diabetes distress. If you are wondering how to screen for distress and tailor education based on the results, we encourage you to join this unique training program.
This two-session training provides the essential steps to address diabetes distress combined with an innovative approach to helping people make sense of their glucose data.
The first session is team-taught by experts in the field of diabetes distress and effective communication approaches. Dr. Larry Fisher kicks off the program by describing the difference between depression and distress and interpreting Diabetes Distress screening results. Dr. Susan Guzman uses a case study approach and step-by-step communication strategies to address responses from the Diabetes Distress screening tool. This session includes an abundance of evidence-based approaches that you can apply in your clinical setting.
Coach Beverly leads the second session. During this three-hour program, Beverly describes insulin dosing strategies, meter and sensor data interpretation, and common issues encountered by people using diabetes technology. Case studies include tools to help individuals discover what changes are needed to get glucose to target, coupled with the communication skills discussed in the first session. In conclusion, the team of instructors review a case study that pulls together all the ReVive 5 elements.
“ReVive 5” breathes new life into our relationship with diabetes, bringing a fresh perspective to both the person with diabetes and the provider.
Can’t join live? That’s okay. Your registration guarantees you access to the recorded version of the series, along with podcasts and resources for one full year.
Accredited Training Program:
- 15+ CEs – Includes the 7-hour ReVive 5 Training Program, Certificate, and 5 FREE bonus courses to supplement content.
- A comprehensive set of assessment tools, educational materials, log sheets, and resources.
Join us to gain the confidence and learn the skills needed to support people with diabetes to move forward in their self-management and discover the expert within.
Team of Experts:
ReVive 5 is taught by a team of 3 Interdisciplinary Experts:
- Lawrence Fisher, Ph.D., ABPP, Professor Emeritus, UCSF
- Susan Guzman, PhD
- Beverly Thomassian, RN, MPH, CDCES, BC-ADM
Speakers Interviews – Learn more about the ReVive 5 Team
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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.
2 Scholarships for DiabetesEd Conference in San Diego | Apply Today
2 Scholarships will be awarded for October 11-13th
– DiabetesEd Training Conference
– Making a Difference & Flower Scholarship
Two Scholarships for those Preparing to Take CDCES
We will award two diabetes educators who provide care and education to under-served communities that lack access to Diabetes Specialists and health care resources. Applicants will be taking their CDCES exam within a year. Each scholarship covers course registration for our Live in San Diego: DiabetesEd Training Conference Registration and 3 nights hotel stay.
We are offering two scholarships, both for the entire registration of the Live Training and 3 hotel nights:
- Flower Scholarship Recipient Seminar – Registration + Hotel (valued at $1500)
- Making a Difference Scholarship Recipient – Registration + Hotel (valued at $1500)
*These scholarships cover the course registration fee and 3 nights hotel stay. It does not cover any other expenses incurred by the winners (including travel expenses, food, transportation, etc.). Please consider travel and other costs prior to applying for the scholarship. Each applicant must currently reside within the United States. If you are interested, please click on the button below to complete the scholarship application.
Apply for Scholarships Today – Attend Live Seminar for FREE ($1,500 value)
Eligibility Requirements for Both Scholarships
The goal of these scholarships is three-fold:
- To support U.S. healthcare professionals who are going above and beyond to improve diabetes care in their community; and
- To support applicants’ efforts to become Certified Diabetes Care and Education Specialists (CDCES) and
- To provide financial assistance with the DiabetesEd Course registration fee.
Flower Scholarship: This scholarship is awarded to Diabetes Nurse Educators and is available because of the generous contribution of an anonymous colleague, friend, co-instructor, and mentor. Our donor worked as a Nurse Practitioner and Diabetes Specialist, serving her community, plus mentoring healthcare professionals about diabetes for over 30 years. With the Flower Diabetes Educator Scholarship, she wants to keep investing in the health of our future by supporting future diabetes educators.
- Applicants must be diabetes nurse educators who come from an under-served community and are providing care and education to communities that lack access to Diabetes Specialists and healthcare resources
- The nurse applicants will be taking their CDCES exam within a year.
- Preference is given to those facing financial hardships that are interfering with their ability to pursue this dream of achieving their CDCES.
