How to Succeed with Person-Centered Coaching
A diagnosis of diabetes often carries a significant emotional response. People with diabetes experience a myriad of feelings as they come to terms with their diagnosis and anticipate their future. As diabetes healthcare providers, we can learn to address these feelings through person centered coaching and help individuals take steps to get to their best health.
This Coaching Cheat Sheet provides a dozen simple coaching strategies for providers to help people believe in their ability to self-manage their diabetes successfully.
Using a person-centered approach, we can identify the individual’s strengths and expertise and then leverage this information to open a door of possibilities. Our choice of communication techniques can spark behavior change in people living with diabetes.
Adopting this style of communication can be a dramatic shift for some providers. Think of it this way: In usual care, the diabetes healthcare provider steers the boat, brings the fuel, and charts the course. Using the person-centered approach, the provider is simply the rudder, serving as a guide, and the individual steers.
Strategies that Work
DO: Mindfully Listen to the individuals’ problems and fears.
The first strategy is carefully listening to the person’s fears and concerns. If someone struggles with nutrition, meds, or behavioral changes, listen to the struggle, and try not to push, advise, or fix it. Listen and reflect on what you think is happening for the first few minutes.
For example, reflecting back could go something like this: “Taking medications is hard for you because you are not sure if they are really working.” Or, “It’s hard to eat more vegetables because you are a long-haul truck driver.” Or, “It sounds like you blame yourself for having diabetes.”
Listening and then reflecting back on the struggles of the individual is the first phase of energizing the visit.
DO: Focus on curiosity before exploring possible changes in behavior.
With a person-centered approach, spend more time in the “curiosity” phase before moving to the “action” phase.”
We might ask, “As a truck driver, I am curious to learn more about your food choices when driving.” As care providers, we may be slightly overanxious to get to the “action” phase, which involves aspects such as action, planning, goal setting, and looking at specific foods and exercise prescriptions. It can be disorienting for providers to delay the “action” phase and spend most of the time exploring the “curiosity” phase, and there’s a perception that it takes longer. In fact, it’s probably more efficient with time. It’s a redistribution of the provider’s time in that more time is spent listening to the individual’s barriers and fears and responding to them.
Curiosity can provide comfort and open the door to insights.
DO: Listen for individual insights and ideas.
After reflecting on the person’s struggles and feelings, the next phase is the “building change” talk. It combines having the person express how a behavior change would benefit them and realistic ways to move to the action phase.
As genuinely curious providers we ask, “what are your ideas about how you can improve this situation?” Then the provider would listen carefully to what the person shares. Along with the struggles and barriers, the individual might say, “I could buy a veggie tray before heading out in my truck,” or “I could try taking my medication every day for a week to see how they affect my blood sugars.”
We want to fine-tune our listening skills so that we can pick up the scent of the trail. People often allude to what they’re willing to do and drop crumbs when they feel safe and heard during the conversation. All we need to do is pick up on the hints and encourage them down the path.
DO: Ask Questions and Collaborate.
Once the individual has identified their motivation and begins brainstorming on ways to make behavior changes, the door is open for respectful collaboration. You’ll want to explore how much change the individual is willing and able to make at that time.
To keep it real and achievable, we start with a very small step by saying, “So, you think you could buy a vegetable tray before heading out?” or “You think you could take your diabetes meds for a week to see if they work?” and let that sit; let the person describe their thoughts and feelings.
Then we might say, “How, if at all, do you see this plan fitting into your life?” We are careful to avoid any form of prescription or declaration and stick with asking questions. If the person volunteers—”I will monitor my blood sugars for a week to see if these diabetes meds work.” Or “I think I could pick up veggie trays on driving days.” We would absolutely reinforce and support these choices.
Strategies To Avoid
AVOID: Pressure, fix, or control.
A person-centered approach energizes individuals to take the lead in managing their condition, in step with their providers and supporters. We are careful to avoid forced solutions or controlling language. As providers, we feel like we have these great ideas that we are sure will fix the person, if only…. However, the truth is, our job is to help the person with diabetes find their own answers and solutions.
Let’s stop “Shoulding” on people.
It’s time to let go of terms like “You must, you should, you have to, it’s better, it’s important, do it for me” since they fall under the category of “controlling motivation”—which can be hurtful and lead to the individual becoming defensive or shutting down. We avoid controlling language because it elicits resistance and defiance. The literature is quite clear about people doing something because someone made them feel guilty, ashamed, or pressured them. The long-term prognosis for behavior change using this approach is underwhelming.
DON’T employ Scare Tactics.
As providers, we genuinely care about people’s health and may try to energize behavior change using fear. Such as, “If you don’t get your A1C down, you are heading for dialysis or amputation.” or “Don’t you want to see your kids grow up?” We don’t generally motivate people by scaring them since research shows it is ineffective, and they may never return for that follow-up appointment.
Short-term, people are usually willing to make changes when they’re terrified—when they first get diagnosed–but that wanes in a relatively short period of time. The question is how to keep the person energized when the initial fear has worn off.
In Conclusion: Celebrate and Recognize Each Person’s Effort
Making behavior changes, like losing weight or adjusting lifelong eating habits, can be extremely difficult.
