Each issue, EducatorWatch highlights some of the most interesting and relevant clinical studies from that stack of journals on your desk. Each study includes an Educator Take-Home Point with insights from a diabetes educator about what this emerging research could mean to you—and your patients.


HYPOGLYCEMIA SURVEY, WORKPLACE EDUCATION, PLANT-BASED PROTEIN A recent large-scale analysis of private insurance claims data found that only 6.8% of adults newly diagnosed with diabetes participated in diabetes self-management education and training (DSMT) [Li et al].

More than 80% of people with type 1 and type 2 diabetes (T1D and T2D) view hypoglycemia as a significant health concern and 62% are concerned about experiencing it—yet knowledge gaps persist in these patients, a recent survey by the American Association of Diabetes Educators (AADE) found.

The online survey of 1,000 U.S. adults with T1D and T2D found that while 98% of patients understand the importance of controlling hypoglycemia, many may be unaware of the causes and symptoms, AADE reported. They also may not know how to prevent and manage the condition.

For example:

  • Of respondents who had not experienced hypoglycemia, approximately 42% were unable to define it correctly.
  • Less than one-third (30%) of respondents cited avoiding alcohol as a way to prevent hypoglycemia.
  • Nearly half (49%) were not aware that taking glucose tablets could help treat an episode.

Sixty percent of those surveyed reported that they had experienced hypoglycemia, and 19% of them visited the emergency room for treatment. Of those who experienced hypoglycemia, 40% experienced it during the night, and the majority reported feeling anxiety (84%), frustration (68%), and fear (60%) about nighttime hypoglycemia.

“In addition to knowing the warning signs and symptoms of hypoglycemia, people living with diabetes should be informed about how to effectively manage and prevent its onset,” said Evan Sisson, PharmD, MHA, CDE, an associate professor at Virginia Commonwealth University School of Pharmacy and former member of the Board of Directors for AADE. “By consistently monitoring one’s blood sugar and working with a diabetes educator, individuals can effectively manage their diabetes and hope to reduce their risk of hypoglycemia.”

EDUCATOR TAKE-HOME POINT FROM JENNIFER L. BUCKNER, RN-BSN: The results from this AADE survey underscore the importance of assessing our patients’ understanding of hypoglycemia and how to treat low blood glucose (BG) levels. We can then identify any learning gaps that patients might have to customize their education and ensure they are equipped to recognize hypoglycemic episodes and how to prevent them.

I like to provide patients with a quick list of go-to foods that help treat lows. In addition, I review signs and symptoms the patient may have when experiencing a hypoglycemic episode. I also teach them mnemonic devices I learned in nursing school: “Hot and dry, sugar high,” or, “Cold and clammy, need some candy.” These best practices give patients the tools they need to better self-manage their diabetes.

Survey shows many people living with diabetes are uncertain about how to properly manage hypoglycemia [news release]. Chicago, IL: American Association of Diabetes Educators; January 20, 2015.


When challenges arise in getting people to the office for diabetes self-management education (DSME), an alternative may exist: Bringing the education to them in the workplace. A recent study focused on Hispanic employees who either had T2D themselves (53%) or a family member with diabetes found there was a “keen interest” in the concept [Brown et al].

Employees said they would be interested in learning more about diabetes and healthy behaviors in a workplace-based setting, especially if the education was tailored for their culture. For example, they recommended including advice on preparing healthier versions of Hispanic foods. Most said they would prefer the programs be presented in Spanish. The workers’ supervisors and administrators expressed support and interest in a workplace diabetes prevention program.

The study, published in The Diabetes Educator, included 36 Hispanic employees (aged 22 to 65 years; 80% women) who participated in a bilingual focus group at a local health fair. Participants were randomly selected from a pool of 86 peers attending the health fair who had expressed interest.

The researchers cited primary barriers to promoting healthier lifestyles, including busy schedules, family responsibilities, and limited resources. Many employees participating in the focus group worked 2 full-time or part-time jobs.

Researchers said next steps include: adapting previously successful diabetes programs for the workplace; integrating information gleaned from the focus groups; and conducting pilot tests of interventions to establish feasibility and refine approaches.

“Future clinical trials will be designed to establish efficacy and cost-effectiveness,” the authors wrote. “If found to be effective, such a workplace program would be generalizable to other service employees who have disproportionate diabetes rates.”

EDUCATOR TAKE-HOME POINT FROM KENDALL L. SMITH, MPH, RD/LD, CDE: Did you know that in many workplace settings, Hispanic employees hold 40% to 50% of the positions in service departments? What an eye-opening statistic!

How does this impact DEs? Traditionally, medically underserved populations such as Hispanics and African-Americans have significant barriers accessing adequate healthcare, coupled with a disproportionate diabetes burden. However, workplace health programs may help overcome these barriers by providing increased accessibility as compared with traditional programs. While major barriers to participating in traditional programs include demanding work schedules and lack of time, workplace health programs can help bridge this gap and mitigate some of those challenges.