- All applicants must be a U.S. residents.
“Making a Difference” Scholarship: Diabetes Education Services is committed to improving equity and access to diabetes training and education for a diverse group of healthcare professionals. We don’t want financial barriers to stop anyone from attending this conference. In appreciation of those who are role models and advocates for practicing the best diabetes care in their communities
- Available to all diabetes educators who are eligible to apply for the CDCES exam who come from an under-served community and are providing care and education to communities that lack access to Diabetes Specialists and healthcare resources
- The applicants will be taking their CDCES exam within a year.
- Preference is given to those facing financial hardships that are interfering with their ability to pursue this dream of achieving their CDCES.
- All applicants must be a U.S. residents.
Special Thanks to the “Making a Difference” and “Flower” Scholarships Donors
These scholarships are available due to the generous contribution of diabetes colleagues, friends, co-instructor, and mentors.
“Making a Difference” Scholarship Donor – Lonnie Vaughn, RNC, BSN, CDCES
Our esteemed donor for the Making a Difference Scholarship, Lonnie, possesses a profound understanding of the challenges that diabetes care and education specialists face in the healthcare setting. As a leader in the field of diabetes management, Lonnie has been championing best care practices at Doctors Medical Center in Modesto for over 30 years. Her role as a certified diabetes educator, trainer, mentor, and advocate is recognized and celebrated by patients and professionals, underscoring the unique value she brings to the cause.
Lonnie’s Vision: Lonnie wants to lift the next generation of diabetes care and education specialists to advocate for under-resourced individuals and fight for evidence-based, compassionate care for ALL people living with diabetes.
A note from Coach Beverly: I met Lonnie over 25 years ago at a conference where I was presenting on diabetes care. Her curiosity and passion for the topic were reflected in her attention, thoughtful questions, and dedication to her community. I invited her to join our live conference team to teach, coordinate, and share her passion and energy for the best diabetes care. She not only rose to the challenge, she surpassed all expectations and became an integral part of our Diabetes Education Services family. Lonnie’s impact on the community is immeasurable. She has mentored and trained over a dozen CDCESs (and hundreds of interns) at Doctors Medical Center, investing in the future of this honorable and essential profession. I am deeply grateful for Lonnie’s years of generous contributions and dedication to ushering in the next generation of diabetes care and education specialists. Thank you, Ms. Lonnie Vaughn, for being such a bright and present light in the world of diabetes care and education.
“Flower” Scholarship Donor Gratitude
Our donor for the Flower Scholarship worked as a Nurse Practitioner and Diabetes Specialist, serving her community, plus mentoring healthcare professionals about diabetes for over 30 years.
With the Flower Diabetes Educator Scholarship, she wants to keep investing in the health of our future by supporting future diabetes educators.
Her vision is to increase diversity in the diabetes education workforce by supporting diabetes nurse educators who come from underserved communities. By increasing the number of diabetes educators who represent the population demographics of those living with diabetes, we can make more meaningful connections on an individual and community level while promoting the best care.
The Flower Scholarship is a tribute to our donor’s last name, which translates to flower. The flower is a perfect symbol for this scholarship that aims to support the growth of novice diabetes educators into Certified Diabetes Care and Education Specialists.
Flowers are a symbol of hope and can be found growing in the most unexpected places, including harsh cities and forgotten spaces. With just a little sunlight and water, they have the ability to thrive in even the most difficult situations and shine their fierce beauty. Given a chance, as these flowers are tended to and nurtured, they grow stronger and brighter, spreading their beauty to new places to give people hope. These resilient flowering seeds perpetuate the opportunity for a future generation of diabetes specialists.
Past Scholarship Recipients
Not Ready to Apply for a Scholarship? You can still join our Conference! 
Join us Live in San Diego and Celebrate Success!
More Info Here >>
The use of DES products does not guarantee the successful passage of the diabetes certification exams. CBDCE & ADCES does not endorse any preparatory or review materials for the certification exams, except for those published by CBDCE & ADCES.
**To satisfy the requirement for renewal of certification by continuing education for the Certification Board for Diabetes Care & Education (CBDCE), continuing education activities must be applicable to diabetes and approved by a provider on the CBDCE List of Recognized Providers (www.ncbde.org). CBDCE does not approve continuing education. Diabetes Education Services is accredited/approved by the Commission of Dietetic Registration which is on the list of CBDCE Recognized Providers.