Find a way to recognize and affirm their efforts even if there is no or little change in clinical measures.
If someone’s A1C has not moved, but they took their medications daily or ate their vegetables, we say, “Wow, I want to recognize the effort you put into this.”
Respond kindly and compassionately to their disappointment, frustration, and fear. It won’t fix the immediate problem, but it helps the person feel that their effort was well-spent. It helps them feel heard instead of just “fixing it” and saying, “Okay, we’ll try a new medication.” Over time, your empathy builds bridges and trust, leading to long term collaboration and better health.
About the author – Coach Beverly has been fine-tuning her guilt-free approach to diabetes education for over 30 years and has witnessed its impact on improving well-being and building connections.
Learn more about effective communication approaches in our ReVive 5 Diabetes Training Program.
Inspired by https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/motivational-interviewing-dos-dont
You are welcome to Download Effective Person-Centered Communication Approaches Cheat Sheet to share with your colleagues.
Inspired by https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/motivational-interviewing-dos-donts
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:
- 7 CEs – Includes the 7-hour ReVive 5 Training Program
- 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
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The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
A Recipe from Mohammed Ali
Mohammed Ali was a fierce competitor and fought for what he believed in.
Yes, the towering figure had a poetic side, that leaned toward justice.
In 1972 Ali was being interviewed by journalist David Frost and was asked how he would like people to remember him when he was gone. Here is his response.
Recipe for Life - Mohammed Ali
“I’d like for them to say he took a few cups of love.
He took one tablespoon of patience,
One teaspoon of generosity,
One pint of kindness;
He took one quart of laughter,
One pinch of concern.
And then, he mixed willingness with happiness,
He added lots of faith and he stirred it up well.
Then he spread it throughout a lifetime and he served it to every deserving person he met.”
When I heard this, I thought it a perfect description of how we approach people with diabetes, starting with a foundation of love. The practice of diabetes care is just a little bit of science and loads of kindness and concern with lots of faith and belief in the ability of each individual.
We spread this over a lifetime of care and share it with generosity to each person we meet.
Join us in Preparing for the 2024 BC-ADM Exam!
Airs April 10th @ 11:30 am
Topics of discussion include
- Exam eligibility and test format
- Strategies to succeed
- Study tips and test-taking tactics
Coach Bev will also review sample test questions and the reasoning behind choosing the right answers. We hope you can join us.
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!
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 | How to Increase Participation in DSMES?
For last week’s practice question, we quizzed participants on how to Increase participation in DSMES. 75% 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: Studies indicate that only 53% of individuals eligible for Diabetes Self-Management Education and Support (DSMES) through their health insurance receive it.
Answer Choices:
- Adjust DSMES charges for Medicare enrollees based on ability to pay.
- Increase access to telehealth delivery of care and other digital health solutions.
- Provide DSMES in non-hospital workplace settings to increase access for employees.
- Incentivize participation through use of giveaways and positive reinforcement.
Getting to the Best Answer
Answer 1 is incorrect. 4.79% chose this answer. “Adjust DSMES charges for Medicare enrollees based on ability to pay.” To ensure parity, Medicare guidelines specifically state that all DSME participants must be billed at the same rate. Billing at a lower rate or offering DSME for reduced rates or free for some, but not for all, is prohibited.
Answer 2 is correct. 74.77% of you chose this answer. “Increase access to telehealth delivery of care and other digital health solutions.” YES, GREAT JOB! To promote equity and outreach to rural and under resourced communities, the ADA encourages leveraging technology platforms and telehealth to deliver DSMES.
Answer 3 is incorrect. About 10.5% of respondents chose this. “Provide DSMES in non-hospital workplace settings to increase access for employees.” This is a tempting answer, but unfortunately it is not accurate. The location where DSMES is delivered must have prior approval as a Medicare recognized site in order to be able to bill for services. Of course, providing onsite worksite wellness and lifestyle coaching is beneficial, but it would not be a billable service unless the facility has a recognized DSMES program and an approved site.
Finally, Answer 4 is incorrect. 9.94% chose this answer. “Incentivize participation through use of giveaways and positive reinforcement.” Although this is another tempting answer and could help improve DSMES participation in real-life, the ADA Standards don’t include this strategy as a means to boost enrollment.
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?
Virtual DiabetesEd Training Conference – Join us Live on April 17th – 19th 2024 at 11:30 AM PST
Join Coach Beverly and Team for two and a half days of knowledge-sharing, fun, and “aha” moments for our Virtual DiabetesEd Training Conference April 17th – 19th, 2024.
Attendees will leave this conference with new tools and a refreshed understanding of the latest advances in person-centered diabetes care. Our team highlights the ADA Standards of Care, medications, behavior change, technology, medical nutrition therapy, and more!
Our instructors co-teach the content to keep things fresh and lively.
Friend Discount: 3 or more only $449 per person. Email us at [email protected] with the name and email of each registrant to get the discount!
Program Details
- Dates: April 17-19th, 2024
- Registration Fee: $399-$569 (see more about reg. options below)
- Friend Discount: For 3 or more people, each person saves $50 off their registration. Email us at [email protected] with the name and email of each registrant to get the discount!
