and nutrition, getting the conversation started. My name is Kevin McManus and I will be moderating today's program. To share a little bit about myself, I am a registered dietitian and assistant professor in the nutrition department at Case Western Reserve University in Cleveland, Ohio. My career has really been focused on helping patients with diabetes really optimize their health and well-being through food and nutrition. And in doing so, I've had the opportunity to serve on several national committees for the Juvenile Diabetes Research Foundation as well as the American Diabetes Association. Before I share a little bit more about the American Diabetes Association and the many benefits of becoming a member, I first want to thank the American Diabetes Association's Diabetes Technology and Nutrition Advisory Group because none of this would have been possible without their guidance. So thank you. The American Diabetes Association is a fantastic professional organization that you can join and become a member today. By becoming a professional member of the American Diabetes Association, you will have opportunities to network and grow professionally. The ADA membership also includes a variety of professional member benefits, including benefits such as access to several professional journals, members-only webinars, and a member directory of thousands of clinicians, researchers, and others working in diabetes. So as you can see, you will have access to a lot of great resources as an ADA professional member. ADA has launched a new CME CE program module series on diabetes technology and nutrition supporting healthy eating habits through CGMs on their Institute of Learning platform. It is a five-module series aiming to help primary care professionals help bridge that gap between diabetes technology and nutrition when treating people with diabetes. In addition to just having these modules, you'll also have access to infographics, handouts, and printable nutrition placemats. The first module is now available and is titled Maximizing CGM to Facilitate Lifestyle Changes. So you can register for it today and the link will be available in the chat. Now let's transition to today's program with Dr. Thomas Martens and Allison Ever. So Dr. Thomas Martens will be our first presenter discussing diabetes technology and nutrition in primary care. Dr. Martens is the medical director at International Diabetes Center, Health Partners Institute, and a consultant in internal medicine at Park-Nicollet Clinic in Minneapolis, Minnesota. He is a long-time supporter of the ADA and has previously chaired the ADA's Time and Range Advisory Group. So thank you Dr. Martens for joining us today. Our second presenter, Allison Ever, will be discussing why, what can I eat, and how does food impact my glucose. Allison is a recently retired registered dietician nutritionist and certified diabetes care and educational specialist. She has over 30 years of experience and Allison is also a long-time supporter of the ADA and she co-chairs the ADA's Diabetes Nutrition Therapy Consensus Guidelines. So thank you Allison for joining us today. Here are the speaker's disclosures and as we're going through the presentations, if you have any questions, please type them in the Q&A box in your control panel and then we'll be answering as many questions as we can at the end of the session. So with that said, I will now turn it over to you Dr. Martens. Thank you so much Catherine. I am Tom Martens. I'm an internal medicine physician at Park Medical Clinic in Minneapolis, Minnesota and I also work as a medical director at the International Diabetes Center. Thrilled to be here today to talk with you about how to help people with diabetes use diabetes technology to optimize their nutrition. So using technology to evaluate the impact of nutrition is not a new concept. We've had finger stick blood glucose monitoring for many years. It appeared back in the 1980s. It's widely taught, it's widely prescribed, widely available in both type 1 and type 2 diabetes. What we know about finger stick blood glucose monitoring is it's well proven. It's been shown to be effective in multiple research studies. It's able to show the impact of nutrition on glycemia. But despite all this, despite availability, outcomes in research studies, in clinical settings, the outcomes have often been disappointing and this is especially true for people with type 2 diabetes not managing with insulin. So type 2 diabetes not on insulin therapy. The value of finger stick blood glucose monitoring tends not to be that great if you look at the data. Likely this is related to the burden of use and ineffective use or non-use of the results in clinic settings. We now have another option. More recently continuous glucose monitoring or CGM has become more available, widely available in primary care settings now. Widely used especially for people with type 2 diabetes and it offers us the potential for easier visualization of data and better access to data with less burden. So let's think a little bit about CGM data. If you think about CGM data, we really have two different types of data that we can gain from CGM devices. The first is point in time data. The person with diabetes has very easy access to a glucose value. But in addition to that, they have a trend arrow that shows whether the glucose is going up or the glucose is coming down and they have a trend line. They can see where the glucose has been and where it's headed. And so very rich point in time data. CGM also offers us the opportunity to look back at retrospective data. Retrospective data is available both to the person with diabetes on their cell phone as CGM metrics, time and range metrics, and is also available for use at the time of clinic visits if you download it from the cloud sources in the form of an ambulatory glucose profile report that gives you a very good sense of what the glycemic patterns are, what the glucose metrics are, and basically gives you a very robust picture to use in discussing CGM data with patients. So the data to help inform whether CGM is useful in helping people to modify their nutrition and behaviors is still emerging. We don't