Question of the Week | Assessment of Hypoglycemia
LM has had type 2 diabetes for over 30 years and takes 1000 mg metformin BID, 30 units of glargine at bedtime, 25 mg empagliflozin, as well as daily lisinopril and lovastatin. A1c was 7.2%, LDL: 56, and eGFR was 38 mL/min/1.73m2 last visit. CGM ambulatory glucose profile report indicates a time in range of 71%, time below range of 4%, and time above range of 25%. LM reports living on a fixed income, relying on social security, and an increase in recent financial stress. They are concerned they may not have enough money to purchase foods by the end of the month.
Select the best answer considering LM’s potential risk factors for hypoglycemia?
- LM has chronic kidney disease, and we note he is taking an ACE and SGLT-2.
- Basal insulin therapy alone.
- Income status.
- All the above.
Unlock insights for managing diabetes distress with the experts!
Join us live on June 17 & 24, 2024 for our
ReVive 5 Diabetes Training Program:
The 2024 ADA Standards of Care now recommends annual screening for diabetes distress. If you are wondering how to screen for distress and tailor education based on the results, we encourage you to join this unique training program.
This two-session training provides the essential steps to address diabetes distress combined with an innovative approach to helping people make sense of their glucose data.
The first session is team-taught by experts in the field of diabetes distress and effective communication approaches. Dr. Larry Fisher kicks off the program by describing the difference between depression and distress and interpreting Diabetes Distress screening results. Dr. Susan Guzman uses a case study approach and step-by-step communication strategies to address responses from the Diabetes Distress screening tool. This session includes an abundance of evidence-based approaches that you can apply in your clinical setting.
Coach Beverly leads the second session. During this three-hour program, Beverly describes insulin dosing strategies, meter and sensor data interpretation, and common issues encountered by people using diabetes technology. Case studies include tools to help individuals discover what changes are needed to get glucose to target, coupled with the communication skills discussed in the first session. In conclusion, the team of instructors review a case study that pulls together all the ReVive 5 elements.
“ReVive 5” breathes new life into our relationship with diabetes, bringing a fresh perspective to both the person with diabetes and the provider.
Can’t join live? That’s okay. Your registration guarantees you access to the recorded version of the series, along with podcasts and resources for one full year.
Accredited Training Program:
- 15+ CEs – Includes the 7-hour ReVive 5 Training Program, Certificate, and 5 FREE bonus courses to supplement content.
- A comprehensive set of assessment tools, educational materials, log sheets, and resources.
Team of Experts:
ReVive 5 is taught by a team of 3 Interdisciplinary Experts:
- Lawrence Fisher, Ph.D., ABPP, Professor Emeritus, UCSF
- Susan Guzman, PhD
- Beverly Thomassian, RN, MPH, CDCES, BC-ADM
Speakers Interviews – Learn more about the ReVive 5 Team
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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.
Upcoming Webinars | Older Adults & Diabetes, FREE Prep for CDCES Exam Webinar
Be a part of our diabetes community while learning about the latest in diabetes care.
Plus, Coach Beverly provides an interactive question and answer session at the end of each live webinar.
Level 2 | Older Adults & Diabetes
Airs live on May 2, 2024, at 11:30 am PT
We are living longer & more people are getting diabetes. The American Diabetes Association has updated the Older Adults Standards, with special attention to considering the reduction of medication & insulin therapy intensity. The older population has unique issues & special needs that require consideration as we provide diabetes self-management education. This online course highlights key areas of assessment, intervention, and advocacy for older clients living with diabetes.
Topics:
- Self-management considerations for older individuals.
- Strategies to prevent complications & maintain optimal quality of life.
- The role of the Diabetes Care & Education Specialist as an advocate.
Intended Audience: An important course for healthcare professionals seeking to gain an understanding of the special issues and evidence-based standards for older adults or studying for certification exams.
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, BC-ADM is a working diabetes specialist and a nationally recognized diabetes expert.
Airs live on May 28, 2024, at 11:30 am PT
Join us to get ready to succeed a the CDCES Exam. This course will transform your test anxiety into calm self-confidence and test taking readiness.
