Which of the following matches the ADA guidelines for diabetes eye care?

1. An eye examination is recommended before pregnancy.  
2. Get eye exam immediately at type 1 diabetes diagnosis, then yearly thereafter.
3. If no retinopathy found on initial exam, refer to trained retinal expert for thorough exam.
4. Only trained opthalmologists can screen for type 1 diabetes eye disease.

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Level 2 | Microvascular Complications, Eye Kidney, & Nerve Disease Standards | 1.5 CEs

Objectives:

1. Eye, kidney and nerve disease
2. Modifiable and non-modifiable risk factors for diabetes complications
3. Screening guidelines and prevention strategies.

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Level 2 | Setting up a Successful DSME Program Standards  | 1.5 CEs

Objectives:

1. The steps involved in setting up a Diabetes Program
2. List program essentials
3. Discuss marketing strategies for success

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

As a child, LR lived with neglect and mistreatment by their parents. Escaping home as a teenager, LR couch surfed at friends but finally ending up living in their car. At the age of 23, LR showed up at our local community clinic with dysregulation, depression, and anxiety coupled with a new diagnosis of type 2 diabetes and elevated triglycerides. LR had limited access to healthy food and carried a BMI of over 35.

After a few months of getting comfortable with the clinic staff, our counselor asked LR to complete the Adverse Childhood Experiences (ACE) screening assessment. After LR finished checking off their adverse childhood experiences, they looked up with tears and said, “I scored a 9 out of 10”.

Adverse Childhood Experiences (ACEs) are common. At least two-thirds of people living in the U.S. have experienced one ACE and over 15% have experienced 4 or more.

Furthermore, a dose-response relationship exists: as the number of adverse experiences increases so does the risk of problems from childhood through adulthood.

These childhood traumas can lead to toxic stress which, over time, can change the biology of our bodiy.

People with elevated ACE scores are more likely to experience a variety of mental health issues, which is not surprising given their painful, confusing, and unsafe childhoods. Based on sound research by the CDC and Kaiser, they are also more likely to suffer from physical diseases, like heart attack and stroke, diabetes, and cancer. They are more likely to break bones and experience unintended pregnancies.

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Join Coach Beverly at an Upcoming Webinar

The Impact of Adverse Childhood Experiences on Health: A Personal Story of Resilience and Hope with Coach Beverly

ADCES National Virtual Meeting – Ready for Viewing
California Coordinating ADCES Chapter – September 30, 2021 at 4:45pm PST
Diabetes Ed Services Webinars – airs October 27th at 11:30 am PST

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Toxic Stress Affects us at the Cellular Level

Research shows that ACEs can lead to a cycle of toxic stress and cellular inflammation. This heightened adrenal-mediated “flight or fight” response over time, can lead to neuroendocrine dysregulation, altered immune response, affect DNA packaging and activate epigenetic tags that can alter genetic makeup.

The CDC Morbidity and Mortality Weekly 2019 report tell us that preventing ACEs could reduce:

• 21 million cases of depression
• 1.9 million cases of heart disease
• 2.5 million cases of excess weight

The first Surgeon General of California, Nadine Burke Harris, MD, MPH, has made it her mission to increase awareness, identify and address ACEs with parents, children, and adults so that we can break the cycle.

Health care professionals at risk for ACEs
People who enter healing professions may be experiencing toxic stress from childhood or current trauma. They may be dealing with burnout, fear, or feelings of deep pain with their past coupled with all the intensity of providing care during the COVID pandemic. This chronic and toxic stress can lead to dysregulation while impairing our ability to cope and care for others. You are not alone.

My own personal journey of experiencing childhood trauma and holding myself together until I ended up in the hospital, has compelled me to share my story with you. And offer a message of hope.

Coach Beverly

As I work on healing and integrating the different aspects of myself, I now feel more attuned to others who have weathered and survived childhood trauma. This awareness has significantly changed the way I hear what people with diabetes are saying and interpret what they are doing. For example, knowing that LR had a very high ACE score, I was able to adjust my expectations and focus on behavior changes that support self-care and self-regulation. When LR doesn’t take their diabetes medications for a few weeks, I provide gentle strength-based coaching to help LR get back on track. I make sure LR knows that they are safe sharing the truth of their story, no matter what.