have a strong sense. We can, however, take a look at some of the randomized control data we have and get a sense of whether it is helpful or not. First big study, the diamond study, remember this is CGM versus BGM in people with type 2 diabetes using multiple daily injections. This data came out back in 2017. CGM looked better than BGM. The CGM group decreased their hemoglobin A1c from 8.5 to 7.7 percent. Was that related to change in medication? Well when we looked, the CGM group had a slightly higher total daily dose of insulin than the BGM group and only there was not a significant difference in other medication changes. So a little bit of increase in insulin but not much. So there's something else going on here. We look at the mobile study. So the mobile study is CGM versus BGM in people with type 2 diabetes using basal insulin but not prandial insulin. Over eight months the CGM group decreased their hemoglobin A1c from 9.1 percent to 8 percent and did significantly better than the BGM group. Was that based on maybe intensification of medications, advancing people to prandial insulin? It really did not look like it. There was no significant difference between the two groups in insulin dosing at the end of the study. There was no significant difference between the two groups in addition or reduction in diabetes medications and so it really looks like some of that difference between the CGM and BGM group really was related to people being able to see their glycemic data and make nutrition choices based on it. Final randomized control trial that I have to present to you today, the immediate study. So this study is recently published data from last year. This is a study that looked at people undergoing diabetes self-management education training. So people seeing the diabetes educators, they took one group and did traditional diabetes self-management education training. They took a second group and randomized them to get the same training plus use an intermittently scanned CGM device and they followed these people over 16 weeks. The study actually, instead of using hemoglobin A1C as their primary endpoint, looked at glycemic metrics, CGM glycemic metrics as their primary endpoint. So what they looked at is change in time and range. Primary outcome measure for the study change in time and range. Just a little reminder about time and range. So time and range is the time spent between a glucose value of 70 and 180 over the course of a period of time, typically about two weeks. And we have international consensus targets for time and range. We would like to keep that over 70% of the patient's average day. We have consensus targets for time below range also. We'd like to minimize that hypoglycemia, keep it under 4%. Let's see how the people did in the study. So here are outcomes from the immediate study. If you look at the top column, time and range, the group that was assigned to diabetes self-management education plus CGM improved their time and range from a starting point about 56% to 76.3%. They were meeting their time and range target. They were over 70% time and range. The group that got diabetes education alone improved from 56% to 65%. So they improved. It was a good improvement, but they were not meeting their time and range targets. So the group using CGM plus diabetes education did 9.9% better. And that carried through to the other measures, the secondary measures. The hemoglobin A1C ended at 7.6% in the CGM plus education group, 8.9% in the CGM plus education group, 8.1% in the education alone group. And so it really did look like the CGM was a very useful adjunct to standard diabetes education training, allowed people to see what was going on and use that information to really improve their nutrition. So how do we as primary care clinicians, and I am among that group, use glycemic data and especially CGM data to maximize the impact of nutritional guidance? I think bottom line, brief, focused nutritional guidance is what we need to be giving to our patients, helping our patients with to help them in knowing what their glycemic goals are, know how to use CGM data to learn about the impact of nutrition on glycemia. And beyond that, just watch, learn, and take action. Beyond that, once we get beyond brief, focused nutritional guidance, we need to use our team. We need to get people more information about the impact of nutrition. And for that, we lean on our diabetes educators. So know your goals. How are we going to teach people to think about glycemic values? Here are the typical glycemic goals. If you are a healthy adult who is non-pregnant, where would we like to see your glucose values before meals? Pre-prandial values, we would like to see them between 80 and 130. That's our goal. About after a meal, one to two hours after eating, we would like to keep that glucose value under 180. So before a meal, 80 to 130. After the meal, we would like to see them not rising above 180. We're going to modify those goals if we're working with an individual who is older, has extensive comorbidities. But as a rule of thumb, that's what we need to be aiming people towards. We do know it's important to have goals setting for patients. And these are the appropriate goals. This study showed that interventions that involve goal setting were more effective than usual care in relation to glycemic control and type 2 diabetes at 6 and 12 months. So help people to know their goals. How about if we're living in the CGM world and we are helping people to understand retrospective goals? Here's where we need to circle back to time and ranges. So our time and range target for glucose values between 70 and 180. Again, we want it to be over 70% of their average day. In the time below range, we would like to obviously minimize hypoglycemia. We'd like to keep that less than 4%, moving people from target range, below range, hopefully to above 70% or even higher. Not everybody's able to achieve that. It's important to keep our goals realistic and achievable and point out to people that every 5% increase in time and range is clinically significant, which is to say that it decreases long-term risk of diabetes complications. So keep our goals achievable. Here's how we can help people to think about point in time goals for people who are using CGM. They are seeing their data essentially in real time on their telephone. So we need to help them to think about that. Say we take a look before breakfast, where would you like to be before breakfast? 