Question of the Week | Low carb diets and SGLT-2’s a good mix?
ST is a 56-year-old presenting for MNT and diabetes education. Their last A1c was 7.4%, and they are currently taking 1000 mg of Metformin and 10 mg of empagliflozin daily for glucose management. They recently read that a very low-carbohydrate eating pattern can help individuals with type 2 diabetes reduce A1C and the need for additional medications and are motivated to implement diet changes.
What would be your primary considerations and guidance in response to ST?
- ST is motivated for change, encourage their desire to implement a very low-carbohydrate diet as it is safe for all individuals with diabetes.
- ST should avoid a very low-carbohydrate diet.
- A very low-carbohydrate diet may be appropriate if ST transitions off the SGLT2 inhibitor.
- ST should follow a fixed carbohydrate intake at each meal to align with their medication regimen.
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- 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
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.
Happy Thanksgiving
Rationale of the Week | Best Action to Avoid Thanksgiving Post Meal Elevation?
Happy Thanksgiving everyone!
For last week’s practice question, we quizzed participants on avoiding Thanksgiving post meal elevation. 78% 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: JR is excited about enjoying Thanksgiving with family but is a little worried about post-Thanksgiving meal blood sugar elevations. JR takes 1 unit bolus insulin for every 10 gms of carb, with a correction factor of 1 unit for every 50 points above 120, plus 23 units of basal insulin at night. For Thanksgiving JR plans to eat:
- 1 cup of mashed potatoes
- Spoonful of green beans
- Gravy
- 1 Roll with lots of butter
- ½ cup of sweet potatoes
- Turkey leg
- A glass of white wine
If JR’s blood Sugar is 173 before the meal, what is the best approach?
Answer Choices:
- Decrease carbs by half and increase intake of high fiber vegetables.
- Take about 7-8 units bolus insulin before the meal.
- Increase basal the night before to prevent post meal elevation.
- Take bolus insulin after meal based on blood sugar response.
Getting to the Best Answer
Answer 1 is incorrect. 11.11% chose this answer. “Decrease carbs by half and increase intake of high fiber vegetables.” Although it is always a great idea to start the meal with high fiber foods to help regulate post meal glucose, we are not big fans of asking JR to reduce their carb intake by half on Thanksgiving. As long as JR takes adequate bolus insulin before the meal, they can enjoy Aunt Martha’s mashed potatoes and some of their favorite stuffing too.
Answer 2 is correct. 78.10% of you chose this answer. “Take about 7-8 units bolus insulin before the meal.” YES, this is the best answer. Trying to gauge exactly how much carbs is in a holiday meal is challenging, but it appears that this meal contains about 65-80 gms of carb. Since JR takes 1 unit of insulin for every 10 gms of carb, they will need about 7-8 units of insulin to cover this holiday feast.
Answer 3 is incorrect. About 3.59% of respondents chose this. “Increase basal the night before to prevent post meal elevation.” This isn’t the best answer, because increasing the basal the night before might cause morning hypoglycemia and isn’t designed to cover post meal elevations.
Finally, Answer 4 is incorrect. 7.19% chose this answer. “Take bolus insulin after meal based on blood sugar response.” Since JR is worried about post meal glucose elevations, the most effective strategy to prevent that from happening is to take the insulin bolus at least 15 minutes before the meal.
Happy Thanksgiving everyone! 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!
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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
- 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
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.
Question of the Week | A1C 13.6% – Next Important Step?
KT is a 17-year-old with newly diagnosed diabetes and an A1C of 13.6%. The provider starts KT on 30 units of basal insulin and 10mg empagliflozin (Jardiance). KT is asked to get C-peptide levels checked and their C-peptide level is 0.9 ng/mL.
Based on this information, what is the next most important step?
- Add bolus insulin and stop empagliflozin
- Discuss the importance of starting CGM
- Evaluate auto immune markers
- Decrease basal insulin and start metformin
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“Becoming a Certified Diabetes Care and Education Specialist (CDCES) is one of the best professional and personal decisions I have ever made.” – Coach Beverly Thomassian
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
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.
Holiday Survival Guide & Reframing Diabetes Distress – Steps to Success
The holiday season can be stressful and throw us off our normal routine. This can compromise sleep and disrupt usual eating habits. In addition, it can trigger feelings of distress and self-doubt for people with diabetes if blood sugars go outside of goal range.
To help everyone feel their best during this holiday season, we have created a handout that highlights ten strategies to survive the holiday commotion. And even if all ten aren’t possible, just pick one or a few to try out. In addition, we have compiled a list of strategies to help reframe and reset when individuals are experiencing feelings of diabetes distress.