In your hospital setting, do you have a person who keeps getting readmitted to the hospital in a diabetes crisis? In your outpatient setting, do you experience frequent no-shows or situations where people aren’t able to make changes in self-care? Maybe, they are struggling with the emotional impact of toxic stress.

Adults who have experienced trauma as children may exhibit the following behaviors:

• Missing appointments
• Not taking meds as prescribed
• Not adopting new lifestyle changes

As Diabetes Care and Education Specialists, if we recognize these behaviors as a response to dysregulation due to toxic stress, we can provide a therapeutic response to start the healing process.

Helpful provider responses when you suspect that participants are not engaging in care due to childhood trauma and toxic stress:

1. Refrain from harsh language or judgement
2. Be curious, ask open ended questions
3. Provide the ACE screening tool to start the conversation
4. Encourage collaboration using a person centered approach
5. Identify mental health resources in you community

Diabetes Care and Education Specialists recognize that the mind and body are a deeply connected, dynamic, and powerful force when they are working together in harmony. When trauma and toxic stress are not recognized or treated, there can be devastating health consequences. We can make a difference in preventing, recognizing, and helping people heal from adverse childhood experiences.

Want to learn more about the ACEs and Healing?

Join Coach Beverly at an Upcoming Webinar

The Impact of Adverse Childhood Experiences on Health:
A Personal Story of Resilience and Hope with Coach Beverly

ADCES National Virtual Meeting – Ready for Viewing
California Coordinating ADCES Chapter – September 30, 2021 at 4:45pm PST
Diabetes Ed Services Webinars – airs October 27th at 11:30 am PST

Resources

ACE Resource Network

ACE Screening Tool and Resilience Inventory

Becoming ACE-Aware Training Program

Nadine Burke Harris, MD TED Talk on How Childhood Trauma affects health

NPR Article – Take the ACE Score and Learn what it does and doesn’t mean

Trauma-Informed Care Fact Sheet

Why should I care about my number?

CDC Vital Signs – Impact of ACES

CDC Mortality and Morbidity Weekly Report on ACEs – 2019

What happened to you? Conversations on Trauma, Resilience, and Healing – authors Oprah Winfrey and Bruce D. Perry, M.D., Ph.D.

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

For our July 27th Question of the Week, 72% of respondents chose the best answer. GREAT JOB! We want to “take a closer look” at this question and determine strategies to choose the best response.

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question 1: JR has type 2 diabetes and is trying to lose weight by eating less and moving more. JR asks your advice about drinking diet sodas.

Based on the recommendations in the ADA Standards of Care, what is the best response?

Answer Choices:

1. Sodas that contain non-nutritive sweeteners help with weight loss and increase sugar cravings.
2. Try to decrease intake of beverages with non-nutritive sweeteners and increase water intake.
3. Drinking beverages with non-nutritive sweeteners is better than drinking sugary beverages.
4. Research has found that drinking beverages with nonnutritive sweeteners decreases diabetes risk.

As shown above, the most common choice was option 2, the second most common answer was option 3, then option 4, and finally option 1.

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Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. Since medical nutrition therapy (MNT) is an integral part of providing diabetes care, regardless of profession, it will be helpful to be familiar with the MNT guidelines in the ADA Standards of Care 5. Thanks much, Coach Beverly

Answers & Rationale

Answer 1 is incorrect, 4.29% chose this answer, “Sodas that contain non-nutritive sweeteners help with weight loss and increase sugar cravings.” According to the ADA “The addition of nonnutritive sweeteners to diets poses no benefit for weight loss or reduced weight gain without energy restriction.” The ADA Standards makes no comment on sugar cravings associated with non-nutritive sweeteners, so the first and second part of this answer are not based on evidence, which makes this answer false.

Answer 2 is correct, 72.39% of you chose this answer, “Try to decrease intake of beverages with non-nutritive sweeteners and increase water intake.” Yes, this is the best evidence based recommendation for fluid intake, health and diabetes management. I recommend flavored sparkly waters or adding a slice of cucumber, lemon or a fresh strawberry to your glass of H2O and calling it spa water.