80 to 130. Where would you like to be after breakfast? Less than 180. And so, you know, we can help them to think about that, but also to be curious. Think about what's making a difference. If there's a day when you have less postprandial hyperglycemia, what did you eat on that day? If you have a better day, what did you eat on that day? So be curious, think about what makes the difference and learn from it. What makes the difference in meals? Again, we need them to think about the impact of food choices on glucose values. They can use their CGM to think about the impact of exercise, think about the impact of illness, stress. They can observe, they can learn, and hopefully turn that into action. Once they've observed and learned, how do we think about optimizing nutrition? How do we think about optimizing nutrition? Well, choose foods and beverages that improve glycemia and also optimize nutrition. Remember, this isn't all just about the glucose values. We want to be encouraging people to eat foods that are nutritionally high value rather than low value and really are going to be improving the big picture. So we can encourage them to choose whole fresh foods for meals and snacks. We can teach them about the plate method. Fill half your plate with non-starchy vegetables such as leafy greens, carrots, broccoli, bell pepper, green peppers. Decrease the portions of food that you notice usually raise your glucose. Avoid sugar-sweetened beverages, always an important point to make because we all see a lot of this. People are drinking a lot of Mountain Dew, even orange juice, and it makes a big impact on glycemia. And finally, limit foods with added sugar such as cereals, sauces, salad dressing. Bottom line, know your goals. Know how to use the CGM data to learn about the impact of nutrition on glycemia. See what's making you rise. See what does better. Watch, learn, and then take action. Here's one I can share with you. This came from one of our many excellent RDN diabetes educators at the International Diabetes Center who shared this with me to help illustrate the importance of counseling on sugar-sweetened beverages. So here's a before. This was an individual who came in for diabetes education having an awful lot of daytime hyperglycemia. Daytime hyperglycemia was hyperglycemic most of the daytime, most of the days. Some very brief focused counseling. Pick a single objective, and that was to decrease sugar-sweetened beverages. They returned three weeks later. The main intervention was decreasing and eliminating sugar-sweetened beverages. What difference did that make? When we look back at the time and range data, we can see they started at 47% time and range. Three weeks later, 93%. So a dramatically different picture just with a very simple intervention. One simple thing that was identified, change made, progress being made. So brief nutritional guidance. It often doesn't take that much really to see early benefits from using CGM to help leverage nutrition, improving glucose. Well, can't everybody just get a brief nutritional message? How come we need an RDN diabetes educator to work with our patients? What is the power of team? And this is it because it isn't all about glycemia. At least part of the picture is nutritional value. Here's a recent study that really, I think, goes a long ways towards illustrating this. So this group looked at a population from the United Kingdom Biobank, took a huge number of individuals. It was an observational study, but they looked at first a group of 40-year-olds who had sustained dietary change from unhealthy dietary patterns to healthy dietary patterns. They actually gained eight to nine years of life expectancy. How about if you make the change from unhealthy to longevity associated diet patterns? Think Mediterranean diet. You can actually get 10 years of gain in life expectancy. Largest gains, more whole grains, nuts, fruits, and less sugar-sweetened beverages and processed meats. So this is, I mean, it's huge. You know, this is as important as counseling on quitting smoking. And our dieticians can help people really leverage all of this to improve not just their glycemia, but their life. So why refer to RDN diabetes educators? Well, beyond our brief nutritional messaging, they can help in avoiding pitfalls. And there are some potential pitfalls here in that the bottom line is that optimized glycemia is not necessarily optimized nutrition. Dietitians can help patients navigate the maze of diets, you know, there are all sorts of diets out there, none of which I think has necessarily been proven to be all that much better as far as weight loss, although some of them do do better as far as long-term outcomes and optimized nutrition, and important to help people navigate that maze. Cultural sensitivity, we all grow up with culture, diet, food, meals are incredibly important to culture, and as we work with people to improve glycemia, we don't want to be taking that away from them, and there are ways to work with culture, with food's impact on culture that allow people to achieve both ends. Finally, we need to avoid the pitfalls of using CGM to improve glycemia in that there are good ways to improve glycemia, and there are ways that are less helpful, and it's a spectrum. CGM can be used to help people improve with healthy eating, but it also can inadvertently cause people to move to unhealthy eating, for instance, highly processed meats. It can also, for some individuals, feed into disordered eating. How do we navigate that? That's not my field of expertise. That is why we need to leverage our team and work with RDN, CDS-trained dieticians. With that, I'd like to hand it off to Allison Everett to help us think more about how do we move beyond just improving glycemia, but actually improve our nutrition. Thank you very much, Dr. Martin, and I'd like to begin by thanking the American Diabetes