Topics covered include:
- Changes in requirements for 2024
- Exam eligibility and test format updates for 2024
- Strategies to succeed
- Review of study tips and test taking tactics.
We will review sample test questions, and the reasoning behind choosing the right answers.
After registering, you will receive a confirmation email containing information about joining the webinar.
Intended Audience: This FREE webinar is designed for individual or groups of diabetes educators, including RNs, RDs, Pharmacists, Nurse Practitioners, Clinical Nurse Specialists, Physician Assistants and other health care providers interested in achieving excellence in diabetes care and becoming Certified Diabetes Care and Education Specialists®.
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, BC-ADM is a working diabetes specialist and a nationally recognized diabetes expert.
More info on our Prep for CDCES Page >>
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.
Rationale of the Week | Euglycemic DKA – What is Best Intervention?
For last week’s practice question, we quizzed participants on what is the best intervention for euglycemic DKA. 55% of respondents chose the best answer. We want to clarify and share this important information, so you can pass it on to people living with diabetes and your colleagues, plus prepare for exam success!
Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer it below: Answer Question
Question: KT is a 54-year-old, who presents to the emergency room with nausea and vomiting. KT weighs 58kg, has been feeling very tired and has diabetes and hypertension.
Meds include: losartan, metformin, and empagliflozin.
Labs: Na 140, K 4.0, Chloride 99, Bicarb 15, Glucose 189, Anion Gap 26, pH 7.1 and positive urine ketones
After infusing 2 liters of normal saline, what would be the best intervention for KT?
Answer Choices:
- Give another 2 liters of NS with 20 meq/L of KCL
- Continue current therapy.
- Start insulin infusion with a dextrose-based solution.
- Give an amp of sodium bicarbonate.
Getting to the Best Answer
Answer 1 is incorrect. 13% chose this answer. “Give another 2 liters of NS with 20 meq/L of KCL.” Since KT has already received 2 liters of normal saline for fluid resuscitation, the next step is to provide a solution with glucose, and possibly potassium depending on KT’s electrolyte levels. Even with euglycemic DKA, KT has depleted their glycogen stores and the cells are in desperate need of glucose for two reasons; to stop burning fat for fuel and to replete glycogen stores.
Answer 2 is incorrect. 13.42% of you chose this answer. “Continue current therapy.” While this answer is tempting, it does not provide a clear plan of action for KT. The only therapy this is currently being provided is an IV of normal saline. Even though KT’s blood glucose is less than 200mg/dL, in order to stop ketosis, we need to start IV insulin along with 5-10% dextrose to preserve blood glucose and replace glycogen stores.
Answer 3 is correct. About 55.20% of respondents chose this. “Start insulin infusion with a dextrose-based solution.” YES! This is the best answer. The next step is to provide an IV solution with 5-10% glucose, and possibly potassium depending on KT’s electrolyte levels. Even with euglycemic DKA, KT has depleted their glycogen stores and the cells are in desperate need of glucose for two reasons; to stop burning fat for fuel and to replete glycogen stores. In addition, in order to stop ketosis, we need to start IV insulin at a few units an hour!
Finally, Answer 4 is incorrect. 18.29% chose this answer. “Give an amp of sodium bicarbonate.” Since KT is in acidosis, this is a tempting answer. However, the acidosis will usually be corrected with administration of IV fluids and insulin. If not, and the pH is still below 7.0, bicarb administration may be considered.
We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!
Want to learn more about this question?
Keynote Presentation on DKA & Euglycemic DKA at
16th Annual Conference
Expanding the Universe of Diabetes Care hosted by CA ADCES
May 3-4th at Universal City, CA
Beverly will be speaking on DKA and EDKA on Saturday – May 4, 2024 at 11:30 am
Below is Saturday’s schedule of topics and flyer for more information. We hope to see you there!