Answer 3 is incorrect, 15.86% of you chose this juicy answer, “Drinking beverages with non-nutritive sweeteners is better than drinking sugary beverages.” According to the ADA Standards, “some people with diabetes who are accustomed to regularly consuming sugar-sweetened products, nonnutritive sweeteners (containing few or no calories) may be an acceptable substitute for nutritive sweeteners (those containing calories, such as sugar, honey, and agave syrup) when consumed in moderation.” Clearly, the ADA Standards do not say that beverages with non-nutritive sweeteners are better than sugary beverages, so this answer is juicy answer is false.

Answer 4 is incorrect, 7.46% of you chose this answer “Research has found that drinking beverages with nonnutritive sweeteners decreases diabetes risk.” According to the ADA, some research has found that higher nonnutritive-sweetened beverage and sugar-sweetened beverage consumption may be positively associated with the development of type 2 diabetes.”

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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Enroll in our Virtual DiabetesEd Specialist Program!

Medical Nutrition Therapy + Meal Planning + Exercise with Guest Speaker Ashley LaBrier | 4 CEs

Topics include:

• Medical Nutrition Therapy Updates and Critical Content
  • Describe person-centered nutrition issues based on assessment and clinic data.
  • Explore national guidelines for medical nutrition therapy and how to individualize interventions from a person-centered perspective.
  • State how to customize nutritional approaches in people living with complications of diabetes.
• How to Eat by the Numbers and Meal Planning Approaches
  • Describe the impact of micro and macronutrients on health.
  • List different meal planning approaches and the pros and cons of each.
  • Describe how to help people with diabetes to read labels and be thoughtful consumers.
• Keeping Well Through Activity and Nutrition
  • Describe activity benefits, precautions, and recommendations

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

According to the ADA Standards, which of the following is the most accurate recommendation to continue to protect JR’s kidney function?

1. Initiate low dose ACE Inhibitor or ARB
2. Focus on lifestyle changes
3. Maintain protein intake to ~0.7 g/kg
4. Reduce sodium intake to 1000 mg per day

Click here to test your knowledge!

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Level 2 | Microvascular Complications, Eye Kidney, & Nerve Disease Standards | 1.5 CEs

Objectives:

1. Eye, kidney and nerve disease
2. Modifiable and non-modifiable risk factors for diabetes complications
3. Screening guidelines and prevention strategies.

---

See Full Calendar for upcoming webinars and events.

Can’t make it live? All paid registrants are guaranteed access to the video presentation, handouts and podcasts.

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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!

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

For our July 20th Question of the Week, 78% of respondents chose the best answer. GREAT JOB! We want to “take a closer look” at this question and determine strategies to choose the best response.

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question 1: LS is 26 weeks pregnant and just discovered she has gestational diabetes. LS asks you what type of meal planning approach will help keep her and the baby healthy.

According to the ADA Standards of Care, what is the most accurate response?

Answer Choices:

1. To promote healthy fetal development, consume about 175 gms of carb a day.
2. Try to eliminate simple carbohydrates to decrease risk of reactive hypoglycemia.
3. Consume the majority of carbs in the morning when you are most insulin resistant.
4. Eat no more than one serving of fruit a day to prevent hepatic fructose toxicity.

As shown above, the most common choice was option 1, the second most common answer was option 2, then option 3, and finally option 4.

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Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. Being familiar with diabetes self-management guidelines and considerations during pregnancy is critical for exam success. If you don’t work with people with diabetes during pregnancy, I encourage you to be familiar with the ADA Standard on Diabetes and Pregnancy and to consider joining our online course for a 1.5 hour painless summary of this standard (see below). Lastly, don’t forget to leverage your common sense and vast health care knowledge to get to the best answer for these specialty topics. Coach Beverly

Answers & Rationale

Answer 1 is correct, 78.69% chose this answer, “To promote healthy fetal development, consume about 175 gms of carb a day.” GREAT JOB. According to the ADA Standard on Diabetes and Pregnancy, the food plan during pregnancy is individualized based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). The DRI during pregnancy recommends a minimum of 175 g of carbohydrate, a minimum of 71 g of protein, and 28 g of fiber, with an emphasis on monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. All people with diabetes during pregnancy need to meet with a RD/RDN for specific guidance and recommendations.