Association for the invitation to participate today, and also my heartfelt thanks to the American Diabetes Association for their very long-term support of the role of the registered dietician and diabetes educators on the healthcare team. We are adrift in a sea of nutrition information, and in many cases, nutrition misinformation, and it's not surprising that many of our patients are questioning the value of nutrition, the information that they receive from their healthcare provider, if it conflicts with what they're hearing on the internet, social media, their cousins, their co-workers, their families. During my presentation today, I will be discussing evidence-based nutrition recommendations and also some clinical applications, some translations to clinical practice. I just wanted to remind everybody that nutrition is a field of medicine, just like other fields of medicine, and these evidence-based recommendations are the result of research, and then careful, thoughtful, peer-driven analysis at that body of literature in order to inform nutrition practice. This is a figure that I really like. It's been in the standards of care and updated over the last few years several times, but it's from Chapter 4, and it's the Comprehensive Medical Evaluation and Assessment of Comorbidities. You can see that patient is in the center of the decision tree for patient-centered care. I'm going to highlight this one box here that really is important because we as clinicians bring our clinical experience and our expertise, as well as our knowledge of the evidence, to our patient encounters. Our patients bring to those same encounters their life experiences and their knowledge of diabetes self-care. It's where all of this intersects, where I call it the magic happens, and there's another word for it, as you'll see on the slide here, shared decision-making. We as diabetes clinicians need to collaborate with our patients to help them make their decisions about their care and also what they choose to eat and drink. Let's see here, moving to the next slide. In Chapter 5 of the Standards of Care, this year it's entitled Facilitating Positive Health Behaviors and Well-Being. There are nutrition recommendations in that chapter, as well as ones on physical activity that we don't have time to discuss today, psychosocial care, smoking cessation, and sleep health, but this is one of the overarching nutrition recommendations that evidence suggests that there is not one ideal percentage of calories, carbohydrates, proteins, and fat for all people with diabetes and at risk of diabetes. Therefore, macronutrient distribution needs to be individualized based on an assessment in that context of shared decision-making and patient-centered care, what makes that patient tick, what types of eating patterns are they following, what are their cultural religious preferences, what is their health literacy, what is their health numeracy, as well as their metabolic goals. This table here, the eating patterns that the Nutritious Consensus Committee that was convened in 2018, and I was a part of that consensus report, and there is a new consensus group that has just been convened in the last week to update, to do a deep dive on the topic of what works best for people with diabetes in terms of eating patterns, but the ones that our committee looked at were the Mediterranean-style eating pattern, plant-based approaches, dietary approaches to stop hypertension, low-carbohydrate and very low-carbohydrate diets, keto diets, low-fats, very low-fat, and paleo. And this table here shows you, and it is in that consensus report, it kind of helps you very quickly see the different types of eating patterns, the foods and beverages that are encompassed in that eating pattern, but more importantly, on the right side of the table, it shows you what the potential metabolic benefits and reported outcomes are. So if you are working with a patient and they don't know what direction to take, and let's say they have high blood pressure and they want to lower it, they have high triglycerides, they want to lower their A1C, or if weight management is their goal, this can help inform maybe the direction that you and your patient can go. Now, we need to operationalize that eating pattern into something that the patient can do every day in real life, so I'm going to be spending a little bit of time talking about eating plans and approaches for people with diabetes, and we have to keep in mind that even though a patient might choose an eating pattern that we are not wild about, it's going to be much easier for the patient to follow an eating pattern that they choose, not one that you tell them to follow. And if you think about your own life and your own self, our eating habits are hardwired, and so sometimes it is, it's difficult and the progress may be slow to change our eating habits. I always say I envy my nutrition physician and nurse practitioner and PA colleagues, they can prescribe a pill that's pretty easy to take, but eating patterns are hard to change. So first off, some terminology. Nutrition professionals are trying to limit the use of the word diet, you'll be seeing a lot more in literature the term eating plan. Diet has such a negative connotation besides as one of my patients pointed out many years ago, diet is die with a T. These are typically not sustainable long term. So an eating plan is something that can help guide that patient, what to eat, when and how much on a daily basis and what's really cool when you help your patient come up with a game plan or an eating plan is that you can use it in any type of eating pattern that they choose to follow. So let's look at the components of an eating plan and carbohydrates play a very big role in the foods that we eat. It's a fact glucose is the preferred source of fuel by the body. So many, many foods contain are from carbohydrate sources. Another fact is the main determinant of that postprandial excursion is the amount of carbohydrate that is consumed and relative insulin response that that person has with diabetes. If they have type one, they don't have an insulin response, right, they'll be matching their desired carbohydrate