>>Register for the Conference
>>Flyer for Event
- Discover the secrets to a successful and sustainable Diabetes Education Program – Tony Song, MBA
- Exercise Success Part 3 & 4 – Jacqueline Thompson, MS, RD, CDCES, MES
- Dynamic Duo: Registered Dietitian & Pharmacist Co-Appointments in Diabetes Care – Christal Pham, PharmD, APh, CDCES, Melanie Barbee, MS, RDN, CDCES, DipACLM
- Advocacy Update: Breakdown the Barriers to Evidence-Based Diabetes Care – Teresa Martin MS RDN CDCES LD
- New criteria and treatment guidelines for DKA, Euglycemic DKA, and HHS – Beverly Thomassian, RN, MPH, CDCES, BC-ADM
- Exercise Success Part 4 – Jacqueline Thompson, MS, RD, CDCES, MES
- Diabetes Technology: Understanding the Differences in the Latest CGMs and Pumps – David Ahn, MD
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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.
Liver Disease in Diabetes: A Call to Action
Like millions of adults worldwide, our close family friend lived with undetected steatosis.
Up to 70% of people with diabetes have steatosis, which increases the risk for progressive liver disease. Unfortunately, much of the time, it is not discovered early enough.
Over 15 years ago, our friends’ steatosis progressed and quickly led to hepatocellular carcinoma. A cursory evaluation of his health history quickly highlights his risk of steatosis. He lived with diabetes for over ten years and had insulin resistance, as evidenced by his dark neck tan (acanthosis nigricans), hypertension, and a BMI well over 30. Even without any access to his lab data or complete medical history, we can easily assume that he was at risk for liver disease. Yet, he did not receive any diagnostic testing or nutrition counseling to address the silent inflammation that was wreaking havoc on his liver.
At 67, his steatohepatitis became evident as his confusion increased. His skin had a faint yellow tinge, and he “just wasn’t himself.” Months later, we were saying an early goodbye to a big-hearted, fearless man who loved his family and community and made a lasting impression on anyone he met.
We are not alone in this tragic story. The statistics are startling. About 70% of people with diabetes have steatosis, and of those, 50% are living with the more serious steatohepatitis, which can lead to severe liver fibrosis and scarring. Over time, these individuals are at risk of developing cirrhosis, liver cancer, and cardiovascular disease. Yet, we are only now catching up with this under-detected and often overlooked condition and its impact on individual and public health outcomes.
We can all become more actively involved in screening for liver disease and advocating for prompt action when it is detected. Together, we can save lives and share a message of hope!
Diabetes care and education specialists can Take Action!
According to the American Diabetes Association Standards of Care, here is a list of actions we can take to identify and prevent progression of liver disease.
- Lab Check: Encourage yearly evaluation of liver health and risk factors. Review annual ALT and AST levels and alert providers for values greater than 30 and evaluate Fib-4 Score.
- Calculate Fib-4 yearly to determine the risk of fibrosis and liver disease (you need the person’s age, ALT, AST, and platelet count). Encourage further imaging for those with elevated FIB-4.
- Take Action: For people with diabetes at higher risk of steatosis based on elevated insulin resistance (BMI 30+, cardiometabolic factors, age 50+), in addition to screening for liver disease, encourage immediate lifestyle changes that decrease steatosis risk and improve health – even before an official diagnosis!
- Lifestyle changes:
- Refer to an RD/RDN for MNT therapy. In the meantime, encourage movement toward the Mediterranean Diet and a 5-10% weight reduction.
- Strength training at least twice weekly and increased activity (150 minutes a week) to improve insulin sensitivity.
- Even small changes in waist circumference indicate decreased visceral adiposity. These critical lifestyle changes decrease hepatic lipotoxicity and promote healing.
More than lifestyle change is often needed. Medications to Treat and Address Steatosis
The following medication is the first FDA-approved treatment for NASH and fibrosis.
- Rezdiffra (resmetirom) – The U.S. Food and Drug Administration approved Rezdiffra (resmetirom) in March 2024, for the treatment of adults with noncirrhotic, non-alcoholic steatohepatitis (NASH) with moderate to advanced liver scarring (fibrosis), to be used along with diet and exercise. Rezdiffra is a partial activator of a thyroid hormone receptor; activating this receptor by Rezdiffra in the liver reduces liver fat accumulation. “Previously, patients with NASH who also have notable liver scarring did not have a medication that could directly address their liver damage,” said Nikolay Nikolov, M.D., acting director of the Office of Immunology and Inflammation in the FDA’s Center for Drug Evaluation and Research. “Today’s approval of Rezdiffra will, for the first time, provide a treatment option for these patients, in addition to diet and exercise.”