In addition to being convenient, workplace health programs for the Hispanic population that are culturally tailored and conducted in Spanish have the potential to be both clinically effective and cost effective. With supportive supervisors, input regarding content, and a format with small focus groups, employees who participate in workplace health programs may benefit greatly from diabetes prevention and self-management initiatives.

It's essential for DEs to understand barriers to access and care for the Hispanic population and other underserved populations and to take steps to counter them. Implementing culturally competent workplace health programs to help improve awareness and treatment of diabetes within the Hispanic population is one way to do that.

Brown SA, García AA, Steinhardt MA, et al. Culturally tailored diabetes prevention in the workplace: Focus group interviews with Hispanic employees. Diabetes Educator. Published online ahead of print January 20, 2015.


When it comes to the risk of developing metabolic syndrome (MetS)—the clustering of cardiovascular risk factors that include hyperglycemia, hypertension, visceral obesity, and dyslipidemia—patients with type 2 diabetes (T2D) may fare better by choosing tofu or tempeh instead of tri-tip roast or turkey.

A Japanese study, published recently in the Journal of Diabetes Investigation, demonstrated that decreased vegetable protein intake and increased dietary acid load are associated with a higher prevalence of MetS in patients with T2D [Iwase et al]. Researchers also found that carbohydrate intake was associated with the quality of dietary protein and dietary acid load

The cross-sectional study, which included 149 men and women (aged 65.7 years ± 9.3 years) with T2D, assessed dietary intake using a validated self-administered diet history questionnaire. Dietary acid load was assessed by potential renal acid load (PRAL) and netendogenous acid production (NEAP).

The study found that carbohydrate energy/total energy was negatively correlated with animal protein energy/total energy, PRAL, or NEAP score. Conversely, carbohydrate energy/total energy was positively correlated with vegetable protein energy/total energy.

Using logistical regression analyses, researchers determined that there was a significantly higher prevalence of MetS in the subgroup of patients with a lower vegetable protein energy/total energy or higher PRAL or NEAP score.

Iwase and colleagues also found that in patients with T2D, low-carbohydrate intake was associated with increased animal protein intake and decreased vegetable protein intake. The authors addressed the potential clinical implications of this finding as it relates to recent research focused on cardiovascular disease and all-cause mortality.

Specifically, low-carbohydrate/high-protein diets have been found in the short term to result in weight loss and favorable effects on risk markers of cardiovascular disease. However, recent reports have suggested that in the long-term, these diets may be associated with a significantly higher risk of all-cause mortality [Noto et al]. Iwase and colleagues postulated that this may be explained by an increased intake of protein from animal sources and decreased vegetable-based protein in low-carbohydrate diets, which they observed in their study and other studies have demonstrated as well [Lagiou et al].

The researchers called for further research to explore the apparent influence of vegetable protein intake and dietary acid load associated with low-carbohydrate intake on metabolic risk factors in patients with T2D. They also pointed out that more studies would be needed in non-Japanese patients to determine if the findings can be generalized in other ethnic groups.

EDUCATOR TAKE-HOME POINT FROM JANNA BAUER, RN, BA, BSN, CDE: While it’s unlikely that I would ever have a highly scientific conversation with a patient about renal acid load as it relates to metabolic syndrome, this study’s findings are in fact quite relevant for the majority of patients I work with daily. Plant-based proteins can offer a number of health benefits for patients—not to mention, greater variety.

As DEs, we teach patients about healthy choices and balance every day. We talk about health risks and long-term goals while keeping in mind that words like complicated, expensive, and unappetizing can be roadblocks to attaining these goals.

Recently, I met with a patient who bemoaned: “Low fat, no salt, low carb—add this, take away that... and my husband is sick of broiled chicken!” As I listened to this patient, I realized that she had learned a lot about self-managing her diabetes through a healthier diet. However, she was feeling frustrated by what she viewed as limited dining choices—while also wondering how long her husband would be able to tolerate the broiled chicken onslaught.

The solution I offered to her was a list of “chicken alternatives” (AKA plant-based proteins). She quickly chose several that she knew both she and her husband would enjoy, along with a few options that were new to them. We then completed a simple mix-and-match sample menu.

The patient was smiling when she announced that the plan was not complicated at all, and that she would be stopping by the grocery store on her way home: Winner, winner vegetable dinner!

Iwase H, Tanaka M, Kobayashi Y, et al. Lower vegetable protein intake and higher dietary acid load associated with lower carbohydrate intake are risk factors for metabolic syndrome in patients with type 2 diabetes: Post-hoc analysis of a cross-sectional study. J Diabetes Investig. Published online February 13, 2015.

Noto H, Goto A, Tsujimoto T, et al. Low-carbohydrate diets and all-cause mortality: a systematic review and meta-analysis of observational studies. PLoS ONE. 2013;8(1):e55030.

Lagiou P, Sandin S, Trichopoulos D, Adami HO, Weiderpass E. Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study. BMJ. 2012;344:e4026.