These Cheat Sheets have lots of helpful tips that you can print and share with your friends, participants, and colleagues!
1. Be a sleep warrior – People living in the United States are chronically underslept. Not getting enough sleep is associated with increased hunger, higher blood sugars, poor concentration, frequent illness, and impaired problem-solving. Make sure to give yourself the gift of at least 7 hours of sleep a night. This sleep will help you make the best choices for your health and will protect against illness and fatigue. You got this.
Goal: Get at least 7 hours of sleep a night. You deserve it.
2. Keep active – Holidays can put our exercise plans to the test, but we have a few ideas for you. Take an after-meal stroll instead of plopping on the couch. After meal walks lower post-meal blood sugars and increases energy by getting muscles activated. Just 10 minutes of walking after meals can make a big difference. You can even put music on and have a small dance session, anything to get your body moving.
Goal: Work toward 30 minutes of activity a day.
3. Don’t forget the Fiber – With all the snacks and tempting foods, whole healthy foods may take a back seat. Enjoy the abundance of seasonal vegetables, fruits, nuts, and grains that are fiber-rich and that decrease inflammation. Examples include; yams, squash, mandarin oranges, almonds, pistachios, quinoa, kale, brown rice, warm oatmeal, salads, and broth-based soups.
Goal: Strive to eat at least 25gms of fiber a day.
4. Enjoy the ultimate beverage – H20. Water is the perfect way to keep hydrated, replenished, and keeps appetite in check. Add a splash of flavor with a jigger of fruit juice or fresh cucumbers, lime slices, or a sprig of rosemary. Be creative. Sparkling waters come in a vast variety of flavors, are calorie-free, and contain no artificial sweeteners.
Goal: Keep hydrated by enjoying plenty of water.
5. Keep an eye on alcohol – While it’s true that red wine offers a beneficial anti-inflammatory compound called resveratrol, drinking too much alcohol can lead to unintended outcomes. Studies show that we make poorer food choices if alcohol is on board. This can offer special challenges in party settings, where temptations are abundant. A drink of alcohol contains about 100 calories and mixed drinks have even more. In addition, alcohol can lead to low blood sugars, especially for those taking insulin or sulfonylureas.
Goal: Limit alcohol to one drink a day for women, two drinks a day for men.
6. You are already sweet enough – Holidays and sugar go hand in hand. If possible, try and eat less than 6 teaspoons of added sugar (does not include natural sugars found in fruit and milk). This goal may not be realistic on all days, but aim for success most of the time. Excess sugar intake can cause inflammation and buildup of fat in the liver. One strategy is to limit sugar intake during the day and save your 6 teaspoons for that special dessert or parties. When looking at labels, it is helpful to know that 1 teaspoon equals 4 gms of sugar.
Goal: Limit sugar to 6 teaspoons a day.
7. Your teeth need extra special attention – Taking care of our teeth and gums improves health. Gum inflammation is associated with blood vessel inflammation. Swollen gums can also lead to an increase in blood sugars. During the holidays, find time for regular oral hygiene. Your mouth (and dental team) will thank you.
Goal: Brush teeth at twice daily and floss at least once daily.
8. Keep connected to friends and family who love you just the way you are! – As enjoyable as holidays can be, reuniting with family can also cause stress and stir-up emotions. Feeling out of sorts can lead to stress eating and decrease self-care. If possible, reach out to a trusted friend to share your feelings or keep a holiday journal. Consider bringing a favorite book along during your travels that you find inspiring and comforting. Give yourself permission to steal away for some quiet time.
Goal: Self-care is important during the holidays.
9. Enjoy an Oxygen Cocktail – Studies show that when humans venture into natural outdoor settings, heart rate and blood pressure improve. Take a moment to appreciate the feeling of the air on your skin, take a deep breath of fresh air, try to find nests in leafless trees, listen to the animal sounds and bird songs and just enjoy that moment.
Goal: Step into nature daily.
10. Take inventory of things that you are grateful for – Find a moment each day to reflect on a few things that brought you joy or good feelings. Maybe it was your cousin who lent you her favorite sweater. Or an Aunt who gave you the best hug. Special moments with a best friend or an after-dinner walk enjoying the fall leaves. These small moments of connection and beauty are one of the most treasured gifts of the holiday season that linger in our hearts and memory long after we say our goodbyes.
Goal: Take note of special moments.
Click here to download 10 Steps to Survive the Holidays PDF – a great handout that includes the info above to print and share with your friends, patients, and colleagues!
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[yikes-mailchimp form=”1″]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.”**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 of continuing education. Diabetes Education Services is accredited/approved by the Commission of Dietetic Registration which is on the list of CBDCE Recognized Providers.”