The following medications are not specifically FDA-approved to treat liver disease but are recommended in the setting of diabetes and metabolic-associated steatosis/steatohepatitis.
Since steatosis and type 2 diabetes share underlying alterations in pathophysiology, including insulin resistance, it is not surprising that agents used to treat type 2 diabetes have demonstrated benefit in treating metabolic-associated steatosis and steatohepatitis.
- Pioglitazone (Actos) reduces blood glucose, and several studies demonstrate it is an effective treatment for steatosis and steatohepatitis. It also reduces the progression of fibrosis and cardiovascular risk. Since pioglitazone can cause fluid retention and weight gain, avoid using it in those with heart failure.
- GLP-1 RAs—this class of medication not only lowers blood glucose but can also lead to significant weight loss and a reduction in visceral adiposity and hepatocellular lipid levels. Several studies demonstrate that it is an effective treatment for steatosis and steatohepatitis. It also reduces the progression of fibrosis and cardiovascular risk.
- SGLT-2 Inhibitors – Recent research published in JAMA reveals that in a retrospective study, SGLT-2 Inhibitors were associated with a higher likelihood of liver disease regression among those with metabolic dysfunction-associated steatotic liver disease and type 2 diabetes. According to Dr. Won Kim, the study’s lead researcher, “SGLT2 inhibitors were distinguished by their association with fatty liver improvement, surpassing other [oral antidiabetic drugs] known for their potential benefits in steatosis.” More research is needed, but since this class of medication lowers blood glucose plus decreases cardiovascular risk, it is already widely used for people with diabetes and insulin resistance.
- Statin Therapy – Lipid-lowering and antihypertensive meds need to be prescribed in people with steatosis as indicated. Statins are safe in individuals with steatohepatitis but avoid their use in those with decompensated cirrhosis.
A Final Note
Even though we lost our close friend due to undetected liver disease, I am hoping that by telling our story, all of us can become more actively involved in screening for liver disease and advocating for prompt action when it is detected. Together we can save lives and share a message of hope.
Coach Beverly
Resources: In addition to the ADA Standards, I utilized this article below, published in the Winter 2024 Edition of Diabetes Spectrum: Nonalcoholic Fatty Liver Disease: A Call to Action.
ReViVE 5 Diabetes Training Program:
Unlocking Hidden Barriers to Diabetes Management
June 17th & 24th, 2024
“ReVive 5” breathes new life into our relationship with diabetes, bringing a fresh perspective to both the person with diabetes and the provider.
The ReVive 5 program is built on sound research from the Embark Trial and will revolutionize your approach to diabetes self-management education.
We have reassembled the Embark training team and created a resource binder of fantastic tools that we are excited to share with you in our ReVive 5 Diabetes Training Program. You are invited to join us to learn a step-wise, proven approach to addressing hidden barriers to diabetes self-management and glucose management.
You don’t need to be mental health expert or diabetes technology wiz to join this training or to integrate these new strategies into your daily practice.
ReVive 5 uses an integrated, evidence-based approach that provides health care professionals with a realistic 5-step approach to addressing the whole person, starting with emotional distress and incorporating a unique, but integrated approach to problem-solving glucose management difficulties.
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 CDCES or BC-ADM Certification Exams.
Can’t join live? That’s okay. Your registration guarantees you access to the recorded version of the series, along with podcasts and resources for one full year.
Accredited Training Program:
- 15+ CEs – Includes the 7-hour ReVive 5 Training Program, Certificate, and 5 FREE bonus courses to supplement content.
- A comprehensive set of assessment tools, educational materials, log sheets, and resources.
Join us to gain the confidence and learn the skills needed to support people with diabetes to move forward in their self-management and discover the expert within.
Team of Experts:
ReVive 5 is taught by a team of 3 Interdisciplinary Experts:
- Lawrence Fisher, Ph.D., ABPP, Professor Emeritus, UCSF
- Susan Guzman, PhD
- Beverly Thomassian, RN, MPH, CDCES, BC-ADM
Speakers Interviews – Learn more about the ReVive 5 Team
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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.