intake with their food. But what we know as Dr. Martin mentioned, we will be seeing that postprandial excursion that peak about one to two hours after the patient eats or the person with diabetes eats. And we need to help communicate this with the patient because if they're going to be seeing their glucose levels showing up on their receiver or their smartphone in real time, they need to have a context of how that food is impacting their glucose management. I think it's very important if you have the time to assess your patient's knowledge to use open ended questions. When we ask a patient, what are sources of carbohydrate? Did you know that when we study adult education that it takes about seven seconds to formulate an answer? So if we ask our patient an open ended question of any sort, we need to have that pregnant pause, we need to stop and start counting to seven to see what their understanding or their knowledges of that question that we're asking. I always say we don't know what our patient knows until they tell us. Follow up question after carbohydrates might be what's the difference between starchy carbs and non starchy carbs such as vegetables? What are sources of protein foods, sources of fats? And as that excellent case study that Dr. Martin presented, what are the drinks that you have with your meals and snacks and do they contain carbohydrate? Many patients unknowingly sip on things, big tumblers of orange juice that they think are healthy but not really aware of the carbohydrate impact that they might be having. Dr. Martin, we're reinforcing each other's presentations here, mentioned the plate method. In a busy primary care practice where I spent the last seven years of my career, I know you don't have a lot of time to do this. So nutrition and meal planning. So a plate method is a really great thing to do. If your patient needs education on carbohydrate counting, they want a calorie level, they want to learn how to count fat grams or the glycemic index, this is the time when I would refer that patient to the registered dietician, diabetes educator for more in-depth training. But I do want to spend just a moment to talk about intermittent fasting. If you are a person that is prescribing medications, insulin, insulin secretogogues, GLP-1 receptor agonists, you need to know what type of intermittent fasting your patient is doing if they are sharing with you that they are doing intermittent fasting because there's actually three categories of intermittent fasting. There's time-restricted, which is the most common. Usually people eat between like 12 and 8 p.m. at night, or they might be doing early time-restricted eating where they're eating early in the morning and stopping at 3. But there's also every other day fasting, and there's the 5-2 plan, which is five days of normal eating and two days of fasting. So if you're prescribing medications and your patient is intermittent fasting, make sure you understand which type. Just another plug for the plate method, it's a nine-inch plate. It's not a platter. So if you have paper in your printer in the exam room, or you have paper that you can draw on on the exam table, giving the patient that idea of that plate size. One of the things, a tip for the plate method, patients often don't always eat just starch or meat or some sort of protein. Oftentimes they have a combination meal like chicken enchiladas or spaghetti and meatballs or hamburger helper. That combination can be half of the plate, but the constant on the other half is the non-starchy vegetables. So how are you in a busy practice going to help operationalize this to help the patient have the skill to do this when they go home? You could ask an open-ended question with that piece of paper and say, what would you do tonight at dinner? And draw on that plate or write on that plate something that they would help you come up with for that dinner meal. How would that work for lunch? And we know all of our patients eat out at some point in the week. How would this work when you're eating out? Another translation to clinical practice, simply reducing the portion of carbohydrates sometimes can make a big difference. When we look at people that maybe have a lot of rice in their diet, I think sometimes it's surprising for primary care providers when I do programs like this to see that a cup of cooked white rice, a cup of cooked brown rice, and a cup of quinoa have equivalent amounts of carbohydrate. So when we're having a patient eat something totally different than the rest of their family, sometimes if they just eat less of what everybody else is eating, it will work better for everybody. So in terms of crucial conversations, in terms of that integration, in terms of CGM and nutrition, as a diabetes educator, we have the luxury of time with patients. A typical first appointment would be 60 minutes. And something that we go through in our diabetes education classes is that it's estimated that a person with a diagnosis of prediabetes has lost about 50% of their beta cell function. It's estimated that a person with a diagnosis of type 2 has lost up to 80%. So I will say over the years, I tell my patients, it's my job to help you keep making insulin as long as possible through the food choices that you make. Many people with type 2 diabetes, as you will probably see in your own practice, will need insulin within 10 to 15 years. GLP-1 is also diminished as well. So kind of going on with this education for patients, if you are providing them with a prescription for CGM and they're going to start seeing their glucose levels in real time, we need to just constantly reinforce that healthy glucose levels are going to keep them healthy long term. And that it is not a personal failure of that person with diabetes, it's a pancreatic failure if at some point in time that medication needs to be increased or added to help that person stay healthy long term. So other things to kind of keep in track, as well as supporting what Dr. Martens was saying, if you are prescribing CGM, you have to give them some glucose targets so they have a frame of reference to where their glucoses should be once they have a diagnosis of diabetes. So