- CEs: 30+ CEs | 18 units for Virtual Conference plus 10+ Bonus CEs. CEs can be applied toward CDCES’s initial application or renewal.
- Speakers: View Conference Faculty
Registration Options
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!
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.
Positively Type 1: A Holistic Perspective for Diabetes Educators
Holistic Diabetes Educator & Author of “Positively Type 1”
An interview with Nick Kundrat, BS, CEP, CDCES, LMT
Nick Kundrat first caught our attention when he shared his incredibly detailed study sheets on our CDCES Exam Prep Facebook Group. He had just passed his CDCES exam and posted his lecture notes on the FB group to support his colleague’s success at the exam, too. This act of generosity made Nick a standout educator, and our team contacted him to help with our national CDR accreditation application. Through this connection, we learned that Nick not only provides diabetes care and education but also lives with type 1 diabetes. He recently published a book, “Positively Type 1” that emphasizes the transformative power of a positive mindset and a holistic approach. Whether you’re a seasoned educator or someone living with Type 1 diabetes, Nick’s message is clear: positivity, understanding, and resilience pave the way for a brighter future.
Let Nick’s words be a call to action. By fostering positivity and empathy, we contribute to a more hopeful journey for everyone touched by Type 1 diabetes.
We hope you enjoy this interview with Nick as he describes his path as a role model of holistic diabetes care and a beacon of hope for the 1.5 million people and their families living with type 1 diabetes. Thank you, Nick, for sharing the knowledge and insights you gained through personal experience and your commitment to lifelong learning. May “Positively Type 1” continue to inspire positive change in the diabetes community.
Interview with Nick Kundrat , BS, CEP, CDCES, LMT
In the realm of diabetes education, where deep struggles often cast shadows on hope, one holistic diabetes educator has embarked on a mission to illuminate a different path—a path that embraces positivity, resilience, and a profound understanding of living with Type 1 diabetes. Join us in this exclusive interview with Nick Kundrat – Holistic diabetes educator and author behind “Positively Type 1,” as we delve into a refreshingly simple and optimistic approach to diabetes care.
Nick Kundrat, a beacon of inspiration in the diabetes education community, didn’t arrive at this revolutionary approach by chance. It was forged through personal experiences, a deep empathy for those navigating the complexities of Type 1 diabetes, and a relentless belief in the transformative power of a positive mindset.
As we navigate the pages of “Positively Type 1,” we discover a manifesto for individuals with Type 1 diabetes seeking a brighter, more empowering point of view on their diabetes diagnosis. In this interview, Nick takes us behind the scenes, sharing the insights, anecdotes, and strategies that have the potential to redefine how we approach diabetes education.
Get ready to challenge preconceptions, embrace a holistic perspective, and embark on a journey that goes beyond the textbooks. “Positively Type 1” isn’t just a book; it’s a paradigm shift—a beacon guiding educators and individuals alike toward a positive, resilient, and fulfilling approach to Type 1 diabetes.
You mentioned being a “Holistic diabetes educator” – what does that mean?
Diabetes education technically includes a myriad of different topics related specifically to diabetes treatment, as well as nutrition, exercise and other lifestyle interventions. Yet in my experience, most diabetes education stops at the first one…. diabetes education. Now arguably, diabetes educators focusing on diabetes education seems like a good thing, right? Well…
While diabetes treatment is an important piece of the puzzle., it’s really only the tip of the iceberg when it comes to a person’s health. Your blood sugar balance is NOT just reliant on your insulin dosing and carb counting. Every other area of your life and health can affect your diabetes treatment in big ways. How you sleep, how you eat, how you think, how you rest, how you move, even how you relate to others are really the foundations of proper blood sugar control.
In my opinion, it is a disservice when health professionals focus solely on the diabetes. Besides… They are working with people. They aren’t working with diabetics, they’re working with people who just happen to also have diabetes. Unfortunately, many doctors and educators are just seeing numbers on a page rather than a whole person.
The holistic approach to diabetes is exactly that. A people first approach to diabetes care. Addressing the foundations of health (sleep, stress, nutrition, hydration, exercise, emotions, detoxification) along with your traditional diabetes care is the only way to cultivate true wellness, rather than just staying stuck in the loop of disease treatment.
In my wellness practice, I utilize a variety of different modalities to help my patients heal at a deep level. We always begin with the health foundations (as mentioned above) as well as optimizing diabetes care. With some clients who want to go even more in depth with their health, we utilize nutritional testing and manual therapy approaches to help rebalance the body at a deep level. I’m blessed to be able to share my experiences in both clinical and holistic health to help my patients feel good and cultivate true wellness.
How does your book tie into the Holistic Diabetes Education model?
A holistic diabetes education means looking at the WHOLE PERSON. What many professionals believe that means is: Diabetes education + exercise + nutrition only. What it really means is taking into account EVERY PART OF YOU… This includes the parts you cannot see. Emotions, feelings, psychology, stress, behaviors, choices and spirituality are all important parts of you that cannot be “seen” but are nonetheless very real, and very important factors in your health journey.