T-Shirt & Book Give Away!!
In celebration of National Diabetes Month, DiabetesEd Services is hosting a T-shirt and Book Give Away! We’d love to hear what you’ll be doing to observe this important month—share your plans with us, and we may feature your response! Submissions due by Nov 29th!! Thank you and we appreciate your participation. Be sure to take a moment to explore our website for resources designed to support Diabetes Educators!
Rationale of the Week | Reluctant to Start Metformin due to Side Effects
For last week’s practice question, we quizzed participants on a person’s concerns about metformin use & potential side effects. 41% 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 is reluctant to start on metformin because they heard it can cause diarrhea and kidney problems. You reassure LS that metformin doesn’t harm the kidneys and can actually improve gut health.
Based on the most recent evidence, which of the following is true?
Answer Choices:
- Hold metformin if the GFR is less than 45 and the person has an occasional alcoholic beverage.
- Metformin increases the growth of bacteria like Akkermansia muciniphila.
- Most people with metformin experience diarrhea, so make sure to increase fiber intake when starting.
- Start vitamin B12 therapy and iron supplements with initiation of metformin.
Getting to the Best Answer
Answer 1 is incorrect. 22.27% chose this answer. “Hold metformin if the GFR is less than 45 and the person has an occasional alcoholic beverage.” The guidelines state not to start metformin is the GFR is less than 45. But if someone is already on metformin their GFR drops below 45 we can continue it with caution and we might reduce the dose. We stop metformin if the GFR is less than 30. We don’t recommend metformin if someone is binge drinking due to the potential risk of lactic acidosis. An “occasional drink” would not reach the threshold to stop the metformin. Download Med PocketCards for more info.
Answer 2 is correct. 41.17% of you chose this answer. “Metformin increases the growth of bacteria like Akkermansia muciniphila.” Yes, this is the best answer. Metformin has been shown to increase gut bacterial diversity with a special nod to one of our favorite mucus protective bacteria known as “Akk”. This beneficial bacteria increase levels of butyrate and protects intestinal mucous lining, which helps to decrease inflammation. Cheers for AKK! Download Med PocketCards for more info.
Answer 3 is incorrect. About 19.51% of respondents chose this. “Most people with metformin experience diarrhea, so make sure to increase fiber intake when starting.” This is not accurate, since only a small percentage of people experience diarrhea. And, if they do, switching them to metformin extended release can decrease intestinal discomfort. Download Med PocketCards for more info.
Finally, Answer 4 is incorrect. 17.05% chose this answer. “Start vitamin B12 therapy and iron supplements with initiation of metformin.” Some, but not all individuals experience B12 deficiency on long term metformin therapy. We would only start B12 replacement therapy after confirming low B12 levels. Download Med PocketCards for more info.
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!
Check out these upcoming class offerings!
All hours earned count toward your CDCES Accreditation Information
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
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.
Diabetic Retinopathy: The Role of Diet in Prevention and Progression
Nutrition Intervention Can Protect Vision
by Christine Craig, MS, RD, CDCES
Recent research highlights the role of diet in preventing and slowing the progression of diabetes retinopathy, which is the leading cause of vision impairment among individuals with diabetes.
While glucose management is essential in reducing the risk of retinopathy, nutritional strategies that target reduced glycemic variability, blood pressure, inflammation, and oxidative stress significantly impact retinal health and vision.
In 2021, it was estimated that 26.43% of individuals with diabetes in the US have diabetic retinopathy, and 5.06% of individuals have vision-threatening diabetic retinopathy.1
Non-Proliferative and Proliferative Retinopathy
Clinically, diabetic retinopathy presents as non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR).
- NPDR occurs in the early stages when blood vessels in the retina weaken, and microaneurysms occur, but there is no new blood vessel growth.
- PDR is when there is a “proliferation” of new blood vessel growth in the retina, and these unstable vessels break and bleed into the vitreous, causing severe vision loss. PDR requires urgent and ongoing medical treatment.
Chronic hyperglycemia, dyslipidemia, nephropathy, and hypertension are factors that increase the risk of diabetic retinopathy.3 In type 1 diabetes, the DCCT and EDIC studies identified that higher mean HgbA1c is the strongest predictor of retinopathy progression. A 1% reduction in HgbA1c was associated with a 35% reduction in the risk of developing diabetic retinopathy.