Answer 2 is incorrect, 15.99% of you chose this answer, “Try to eliminate simple carbohydrates to decrease the risk of reactive hypoglycemia.” This is a juicy answer. It is true that eating less simple carbs, including processed foods and beverages, is a good idea before, during and after pregnancy. However, the second part of the answer makes this response incorrect for two reasons; the term “reactive hypoglycemia” is not a generally accepted diabetes term in this context and eliminating simple carbs would potentially increase the risk of hypoglycemia.

Answer 3 is incorrect, 3.02% of you chose this answer, “Consume the majority of carbs in the morning when you are most insulin resistant.” Part of this answer is correct. During pregnancy, many people are more insulin resistant in the morning. But, if a person is more insulin resistant in the morning, they would decrease the consumption of morning carbs to prevent post breakfast spikes.

Answer 4 is incorrect, 2.31% of you chose this answer “Eat no more than one serving of fruit a day to prevent hepatic fructose toxicity.” During pregnancy, incorporating a variety of fruits in the meal plan is a great idea, since they are packed with micronutrients, vitamins and fiber. They are carbohydrates and will increase blood sugars, so portion size and timing are important to consider when working them into the meal plan.

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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Level 2 | Pregnancy & Diabetes Standards | 1.5 CE

This course reviews those special needs while focusing on Gestational Diabetes and Pre-Existing Diabetes. Included are the most recent diagnostic criteria, management goals, and prevention of complications during pregnancy. A helpful review for the CDCES Exam and for those who want more information on people who are pregnant and live with Diabetes.

Topics include:

• Three issues that affect pregnancy with diabetes
• The unique attributes of pre-existing diabetes in pregnancy and gestational diabetes
• Diagnostic criteria and management goals for gestational diabetes
• Potential short term and long term complications of fetal exposure to hypoglycemia
• Prevention measures to keep mother and baby healthy

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

I felt pretty discouraged reading through the New England Journal of Medicine (NEJM) summary of the state of diabetes treatment and control in the U.S. from 1999-2018. We have stalled in improving diabetes outcomes in spite of exciting new therapies and dazzling technologies.

Based on this “Diabetes Report Card” for the U.S it seems pretty clear that changes in our care delivery system are urgently needed. First, let me share the data, then we consider how Diabetes Care Specialists (you and me) can drive the improvement arrow in the right direction.

The data summarized below is extracted from the National Health and Nutrition Examination Survey (NHANES) which assesses national trends in diabetes care and outcomes for the past decade.

Summary of the major findings of the Diabetes ABC’s.  A1C, Blood Pressure and Cholesterol.  
Data is compared from the 2007 -2010 period to the 2015-2018 time period.

Reaching A1c Target of less than 7%?

• The percentage of people with diabetes and an A1c of less than 7%, declined from:
  • 57.4% in 2007-2010 to
  • 50.5% in 2015 to 2018

Coach Bev’s Report Card Comment: Blood glucose levels trended up.  GRADE C-

Reaching LDL target of less than 130 mg/dL?

• The percentage of people with diabetes and an LDL of less than 130 leveled off, with slight movement in the right direction.
  • 52.3% in 2007-2010 to
  • 55.7% in 2015 to 2018

Coach Bev’s Report Card Comment: Lipid levels improved slightly.  GRADE B-

Reaching blood pressure goal of less than 140/90 mm Hg?

What are the barriers and how can Diabetes Care and Education Specialists help improve the grade?

The year 1999 got off to a good start with improved diabetes control but stalled and declined as the decade moved forward. There are several possible reasons as cited by the authors.

Sluggish initiation of first-line therapies. In 2015–2018, only 56.3% of adults with diabetes were using statins, 59.5% were using metformin, and 60.3% were using an ACE inhibitor or ARB.

These results are consistent with those of previous studies and point to clinical inertia as a potential culprit.