Your beliefs are a very important part of the “unseen” parts of your health puzzle. What you believe about the world, about your body, about health in general, and about your diabetes set the stage for how you will act in the world (and how well you will do actually treating your diabetes!
Beliefs determine our thoughts, which determine our feelings, which determine our actions. In other words, what you believe, determines how you act. So if you believe:
“Well my body is broken, I cannot get any better, and nothing ever works in my favor,” you will continue to run yourself in self limiting circles, keep making poor decisions and keep struggling with your health and diabetes treatment.
But if you believe:
“My body is strong and resilient, I can always make positive change and get healthier, and my struggles are opportunities to grow and change,” you will be able to make choices that lead you in a positive direction with your health and your diabetes treatment.
If you can shift someone’s beliefs, you can shift their entire lives. This was the goal for Positively type 1 – to shift the negative beliefs (that most of us living with type 1 diabetes hold) in a more positive, optimistic direction.
What inspired you to write “Positively Type 1”?
My book writing journey actually began at a very young age when I was diagnosed with Type 1 Diabetes myself. At age 4, after becoming terribly sick, my parents and I were told to head to the emergency room. We expected to be checked in, seen by the doctor, then be checked out with some antibiotics. But instead, a terrible nightmare ensued…. Being diagnosed with an incurable, life-long chronic illness: Type 1 Diabetes.
Growing up with a fantastic support system, the daily struggles of diabetes were outweighed by a very happy, healthy childhood filled with sports, school, activities, family and friendships. Yet still I spent lots of time with doctors and educators who helped me navigate my complex chronic condition.
Naturally, as an adult, I was led into the healthcare field, where I soon became the educator (instead of the educated). After spending countless hours around diabetes educators and endocrinologists as a patient, and countless hours on the other side of the coin, educating patients myself in hospitals & clinics, I arrived at a startling conclusion….
There is lots of negativity in the diabetes space. A LOT.
When I (and nearly everyone else I know with diabetes) was diagnosed with type 1, I was never given a pep talk and was never given much hope. Instead I was told:
“Your body is broken”
Your pancreas doesn’t work”
“Your body turned against you”
“You wont get to be like other kids”
While there is some truth in these statements, telling a 4 year old child these things can (and will) drastically shift their beliefs about their bodies and about themselves.
As an educator, I noticed most practitioners are approaching Type 1 diabetes through a similar lens.
“Well, it’s just something you have to manage”
“You’ll be stuck with this forever”
Which again there is some truth to, but statements like these lack a vital ingredient in the recipe of health and healing… HOPE!
If I’ve learned one thing as a diabetes patient and educator… Sometimes all it takes to drastically change someone’s life is a little dose of hope.
This was the inspiration behind writing Positively Type 1.
Tell us a little about the book itself. What can readers expect to learn?
In each chapter, I explain a different skill or character trait you learn living with Type 1. Allow me to share a few examples:
A person with type 1 diabetes makes on average over 180 more decisions per day (between insulin dosing and carb counting) compared to someone without diabetes. Through this, we become INCREDIBLE problem solvers.
With type 1, you learn to be extremely tuned in to every little shift and change in your blood sugar levels. This helps us build incredible levels of self awareness.
Having to endure countless needle-sticks and finger-pricks helps you cultivate a mental and physical toughness unlike any other group of people I’ve ever met.
And many more!
Plus, so that you aren’t just hearing from me, I sat down and interviewed amazing young type 1 warriors whom I’ve worked with as patients. So you get to hear from inspiring young voices who are doing a kick A** job with their diabetes mindset and treatment.
Overall, it’s an easy, lighthearted, humor filled read that will hopefully leave you smiling and filled with hope.
Who is your book for?
Positively Type 1 is for anyone with type 1 diabetes, or those who love someone with type 1 diabetes. It’s written for all ages, but many of the “Type 1 Interviews” at the end of the chapters are with young adults, so it may particularly resonate with the preteen/teen age group.
In Conclusion…
As we conclude our exploration of “Positively Type 1” with Nick, it’s evident that the book is more than words on paper—it’s a source of inspiration for both educators and individuals with Type 1 diabetes.
The insights shared today emphasize the transformative power of a positive mindset and a holistic approach. Whether you’re a seasoned educator or someone living with Type 1 diabetes, the message is clear: positivity, understanding, and resilience pave the way for a brighter future.
Thank you, Nick, for guiding us on this empowering path. May “Positively Type 1” continue to inspire positive change in the diabetes community.
Learn More:
To learn more about Nick’s holistic wellness practice, please visit his website:
To purchase a copy of Nick’s book from amazon, please visit:
Nick Kundrat Educational Background and Bio
- Bachelors in Exercise Science and Sports Medicine (BS)
- Clinical Exercise Physiologist (CEP)
- Certified Diabetes Care and Education Specialist (CDCES)
- Licensed Massage Therapist (LMT)
My name Nick and I’m a passionate educator, coach and the founder of Blueprint Wellness. My story began with years of struggle with multiple chronic illnesses. At my worst, I had over 12 chronic diagnoses including; POTS, Type 1 Diabetes, Hashimotos, EDS, parasite/fungal infections, lymes disease, mast cell activation syndrome, mold toxicity and depression/anxiety. After years of being severely debilitated with tons of “mystery symptoms,” and working with some of the best holistic doctors and practitioners who weren’t able to help me, I was truly sick of being sick.