if you think about an oral glucose tolerance test, we've all heard of those before, you probably sent referrals for them or orders for them. It is normal, considered normal, after a glucose challenge to have a glucose under 140 milligrams per deciliter. That's normal. Our patients go on the internet and they look and they are encouraged by often people that don't have diabetes that are wearing CGM to have a flat line in their postprandial excursion. And once again, we need to reinforce to our patients that it is normal for your glucose levels to go up a little bit. When our patients ask us, what can I eat? My common response over the years is I encourage them to become, as Dr. Martens said, curious. I tell them they can become their own science experiments. We want them to help by looking at what happens before they eat at their glucose level and one to two hours later, they can see that cause and effect relationship between their food choices and their beverage choices. I should also kind of reinforce and remind you that the renal threshold for glucose is 180. And that's where that kind of 180, that peak postprandial number kind of comes in. And sometimes this is a hook for me, too, as a diabetes educator, I'll share with my patients, if your glucoses are consistently over 180, 200 at bedtime, you're going to be getting up a lot over the night with glucoseuria. So evidence-based strategies. These are right from the standards of care in chapter five. It's a level evidence that we should provide education on the impact of carbohydrates and also fat and protein. And as previously mentioned, we need to encourage people to eat more whole, less processed foods. One of my nutrition one-liners that I share with patients is eat your food, don't drink it. I would have a hard time eating three oranges in a sitting, but if I drink 12 ounces of orange juice, it's pretty easy to gulp that down and I don't even have to chew. We also wanna emphasize heart-healthy fats because we know more people with diabetes die of heart disease than they do of diabetes. Translation into clinical practice, when I'm talking to patients about what could they do, what could they try to see if they could blunt or reduce that postprandial excursion is think of their stomach as a big mixer. When they eat a meal and they add some fiber to it or some protein or some healthy fat, they can experiment to see if they can have a different result in their glucose excursion. This is just a picture of the AGP report, something that we look at too as registered dieticians and diabetes educators in the group. If you're busy, sometimes that 14 day or seven day overlay that kind of graphs all those glucoses are really helpful as a registered dietician with the luxury of time that I have in my appointment, I can often have a little bit more time to dig into those daily details. This is an example of a patient that I worked with before I retired in September, but a 58 year old male with a diagnosis of diabetes of 15 years. I printed off with the exam room printer, we didn't have color, we just have black and white, but I would actually draw on it. I'd write down, this is your medication, you're on metformin, 1000 milligrams BID. This patient was trying to follow a low carbohydrate eating pattern, but his time and range was only 53%. He agreed to come and meet with me because he was so frustrated that his efforts on the low carb diet were not succeeding. And what we found as we looked at this AGP report was that he was never really even during his waking hours when he was following that low carbohydrate diet, he wasn't really in range. But what was happening, which he admitted to when we had our visit was he was so frustrated and so hungry at bedtime that he would often snack on chips or cereal and milk. And he was completely missing that his glucose levels were rising overnight. So with a diagnosis of 15 years and only taking metformin, what we talked about was that progressive nature of type two diabetes, even though he was trying really hard, it was time to advance his therapy. So we circled back with his PCP and he was started on a GLP-1 receptor agonist. So just in summary, Dr. Martin and I have been kind of reinforcing the same thing, be curious, trial and error. A patient might decide that if their blood glucose goes up after something they eat, that will be an occasional once in a while food, but they will still enjoy it every so often. And then that it can't be stressed enough, working with a patient with shared decision-making. And if you don't have time, diabetes education and medical nutrition therapy are covered by almost every insurance provider and would really encourage you to make the referrals to support the work that you are doing with your patient as well. And with that, I think we're done. Thank you so much again, Dr. Martins and Allison for a great presentation and really sharing such, such valuable information. We're gonna now take some time to answer questions that we have from our audience today. So if you haven't done so already, please submit your questions by typing them in the Q and A box, but we've already received some excellent ones. We're gonna go ahead and get started with them. So the first one is for you, Dr. Martins. The question was, would you say that CGM is now the gold standard for assessing blood glucose levels in people with type one diabetes as well as type two? Yeah, no, that's a very good question. I think CGM has become the standard for people with type one diabetes. We know based on randomized control trial data that it is helpful for people with type two diabetes if you're using insulin. And so that which leaves this huge portion of people with type two diabetes who are managing with non-insulin therapies or with lifestyle. For that group, we do not have complete randomized control trial data. And so is it the standard of care? I think it is not. I think BGM, we know it works. People can use it and continue to use it. Some people like it and some people like it better. And so I think these are technologies that both have their place and purpose. For a lot of people, CGM data is just much easier to visualize, much