In addition, achieving glycemic and blood-pressure control often entails the use of multiple agents. However, the study found that only 60.6% of participants with an A1C level of 7% or higher and 52.8% of those with a blood pressure of 140/90 mm Hg or higher were treated with more than one glucose-lowering or blood-pressure-lowering medication, respectively.  

Coach Beverly suggested action: Diabetes Care and Education Specialists can continue to raise awareness of the ADA Standards of Care for Diabetes and advocate for initiating first-line and add-on therapies in their work settings. Plus, we can encourage a streamlined referral process to facilitate participant access to DSMES and to RD/RDN for initial and ongoing lifestyle and nutrition counseling.

Care Gaps for Young People, Ethnic Groups and Uninsured Populations

The study found that younger people, Mexican Americans, and persons without health insurance were more likely to be untreated when risk-factor targets were not achieved. These gaps are especially magnified in under-resourced areas.

In addition, given that the rates of diabetes-related complications are higher in people of color and uninsured populations and that type 2 diabetes discovered in young adulthood have a more aggressive clinical course than diabetes, immediate action is required to improve outcomes.

Coach Beverly suggested action: Diabetes Care and Education Specialists continue to take a leadership role in intentional and unrelenting outreach to provide DSMES and MNT to under-resourced communities using novel and evidenced-based approaches. Since prediabetes rates are also higher in many of these communities, establishing easily accessed Diabetes Prevention Programs and networking with community health workers and leaders can contribute to improved health outcomes.

Medications are too expensive for many people

Even though we have a slew of new and highly effective classes of diabetes medications, they are out of the financial reach for many. As patents expire and the medications are available as generics, access and affordability will increase. In the meantime, a realistic approach to providing affordable diabetes treatment is needed.

Coach Beverly suggested action:

Diabetes Care and Education Specialists can help craft a medication plan that is realistic and affordable. For people with no insurance or large co-pays, consider using available generic diabetes medications. These medications often cost $10 or less for a 3-month prescription. They include: metformin, sulfonylureas, and pioglitazone. In addition, Walmart offers Reli-On insulins including Regular, NPH, and 70/30 insulin for $25 a vial. There are also online resources like GoodRx.com that help people find discounts on their usual medications and the different pharmaceutical companies also offer discount programs based on need.

See Insulin Cost Savings Guide for an abundance of resources and useful links.

In conclusion, Diabetes Care and Specialists are perfectly positioned to influence health delivery systems and advocate for best clinical practices. We can be catalysts for establishing DPP and DSMES programs in under-resourced communities and advocate for access to affordable medications and technologies to help participants reach their targets for A1C, Blood Pressure, and Cholesterol while improving quality of life.

With a concentrated effort, maybe our next report card will be a little bit better!

With hope, Coach Beverly

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Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Based on the recommendations in the ADA Standards of Care, what is the best response?

1. Sodas that contain non-nutritive sweeteners help with weight loss and increase sugar cravings.
2. Try to decrease intake of beverages with non-nutritive sweeteners and increase water intake.
3. Drinking beverages with non-nutritive sweeteners is better than drinking sugary beverages.
4. Research has found that drinking beverages with nonnutritive sweeteners decreases diabetes risk.

Click here to test your knowledge!

---

See Full Calendar for upcoming webinars and Virtual Courses.

Can’t make it live? All paid registrants are guaranteed access to the video presentation, handouts and podcasts.

---

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

Email Address Sign Me Up!

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.

Want to learn more about Hospitals & Hyperglycemia? Join us for our

Level 2 | Hospitals & Hyperglycemia Standards Webinar
1.5 CEs

Topics include:

• The impact of hyperglycemia in the hospital setting
• The importance of inpatient glucose control
• Three strategies to get glucose to goal in the hospital setting

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See Full Calendar for upcoming webinars and Virtual Courses.

Can’t make it live? All paid registrants are guaranteed access to the video presentation, handouts and podcasts.

---

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE!  Sign up below!

Email Address Sign Me Up!

Accreditation: Diabetes Education Services is an approved provider by the California Board of Registered Nursing, Provider 12640, and Commission on Dietetic Registration (CDR), Provider DI002. Since these programs are approved by the CDR it satisfies the CE requirements for the CDCES regardless of your profession.*

The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.