Funny enough, being severely sick was the best gift I could’ve ever received. If I hadn’t been knocked out with illness, I never would’ve been forced to change my habits, and make an important shift in the way I thought about health.
Everything changed when I began focusing on cultivating wellness, rather than treating my diseases. I decided to completely disregard any diagnoses or labels, and embark on a mission of learning what a healthy human eats like, moves like, looks like, acts like, thinks like and functions like…. and cultivating habits and practices that would get me there.
And now after going on that journey myself, I have devoted my life to becoming the holistic practitioner I needed during my toughest health trials & tribulations.
I’m now blessed to be able to guide others on their journey to health, utilizing a unique blend of holistic and clinical approaches to facilitate real, deep healing for those who are also sick of being sick. I’m not simply after helping you “relieve your symptoms” My goal is to help you cultivate real health, evolve out of disease and grow into the person you were made to be.
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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and our CPEU courses have received Prior Approval* from the Commission of Dietetic Registration (CDR), Provider DI002. Since our CPEU courses received Prior approval* from the CDR, these CPEU courses satisfy the CE requirements for the CDCES /BC-ADM regardless of your profession!
The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Question of the Week | Which statement is accurate regarding treatment of steatosis?
Up to 70% of people with diabetes have steatosis. Those at higher risk of moving to steatohepatitis include individuals with prediabetes and diabetes who also have cardiometabolic risk factors.
According to ADA Standards, which of the following is an accurate statement regarding treatment of liver disease in diabetes?
- GLP-1 Receptor agonists help with weight loss but do not improve steatosis.
- Pioglitazone therapy is indicated for individuals with steatohepatitis.
- Avoid insulin therapy in individuals with steatosis and advanced cirrhosis.
- Statin therapy is not effective at LDL lowering for individuals with steatosis.
Want to learn more about this question?
Critical Assessment in Diabetes Care | Fine-Tuning Diabetes Detective Skills
Level 2 | Standards of Care Intensive
This course integrates the American Diabetes Association’s (ADA) Standard of Care on elements of a comprehensive medical assessment (Standard 4) of the individual living with prediabetes, diabetes, or hyperglycemia. Through case studies & real-life situations, we discover often hidden causes of hyperglycemia & other complications, such as liver disease, sleep apnea, pancreatitis, autoimmune diseases, fractures, & more. We delve into therapy for complicated situations & discuss management strategies for other conditions associated with hyperglycemia such as Cystic Fibrosis, & Transplants.
Objectives:
- Identify common yet often underdiagnosed complications associated with type 1 & type 2 diabetes.
- State strategies to identify previously undiscovered diabetes complications during assessments.
- Discuss links between hyperglycemia & other conditions including transplant, cystic fibrosis, & liver disease.
Intended Audience: These courses are knowledge-based activities 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 enhancing their diabetes assessment skills and preparing for certification.
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!
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 | Assessing for Food Insecurity with Diabetes
For last week’s practice question, we quizzed participants on assessing food insecurity with diabetes. 60% 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: Food insecurity affects 16% of adults with diabetes compared with 9% of adults without diabetes.
Based on the ADA standards of care, which is the most accurate statement regarding food insecurity and people with diabetes?
Answer Choices:
- Food insecurity is defined as uncertain availability of nutritionally adequate food at least once a week.
- Conduct food insecurity screening and income assessment once every 3-5 years.
- Any health care team member can screen for food insecurity using The Hunger Vital Sign.
- People with food insecurity are less likely to experience hyperglycemia due to decreased caloric intake.
Getting to the Best Answer
Answer 1 is incorrect. 31.96% chose this answer. “Food insecurity is defined as uncertain availability of nutritionally adequate food at least once a week.” Although this answer is partially correct, the last part, “at least once a week” makes this answer incorrect. According to the USDA food insecurity is defined as, “the limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.” It doesn’t include a time span or frequency.
Answer 2 is incorrect. 5.08% of you chose this answer. “Conduct food insecurity screening and income assessment once every 3-5 years.” This answer also has elements of accuracy, but flails at the end. The ADA Standards recommend conducting food insecurity screenings on a yearly basis and helping individuals access needed resources.
Answer 3 is correct. Great Job! About 60.05% of respondents chose this. “Any health care team member can screen for food insecurity using The Hunger Vital Sign.”
The Hunger Vital Sign identifies households as being at risk for food insecurity if they answer that either or both of the following two statements is ‘often true’ or ‘sometimes true’ (vs. ‘never true’):
“ Within the past 12 months we worried whether our food would run out before we got money to buy more.”
“ Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
Finally, Answer 4 is incorrect. 2.91% chose this answer. “People with food insecurity are less likely to experience hyperglycemia due to decreased caloric intake.” There is no scientific evidence to support this answer and people with food insecurity can experience periods of adequate food intake interspersed with inadequate food intake.