easier to see the impact of lifestyle, of nutrition. And so a lot of people really thrive on it. And it does seem to decrease the burden of management a bit. Yeah. Thank you, Dr. Martens. That's really, really informative. Alison, the next question is for you. So one of our audience members asked, in the region where I practice, there is a shortage of dieticians. Any recommendations in these cases where we can't refer most of our patients to a dietician? What can we do? Well, I know that for dieticians and diabetes educators, there was a silver lining with COVID and that was telemedicine. And I think if you don't have a dietician in your practice or want to refer, look to see if at a larger metropolitan area, there might be somebody that you could refer that patient to. I mean, I have always over the years, I've looked at any patient that ever came in, we looked at injection sites for insulin shots and things like that. But for the most part, a dietician doesn't have to touch somebody. And the other thing that's so amazing about telemedicine is that patient can go into their kitchen and pull something out of their cupboard. And we can look at foods, I can see what they're eating out of. I've done knife skills classes where patients were afraid to cut vegetables because they were afraid they were gonna cut themselves and who can bring a knife into a clinic, right? That would be a big problem. But the other thing is, is I worked in a primary care practice group of 14 clinics. When I started as the manager of the nutrition program, we weren't teaching diabetes education and we were able to add, we have five staff from two. And the last three people that I hired were not diabetes educators, but they had an interest. So if you have a practice, hire somebody part-time. There's a lot of people that like working part-time, get your, train your own diabetes educator and it's a source of income and referral to your practice as well. That is a really good suggestion. Thank you, Alison. Dr. Martens, the next question is for you. Can you address the lag time from CGMs compared to the finger stick or blood glucose meter? Sure, yeah, no, very good question. So blood, finger stick blood glucose testing, you have pretty immediate response. You're measuring glucose from the blood. CGM is a little different. So you have a sensor with a tiny electrode that sticks just beneath the skin into the interstitial fluid, which is a different compartment, right? And so when we think about lag time, what we're thinking about is the amount of time it takes for the glucose to get from your bloodstream into the interstitial fluid. And there is a lag time there. It's about five to seven minutes typically. And then that is worth making people aware of because there's a lag. If they're watching their glucose on their cell phone based on CGM data, there's a lag there. And it's worth being aware of, especially if they're hypoglycemic or they're headed towards being hypoglycemic, that it's slightly less than real time. On the other hand, CGM has some benefits that help to partially compensate for that in that you have trend arrows, you have trend lines. And so you can much more easily see where things are headed with a CGM. But lag time, it is real. It's worth being aware of. And it's one of the components of CGM technology that's really hard to get around just because we're measuring the glucose from the interstitial fluid rather than the blood. And that's one reason why, Dr. Martens, that blood glucose monitoring will never go away because if a person feels like they're going low and their sensor glucose data is saying that they're not, we always need to trust our feelings. Or if you don't have a glucose meter, we always say, if in doubt, treat, right? So- Well, exactly. And in fact, that is called out in the standards of care, the ADA Standards of Medicare Care for Diabetes 2024 calls out that people using CGM should have continued access to finger-stick blood glucose monitoring just for that reason. If you're seeing something that doesn't make sense, all of this technology is imperfect. And so if what you're seeing doesn't make sense, try and confirm it with a different technology or just act on it. Thank you both. Allison, the next question is for you. Sometimes the same diet results in erratic glucose levels after some time. How should we handle those situations? So the same diet? So they eat the same thing one day, is that what they're getting at? And then the next day- That's what the question seems to imply. Yeah, I think it has to do, I mean, there's so many things going on too. Have they been physically active? What's their stress level? You know, we know the flight or flight response. The food preparation, you know, did they make it? Did they eat it out? And also I think if you look at the big picture and our goal is, you know, less than 160, 180, two hours after eating, if one day it's 140 and the next day it's 150, I'd say that's in the ballpark. I mean, so. There's a lot of different physiologic variables that go into that. You know, starting with, for instance, if you eat a salad before you eat that donut, you're going to have a different glycemic response than if you eat the donut before the salad. Things like gastric emptying, we know that diabetic autonomic neuropathy can affect gastric emptying, but so can GLP-1 medications. All that stuff makes the difference. And so there are all these physiologic variables. And so what I tell my people is, you can carb count, it's never going to be perfect. Nobody can be perfect because there's all these other physiologic variables and diet variables that feed into it. So you do the best you can, knowing that you'll never be perfect at it because nobody is. Thank you both. Dr. Martens, the next question is for you. What are most insurance requirements these days for being able to get a CGM? Sure. So insurance requirements for being able to get a CGM vary from insurer to insurer. If you're talking about commercial insurance, Medicare right at this point will cover CGM for anybody who is using insulin. They've dropped the requirement for the four time per day glucose checks. They have dropped the