Eye Screening Guidelines
Screening is essential; 2019 data indicates that 64.8% of individuals with diabetes had completed an eye exam in the past 12 months.2
The ADA Standards of Care recommends that adults with type 1 diabetes be screened within five years of diagnosis and individuals with type 2 diabetes be screened at the time of diagnosis. followed by an annual screening. If the eyes are healthy on exam and glucose is within the target range, eye specialists can consider extending screening to every 2 years.3
Diet and Retinopathy Risk
An individual’s diet plays in important role in retinal health.
Research has associated the consumption of fatty fish, fruits, vegetables, and antioxidant-rich foods with a reduced risk of diabetic retinopathy.4
In contrast, dietary patterns that contribute to glucose elevation and increase advanced glycation end-products (AGEs) contribute to retinal inflammation and microvascular damage.4 Focus on dietary interventions that support glycemic, lipid and blood pressure management help reduce risks or slow profession of this condition.3
Just as in general diabetes management, no one diet pattern is recommended; however, there is some evidence for specific nutrients. Research on nutrients such as omega-3 fatty acids, fiber, lutein and zeaxanthin, Vitamin C, Vitamin E, and Zinc have shown positive association with lowering diabetic retinopathy risk.4 To meet these nutrient needs, whole food-based diets rich in vegetables, whole grains, legumes, lean proteins, and healthy fats may be considered.
The Dietary Inflammatory Index (DII)
The Dietary Inflammatory Index (DII) is a scoring system that measures the inflammatory potential of individual diets based on 45 parameters, including various macronutrients, micronutrients, and phytochemicals. Liu and colleagues5 found that a one-point increase in the DII score was associated with 38% increased odds of having diabetic retinopathy. Their research also noted the relationship between higher HbgA1c, duration of diabetes, and increased retinopathy risk. While the research used NHANES data, the small sample size and retrospective cross-sectional analysis limit the ability to conclude causation.
We can consider the benefits of increasing anti-inflammatory foods and decreasing inflammatory foods, but additional information is needed to implement direct recommendations.
Role of Diabetes Educators in Prevention
As Diabetes Care and Education Specialists (DCES), we can support the prevention of diabetic retinopathy by helping individuals manage glucose through dietary patterns to reduce risk and slow progression. Although barriers exist to adopting anti-inflammatory diets rich in whole foods, antioxidants, and essential nutrients, understanding the potential connection beyond glycemic management can guide additional nutrition interventions.
Programs that support retinal photography with remote reading can increase access to screening in areas lacking accessible services. Additionally, ensuring blood pressure, lipid and renal screening and management, understanding the role of physical activity, and long-term glucose management can support vision health. DCES can empower patients to make sustainable lifestyle changes that support retinal health through individualized counseling and interdisciplinary collaboration with eye care providers.
References:
- Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol.2023;141(8):747–754. doi:10.1001/jamaophthalmol.2023.2289
- Healthy People 2030 Data Report. Downloaded on October 18th 2024 from https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increase-proportion-adults-diabetes-who-have-yearly-eye-exam-d-04
- American Diabetes Association Professional Practice Committee; 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2024. Diabetes Care1 January 2024; 47 (Supplement_1): S231–S243. https://doi.org/10.2337/dc24-S012
- Bryl A, Mrugacz M, Falkowski M, Zorena K. The Effect of Diet and Lifestyle on the Course of Diabetic Retinopathy-A Review of the Literature. 2022 Mar 16;14(6):1252. doi: 10.3390/nu14061252. PMID: 35334909; PMCID: PMC8955064.
- Liu, R., Zhang, J., Gu, W. et al.Dietary Inflammatory Index and diabetic retinopathy risk in US adults: findings from NHANES (2005–2008). BMC Ophthalmol 24, 46 (2024). https://doi.org/10.1186/s12886-024-03303-1
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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
- 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
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.
Question of the Week | Best Action to Avoid Thanksgiving Post Meal Elevation?
JR is excited about enjoying Thanksgiving with family but is a little worried about post-Thanksgiving meal blood sugar elevations. JR takes 1 unit bolus insulin for every 10 gms of carb, with a correction factor of 1 unit for every 50 points above 120, plus 23 units of basal insulin at night. For Thanksgiving JR plans to eat:
- 1 cup of mashed potatoes
- Spoonful of green beans
- Gravy
- 1 Roll with lots of butter
- ½ cup of sweet potatoes
- Turkey leg
- A glass of white wine
If JR’s blood Sugar is 173 before the meal, what is the best approach?
- Decrease carbs by half and increase intake of high fiber vegetables.
- Take about 7-8 units bolus insulin before the meal.
- Increase basal the night before to prevent post meal elevation.
- Take bolus insulin after meal based on blood sugar response.
Want to learn more about this question?
Register for these FREE courses today!
Why Attend These Webinars?
All hours earned count toward your CDCES Accreditation Information
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
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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