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?
Virtual DiabetesEd Training Conference – Join us Live on April 17th – 19th 2024 at 11:30 AM PST
Join Coach Beverly and Team for two and a half days of knowledge-sharing, fun, and “aha” moments for our Virtual DiabetesEd Training Conference April 17th – 19th, 2024.
Attendees will leave this conference with new tools and a refreshed understanding of the latest advances in person-centered diabetes care. Our team highlights the ADA Standards of Care, medications, behavior change, technology, medical nutrition therapy, and more!
Our instructors co-teach the content to keep things fresh and lively.
Friend Discount: 3 or more only $449 per person. Email us at [email protected] with the name and email of each registrant to get the discount!
Program Details
- Dates: April 17-19th, 2024
- Registration Fee: $399-$569 (see more about reg. options below)
- Friend Discount: For 3 or more people, each person saves $50 off their registration. Email us at [email protected] with the name and email of each registrant to get the discount!
- CEs: 30+ CEs | 18 units for Virtual Conference plus 10+ Bonus CEs. CEs can be applied toward CDCES’s initial application or renewal.
- Speakers: View Conference Faculty
Registration Options
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!
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.
Plant Based Diets – What Approach is Best?
The health benefits of plant-based diets are not a new topic, but as they continue to be a top headline in the news and on social media, #plantbased, we have more and more clients expressing interest in this dietary pattern.
When JR asks, “I just read about a plant-based diet; do think I have to avoid all meat?” What are we to answer?
Plant-based diet is a general term to include eating patterns that emphasize whole grains, legumes, vegetables, fruits, nuts and seeds, and discourage animal products. The popularity of this diet has grown as more evidence associates it with lower rates of hypertension, hyperlipidemia, cardiovascular mortality, obesity, cancer, and the prevention of type 2 diabetes.1 Research has also associated a higher intake of meat and processed meat with an increased risk of these similar chronic diseases.1 Definitions of plant-based can vary widely from avoiding all animal products to reducing intake of animal-based foods; Mediterranean, DASH diet, and Planetary diet approaches may fit within this definition.
Different Types of Plant Based Diets Include:
- vegan (avoiding all animal products),
- lacto-vegetarian (including only dairy),
- lacto-ovo-vegetarian (including dairy and eggs),
- pesco-vegetarian (including fish and often dairy and eggs),
- or flexitarian (occasional consumption of meat, dairy, and/or fish).
As we review articles and noteworthy news, we might ask ourselves what plant-based definition has been used.
A vegan Diet, in persons with type 2 diabetes, is effective in reducing HgbA1c and body weight.1 The 2019 Nutrition Therapy for Adults with Diabetes or Pre-Diabetes Consensus report2 stated that a vegetarian or vegan diet can reduce A1c by 0.3-0.4% in people with type 2 diabetes, and plant-based eating patterns reduce weight, waist circumference, and LDL. A 2017 systemic review and meta-analysis3 of 14 studies found in 8 observational studies that vegetarian diet patterns (excluding meat and meat products) reduced the prevalence and incidence of type 2 diabetes compared to Omnivore diets. In five studies, no significant associations between a vegetarian diet and diabetes risk were observed, however, lack of definition of the degree of vegetarian, duration and actual intake, or specificity in diet quality could have affected the results.
A plant-based diet may not always be healthful, as it could include refined grains, starches, sugars, and processed plant-based products. Refined carbohydrates and highly processed foods are independently associated with a higher risk of type 2 diabetes. The ADA Standards of Care emphasize diet quality in every reviewed eating pattern. A 2019 meta-analysis4 of 9 total observational studies (307, 099 total participants) across North America, Europe, and Asia found that greater adherence to a plant-based diet was inversely associated with risk with diabetes, and this risk was further reduced when considering diet quality. In this study, it is essential to note that, when studies were combined, even the highest category of adherence to plant-based dietary patterns still included about 1.6-4 servings of animal-based foods per day; this may be from fish, dairy, meat, or poultry.4
Comparison Study: A 2024 cross-sectional study5 completed in Germany compared vegans, flexitarians (up to 50 grams of meat or processed meat products per day), and omnivores (>170 grams/day of meat and processed meat consumption). The vegan diet was associated with the most significant benefits to cardiovascular health; however, metabolic syndrome score and arterial stiffness were more favorable in flexitarians than in other groups. The vegan and flexitarian diets were associated with lower blood lipids, reduced insulin resistance, and a higher diet quality index than the Omnivore diet. Dietary intakes of soft drinks, dairy products, sweets, meat, and processed meat were all associated with higher total and LDL cholesterol levels and Metabolic syndrome scores. However, regarding how the study categorizes food groups, we are unsure if the type of meat or dairy would have changed these outcomes. Simple categories of plant-based or omnivore may not fully explain the synergy of health impacts from diet intake.
What are Americans eating now?