requirement to be on more than two injections per day. So you no longer have to be on MDI. So Medicare as a DME item will provide CGM for anybody using insulin to manage their diabetes. Or people who have problematic hypoglycemia. And there's some parameters around how that's defined. Commercial insurance is fairly variable. Typically it follows Medicare guidance and most insurers will cover people using insulin to manage their diabetes. For people on non-insulin therapies, it's a lot more variable. Just depends on your commercial coverage. The nice thing is a lot of times that's a pharmacy benefit and not a durable medical equipment benefit, which makes it a lot easier to order. And I'll just throw in like, we've had some luck with patients that haven't had insurance coverage to take their prescription and ask the pharmacist to run it through GoodRx. And that tends to bring the price down as low as you can get. And what we'll say, maybe you can't afford to wear it all the time, but maybe when you first get started on your new eating plan or your new medication. And we definitely encourage patients to wear it for the two weeks before their appointment with their care provider. So they can take that information in to the provider to help use when they look at their medications. Yep. Very good thoughts. Yep. Thank you both. All right, Allison, this is a long question. We're gonna get it from both angles, right? Yeah, it's great. I love that. I love it. This is a long question, but I think it relates to kind of what both of you tapped into about cultural sensitivity. So the type of eating pattern shown in the table on the slides does not represent all cultures. For example, in the Rio Grande Valley in Texas with over 90% Mexican descent population, changing the eating pattern to Mediterranean is just not practical. The original or authentic Mexican diet includes much vegetables, fish soups, which are healthy eating. There are not much studies on Mexican diet and its effect on diabetes. How can our medical care professionals familiarize themselves with diets based on the cultural background of their patient population? Well, I think to immerse, hopefully if they're working with that patient population to try to really understand what they're eating. And that's where I was trying to get at. If I don't know that plantains are a source of carbohydrate or a different type of plant as a healthcare professional, I'm not gonna be able to help that patient. So culturally learning the sorts of foods that that patient's culture eat, and then which ones contribute carbohydrate, and then eating smaller portions of that, trying to determine what are the non-starchy things. I think there's so many times I've seen so many people over the years as a diabetes educator and a dietician that adopted Western eating behaviors. And within a few years developed type two diabetes after a 40 pound weight gain, because there was only one Coca-Cola machine, in their, a soda pop machine in their village that they lived in. And now they're living across the street from an AM, PM, mini mart. So there's many times that we encourage people to go back to their old eating habits. And to Dr. Martin's case study, it's usually the beverages too that we work on as well. So I don't know if you have anything to add. Just to put it out there, watch the highly refined foods. And that is not part of most people's traditional diet, but it's highly processed foods a lot of times are the culprit. And that is a key failing of the Western diet, highly processed foods, keep an eye out for it. And we need to, as culturally sensitive providers need to be really aware of the way we are working with patients to meet them where they're at. And this avoid all white food business is just hocus pocus. And you can eat a healthy diet in any cultural context. It's just a matter of meeting people where they are at. And not having your own lens applied to their diet, for sure. Yeah. And I think culturally too, there's a lot of fear about some medications as well. I think as a diabetes educator, that's one of the things that I learned, eating and the food, but also the medications and some of that long held health beliefs too, that once you start working with that patient population, understanding their culture and their beliefs can be very helpful. And if you don't understand that, you likely won't succeed, honestly. Such great points about building rapport with patients. We have so many great questions, but we're just going to finish with one last one for Dr. Martens that came up actually from a few different audience members. Is it acceptable to diagnose diabetes with CGM data or does it have to be through an A1C blood draw or finger stick? That is a really good question. So CGM, you get a pretty good glycemic picture and wouldn't it be nice if we could diagnose diabetes like that? At the present time, we do not have criteria to diagnose diabetes based on CGM data. So we're left with the three modalities that we have, hemoglobin A1C, fasting glucose or the glucose tolerance test. And all of those are imperfect in their own ways, but yet useful. And CGM as a diagnostic tool for diabetes, I suspect that data will come. Right now, we don't have it. Thank you so much again, Dr. Martens and Allison for such a great presentation and answering all of these fantastic questions from our audience. As a reminder, be sure to enroll in the new Diabetes Technology and Nutrition course. Modules will be released weekly and the first module is currently available. So you can find the link for that in the chat. Please also remember that you can return to the Institute of Learning to receive your continuing education credit for completing those. Before we conclude our program today, I would like to thank each of you for joining us and we hope to connect with you in person at the 84th Scientific Sessions in Orlando this June. Thank you again for joining us. Thank you to our presenters and enjoy the rest of your afternoon. Thank you.

Dr. Thomas Martens

Allison Ever

nutrition

diabetes management

continuous glucose monitoring

CGM technology

glycemia

individualized eating plans

cultural sensitivity