Earth Day Celebration
Happy Earth Day Everyone!
In celebration of Earth Day, we are excited to highlight the role of native plants in supporting wildlife and resilient environments.
By choosing plants that originated from your geographic area, we can help support regional ecosystem and offer pollinators, birds, butterflies and other healthy critters needed food, pollen and building materials for their survival. It’s good for humans too. We thrive in healthy ecosystems and experience improved quality of life.
Common Native Plants in the U.S.
When Coach Beverly first moved to her house 24 years ago, she just planted flowers and grasses that she found visually appealing and could tolerate the heat of our region. Her house and office are situated on an acre of land, so there was lots of space to plant a wide variety of foliage and trees to provide shade and beauty. But, she wasn’t yet tuned-in to the native plant and animal habitats of our new home.
To be honest, 25 years ago, I didn’t give much thought to supporting native plants or animals.
Over time, Coach Beverly started learning about the impact habitat loss for creatures and pollinators. She researched which plants support the local area and found a nearby native nursery. Now, she and husband are working hard to make their land a nourishing and welcoming space for pollinators, birds, amphibians, lizards and more. With the help of a few great websites and a visit to the local native nursery, they incorporate plants that support their community of animals and are drought tolerant.
Water Source
In addition to plants, providing a water source can be a game changer for thirsty pollinators, birds and others animals too. Simply placing a bowl of water, bird bath or even creating a small pond can make a big difference in supporting a variety of wild life. Last year, Coach Beverly dug a frog pond and within a few short weeks, frogs, toads and birds arrived to enjoy a drink, take a swim or a bath. A year later, our pond is teaming with tadpoles, mosquito fish, water beetles, dragonflies and lots of microscopic creatures. This lively pond brings family and visitors an abundance of joy and wonderment. Plus, they notice how connecting with nature improves mental health and helps with stress management and well being.
Nature is Therapeutic
For people with diabetes or other chronic health issues, caring for plants and living beings can be very therapeutic and gratifying, and it doesn’t have to be complicated. Just take one step at a time. Start with potted herbs, plants, vegetables or flowers. Or through some wildflower seeds on a patch of untended earth and see what happens. For the more adventurous, planting a native garden is great excuse to get outside, bend, shovel and keep active. Plus, there is nothing like a fresh tomato warm from the vine that you have nurtured to frutition.
Not Sure What Plants are Native to your Region?
To get started, check out the article, Audubon – 20 Common Types of Native Plants, which includes a helpful list of 20 different native plants that support wildlife in the United States. You can cross-reference plants with your zip code finder above to see if these would be a good addition to your neighborhood. For example, in Chico, California, the California Christmas-Berry is a great food source for local birds and is drought tolerant.
In general, consider adding these native plants to your wish list:
Trees: Oaks, Pines, Dogwoods and Willows.
To bring color to your yard, porch or planters try planting Sunflowers or Coneflowers.
Treats for you and our bird friends include Blueberries, Elderberries, or Service berries.
Websites to Discover Native Flora for Your Region
The National Wildlife Federation (NWF) also provides a wonderful website, Native Plant Finder – NWF, to determine by zip code, native plants for your area. You can create and save your own personalized plant list too.
The Plant Native website, provides a listing of native nurseries throughout the U.S.
I also encourage you to visit www.Earthday.org and Project Regeneration for other great ideas to improve the health of our planet.
Each of us can make a difference
Many of us feel discouraged about what is happening to our planet, but there is a rising awareness of our impact and also a rising belief in our ability to protect this beautiful earth. Each action matters. Your action matters. And you can just start by planting one bush, flower, tree, plant or another acting on another idea that is meaningful to you. Thank you in advance for your action.
For all the earth has given me and I want to give back to this beautiful blue planet. Each intention and action matters.
Each action, no matter how small, matters. We can do this!
With wishes for improved planetary health,
DiabetesEd Services Team
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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.
Rationale of the Week | ADA Standards for Gestational Diabetes
For last week’s practice question, we quizzed participants on ADA Standards for gestational diabetes. [%] of respondents chose the best answer. We want to clarify and share this important information, so you can pass it on to people living with diabetes and your colleagues, plus prepare for exam success!
Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer it below: Answer Question
Question: LS has type 1 diabetes and is here for the first visit after confirmation of pregnancy. LS has been using non-adjunctive continuous glucose monitoring (CGM) along with insulin pump therapy to manage diabetes. Previous visits have focused on preconception counseling and last A1c was 6.4%.
According to the 2024 ADA Standards of Care, what do we recommend regarding glucose monitoring during pregnancy?
Answer Choices:
- Recommend continued CGM use with the addition of post-prandial glucose monitoring.
- LS can continue use of non-adjunctive CGM device approved for use during pregnancy.
- Recommend continued CGM with the addition of scheduled blood glucose monitoring.
- Recommend LS move to blood glucose monitoring and check fasting, pre-prandial and post-prandial glucose values.
Getting to the Best Answer
Answer 1 is incorrect. [%] chose this answer. “Recommend continued CGM use with the addition of post-prandial glucose monitoring.” Choice A is not the best answer. The 2024 ADA Standards of Care do recommend CGM use for individuals with type 1 diabetes during pregnancy but simply monitoring post-prandial glucose is insufficient. Keep reading below.
Answer 2 is incorrect. [%] of you chose this answer. “LS can continue use of non-adjunctive CGM device approved for use during pregnancy.” Choice B is not correct. We can continue use of CGM devices during pregnancy, but blood glucose monitoring is recommended in addition to CGM.
Answer 3 is correct. About [%] of respondents chose this. “Recommend continued CGM with the addition of scheduled blood glucose monitoring.” Answer C is correct. The 2024 Standards of Care recommends CGM for individuals with type 1 diabetes during pregnancy but also recommends that it not replace pre-prandial and post-prandial blood glucose monitoring. Fasting, pre-prandial and post-prandial blood glucose monitoring is recommended for individuals with diabetes in pregnancy.
Finally, Answer 4 is incorrect. [%] chose this answer. “Recommend LS move to blood glucose monitoring and check fasting, pre-prandial and post-prandial glucose values.” Response D is not the best answer. We will recommend LS add blood glucose monitoring, but LS does not need to transition off CGM therapy.
We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!
Want to learn more about this question?
Join us live on June 11th at 11:30 am PST for our
Pregnancy & Diabetes
Level 2 Standards of Care Intensive
Pregnancy with diabetes is confronted with a variety of issues that require special attention, education, & understanding. This course reviews those special needs while focusing on Gestational Diabetes & Pre-Existing Diabetes. Included are the most recent diagnostic criteria, management goals, & prevention of complications during pregnancy. This is a helpful review for Certification Exams & those who want more information on people who are pregnant & live with diabetes.
Objectives:
- List three issues that affect pregnancy with diabetes.
- Describe the unique attributes of pre-existing diabetes in pregnancy & gestational diabetes.
- State the diagnostic criteria & management goals for gestational diabetes.
- Potential short-term & long-term complications of fetal exposure to hypoglycemia.
- Prevention measures to keep mother & baby healthy.
Learning Outcome:
Participants will gain knowledge of special considerations, individualized goals, and standards for people experiencing diabetes during pregnancy to improve outcomes.
Target Audience:
This course is a knowledge-based activity designed for individuals or groups of diabetes professionals, including RNs, RDs/RDNs, Pharmacists, Nurse Practitioners, Clinical Nurse Specialists, Physician Assistants, and other healthcare providers interested in staying up to date on current practices of care for people with prediabetes, diabetes, and other related conditions. The practice areas for RDs/RDNs for CDR reporting are healthcare, preventative care, wellness, and, lifestyle along with, education and research.
CDR Performance Indicators:
- 9.6.7
- 9.6.8
- 10.3.1
Instructor: Beverly Thomassian RN, MPH, CDCES, BC-ADM is a working diabetes specialist and a nationally recognized diabetes expert.
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
- Rationale of the Week | What do the NEW 2025 ADA Standards Say?
- Renewing your CDCES – Important Updates to Keep in Mind
- Question of the Week | Best Meds to Treat MASH – 2025 Standards
- Rationale of the Week | Low carb diets and SGLT-2’s a good mix?
- Entering the Field of Diabetes Education – Building a Bridge Program
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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