Transitional dietary approaches that emphasize foods primarily from plants while also including animal foods may be a more realistic approach for many people. Despite the increasing interest in plant-based diets and a 54% growth in 2023 of plant-based product sales in the US market, only about 4% of Americans follow a vegetarian diet. Data from a recent March 2023 publication7 compared average consumption from 17 food categories to the Dietary Guidelines for Americans recommendations. Many categories fell short, with only refined grains, added sugars, proteins, and nuts, seeds, and soy meeting or exceeding the guidelines. There is a need for an overall shift in diet to improve the intake of foods touted as beneficial within plant-based diets.
Barriers to implementing a plant-based diet include lack of knowledge, cultural acceptability, and cost.7
Like JR, many people may need to learn what it means to follow a plant-based diet. Understanding the individual’s interest, discussing the range of definitions and outcomes, and emphasizing transitional dietary changes could empower change.
- All-or-nothing thinking can hinder change; reducing total meat consumption while focusing on other aspects of diet quality (reduced refined grains or sugar) can also provide health benefits.
- JR motivations, interests and other clinical conditions will direct our recommendations. He reports that he has never tried “vegan foods.” Reviewing with JR the food choices he is making that fit within the plant-based diet, discussing meal modifications, and providing new recipes may support confidence while exploring new flavors and dietary changes. (Check out the resource list for recipe ideas).
- Cost is another barrier that we must take into consideration. The 2023 article in Nutrients5 reported that consumption of “healthier” versus “less healthy” diets had a higher price difference per person than typical dietary patterns. Low-cost empty-calorie foods explained much of this cost difference and not necessarily animal-based proteins. Finding affordable food items can improve diet implementation.
- One suggested alternative is incorporating recipes that include frozen fruits and vegetables, bulk grains, and dried or canned beans which can have a lower cost per calorie than meat-based foods.
The benefits of plant-based diets are well known, and future research is needed to examine different plant-based diet variations, combinations of foods, and degrees that are most beneficial and achievable. The 2024 American Diabetes Association Standards of Care emphasizes that there is no one-size-fits-all approach to dietary recommendations, and we need to individualize our recommendations based on cultural background, personal preferences, co-occurring conditions, and socioeconomics. They recommend “food-based dietary patterns should emphasize key nutrition principles: inclusion of non-starchy vegetables, whole fruits, legumes, whole grains, nuts/seeds and low-fat dairy products and minimizing consumption of meat, sugar-sweetened beverages, sweets, refined grains, and ultra-processed foods.”8
Strategies to Increase Plant Food Intake
We can support persons with diabetes and JR by asking questions and being curious.
- “Tell me what interests you in a plant-based diet?”
- “What is your current diet intake, and what modifications are realistic for you now?”
- “Are you interested in modifying the types of foods you are consuming and learning about incorporating more plant-based food choices?”.
Based on JR’s response, we can confidently support a dietary pattern that is vegan, vegetarian, or a more flexible nutritional pattern that focuses on nutrient density and food quality.
Blog contributed by nutrition expert Christine Craig, MS, RDN, CDCES
References:
1. Sabrina Schlesinger; Diet and Diabetes Prevention: Is a Plant-Based Diet the Solution?. Diabetes Care 2 January 2023; 46 (1): 6–8.
2. Alison B. Evert, Michelle Dennison, Christopher D. Gardner, W. Timothy Garvey, Ka Hei Karen Lau, Janice MacLeod, Joanna Mitri, Raquel F. Pereira, Kelly Rawlings, Shamera Robinson, Laura Saslow, Sacha Uelmen, Patricia B. Urbanski, William S. Yancy; Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care 1 May 2019; 42 (5): 731–754
3. Lee Y, Park K. Adherence to a Vegetarian Diet and Diabetes Risk: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients. 2017 Jun 14;9(6):603.
4. Qian F, Liu G, Hu FB, Bhupathiraju SN, Sun Q. Association Between Plant-Based Dietary Patterns and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA Intern Med. 2019;179(10):1335–1344.
5. Bruns, A., Greupner, T., Nebl, J., & Hahn, A. (2024). Plant-based diets and cardiovascular risk factors: a comparison of flexitarians, vegans and omnivores in a cross-sectional study. BMC Nutrition
6. U.S. consumers’ eating patterns differ from Federal recommendations downloaded on 2/14/2023 fromhttps://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=106562.
7. Viroli G, Kalmpourtzidou A, Cena H. Exploring Benefits and Barriers of Plant-Based Diets: Health, Environmental Impact, Food Accessibility and Acceptability. Nutrients. 2023 Nov 8;15(22):4723.
8. American Diabetes Association Professional Practice Committee; 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S77–S110. https://doi.org/10.2337/dc24-S005
Checkout these websites with more information:
-
- Carbohydrate Factors; A Precise for Method for Meal Planning » an incisive article by a leader in nutrition therapy, Dana Armstrong, RD, CDCES. Dana describes an easy and accurate method for determining carbohydrate content of food beyond label reading. (do we use this anymore?)
-
- Diabetes and Diet: Food can be powerful in preventing and reversing diabetes. However, dietary approaches have changed as we have learned more about the disease. Published by the Physicians Committee for Responsible Medicine.
-
- Plant-based nutrition for healthcare professionals: implementing diet as a primary modality in the prevention and treatment of chronic disease.
-
- Low Fat Vegan Diet Improves Glycemia and CV Risk in Type 2 Diabetes » Diabetes Care 2006
-
- Plant-based diet may benefit patients with diabetes – Smart Brief: Plant-based food articles (update title)
-
- Nutritional Update for Physicians: Plant-Based Diets » Philip J Tuso, MD; Mohamed h Ismail, MD; Benjamin P ha, MD; Carole Bartolotto, Ma, RD Perm J 2013 Spring;17(2):61-66
-
- Preparing to Prescribe Plant-Based Diets for Diabetes Prevention and Treatment » Treatment of Type 2 Diabetes Plant-based eating patterns combined with exercise have been found to improve diabetes control and reduce the need for medication in intervention trials as far back as 1976.
-
- Vegetarian Starter Kit an easy to read and colorful handout for patients interested in learning more about a vegetarian diet. Published by the Physicians Committee for Responsible Medicine.
-
- Vegan Cooking – Lose the Eggs, Milk and Butter>> This article outlines vegan cooking using flax seed, tofu, soy yogurt, Ener-g egg replacer and bananas.
-
- Meatless Monday Campaign – https://www.mondaycampaigns.org/meatless-monday
-
- VegWeb: https://vegweb.com/recipes/
Videos
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- Forks Over Knives » feature film which examines the profound claim that most, if not all, of the degenerative diseases that afflict us can be controlled, or even reversed, by rejecting animal-based and processed foods (available on Netflix).
-
- Reversing Diabetes » by Neal Barnard (move this up to here, it is a video)
-
- Engine 2 Diet » by Rip Esselstyn (this is also a video)
Reading
-
- The China Study » The Most Comprehensive Study of Nutrition Ever Conducted And the Startling Implications for Diet, Weight Loss, And Long-term Health by T. Colin Campbell
-
- Whole: Rethinking the Science of Nutrition » by T. Colin Campbell
-
- Breaking the Food Seduction » by Neal Barnard
-
- The Cancer Survivor’s Guide » a comprehensive text on the scientific link between diet and cancer, the benefits of a plant-based diet, including nutrition information, and more than 130 easy and delicious recipes. (free)
-
- Veggie Nice Recipe Book >> Veggie Nice gives you a month’s worth of meatless main-dish recipes.
-
- Nourish: The Definitive Plant-Based Guide for Families by Reshmah Shah, MD MPH and Brenda Davis, RD
-
- Plant-Based Nutrition: The Idiot’s Guide
Website Resources
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- Dr. John McDougall based in Santa Rosa, California » (has a great newsletter)
-
- Vegetarian Starter Kit (English and Spanish) » whys and how’s of a healthier diet, the New Four Food Groups guidelines, practical tips for beginning a vegetarian diet, and delicious low-fat, no-cholesterol recipes. This has been updated per above.
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- Plant Based Plate Method » Physicians for Responsible Medicine version of the USDA “Plate Method” which includes low fat, plant-based foods.
-
- The Vegetarian Resource Group: https://www.vrg.org
-
- Food and Plant: Planetary Diet Resources https://foodandplanet.org/
-
- Plant-based prevention of disease organization: https://www.preventionofdisease.org/
- Plant Based Eating Resource Page
Take Education Courses
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- Nutrition Therapy and Exercise
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- PCRM Nutrition CME (free CMEs)
-
- Certificate in Plant-Based Nutrition, provided by eCornell.
Menus and Recipes
Menu Planning –
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.
Question of the Week | How to Increase Participation in DSMES?
Studies indicate that only 53% of individuals eligible for Diabetes Self-Management Education and Support (DSMES) through their health insurance receive it.
Which of the following approaches to increase participation in DSMES is based on the ADA Standards of Care?
- Adjust DSMES charges for Medicare enrollees based on ability to pay.
- Increase access to telehealth delivery of care and other digital health solutions.
- Provide DSMES in non-hospital workplace settings to increase access for employees.
- Incentivize participation through use of giveaways and positive reinforcement.
Want to learn more about this question?
Virtual DiabetesEd Training Conference – Join us Live on April 17th – 19th 2024 at 11:30 AM PST
Join Coach Beverly and Team for two and a half days of knowledge-sharing, fun, and “aha” moments for our Virtual DiabetesEd Training Conference April 17th – 19th, 2024.
Attendees will leave this conference with new tools and a refreshed understanding of the latest advances in person-centered diabetes care. Our team highlights the ADA Standards of Care, medications, behavior change, technology, medical nutrition therapy, and more!
Our instructors co-teach the content to keep things fresh and lively.
Friend Discount: 3 or more only $449 per person. Email us at [email protected] with the name and email of each registrant to get the discount!
Program Details
- Dates: April 17-19th, 2024
- Registration Fee: $399-$569 (see more about reg. options below)
- Friend Discount: For 3 or more people, each person saves $50 off their registration. Email us at [email protected] with the name and email of each registrant to get the discount!
- CEs: 30+ CEs | 18 units for Virtual Conference plus 10+ Bonus CEs. CEs can be applied toward CDCES’s initial application or renewal.
- Speakers: View Conference Faculty
Registration Options
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!
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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