CDE and Dietitian

So after my first appointment with the CDE, where I literally learned nothing, I essentially gave up on that service. The CDE also advised me that I only needed to test once a day (I’m on insulin). Rather than go to the effort to find a new CDE willing and able to support my goals, I just decided to be my own advisor and let my meter be my guide.

Am I missing out on something valuable here?
The same story and question apply to me experience with the dietitian.

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CDEs and dietitians can prove a useful ally if they don’t force their values on the transaction. A dietitian that tries to sell a minimum amount of carbs per day as absolutely necessary after s/he hears that I carb limit as a basic tactic of my treatment plan is not one I’d want to spend much time with. A CDE can be very useful as a troubleshooting help like with failed absorption sites or refreshing your sick day rules when you’re suddenly ill.

Encouraging/approving insulin using diabetics to only fingerstick once per day is not defensible. Does s/he want you to fingerstick before you drive through his/her neighborhood? How about using fingersticks to inform your diet? What about when you feel a bit off? How about after taking a correction dose of insulin to treat a high BG? What about first thing in the morning? Or before a crucial exam you’re taking to boost your career?

Neither is essential to my diabetes care but I think for beginners may play a valuable role.

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I’ve never really understood why some health professionals seem to want people to limit the amount they’re testing?

I’ve been told in the past I test too much, but If it improves your control and it’s not a financial burden why is that a problem?

Perhaps if you’re testing every 5 minutes, but I’ve often been told testing more than 8 times a day is over kill. Which doesn’t add up to me.

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There are 2 kinds of CDEs in this world…

  1. nurses who wanted a day shift job
  2. people who for good reason (self or a loved one had diabetes) devoted their career to learning everything about it they possibly could and want to help others with it.

Find someone that fits #2. They’re out there.

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I’m only on basal insulin, no bolus. But I will often test before meals, and after, to see the effect of the meal. She said I could get all the info I needed by testing once a day if I staggered the testing times throughout the day. I had no intention of eating the same thing each day, though, so that would take years and some serious software.

Hi @Adam_W,

We learned a huge amount from a good CDE and a good dietician. We also asked a lot of follow-up questions on email after that over several months. Even now we still occasionally ask and get valuable answers.

We have also learned NOTHING from some CDEs.

So far we have taken about 12 training sessions on different topics from our diabetes clinic (we have taken pretty much every seminar but two). Most of them have been truly valuable. We have also learned valuable things from other session participants.

I have a scientific background and always come prepared, so I am a difficult audience:-) I think there is a real benefit from good CDEs and dieticians. if you are disappointed in yours, based on how much we have benefited from our contacts with good ones, I would suggest you keep on trying others if it is possible for you.

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@WestOfPecos, thanks. That’s exactly what I was wondering. Is it really worth the effort, and money (insurance covers it, but only after the deductible has been met), to keep trying. I have access to one outside of insurance (a service provided by work) without any cost. I might try to pick her brain a bit about questions I may have. I’m on a relatively good ride right now, but I’m not even 9 months in yet so I know things are bound to get crazy at some point.

One has to understand that CDEs and Dieticians are mostly focused on Type 2 not on insulin. And they have a “model” of treatment that testing is a way to inform the doctor about how you are doing so they can increase or decrease your treatment. So why would you need more than one test strip?

I actually attended AADE like two years ago where one presentation showed a study that if patients took action (like not eating donuts for breakfast) based on test results they had better outcomes. That this was a surprise to diabetes educators may seem shocking, but that is the world. Apparently many educators don’t believe patients will make changes to their diet based on test results. I’m sure it doesn’t help that historically they advised (and still do) a low fat, high carb diet and didn’t want patients lowering their carbs.

Get your doctor to accept that you will be acting on the test results and that the tests are not for him and most doctor should be reasonable and let you have more strips.

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This is amazing to read - that they were surprised. I am aghast - but unfortunately not totally surprised myself.

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@Adam_W, maybe I should rephrase my comments a little bit. For a T1D, these seminars were extraordinarily valuable. Some were much more valuable than others, in particular the ones about treating sickness, and dealing with sports. The ones about insulin calculations were good but few surprises.

For a T2 that is not using bolus insulin, they would not have been as relevant, because a lot of the lectures focus on bolus and correction. So I am not 100% sure that what I posted applies to you as well. I always feel the need to be ready for contingencies, so I think I would probably want to understand better what I will need to do if I get there.

There were a couple of discussions that would have been really interesting for you too now. In particular, we had a CDE who had been a T1 for 40+ years, and who had great practical thoughts and ideas. She was also able to talk about what you need to do in real life vs in theory. She knew a lot about good gear, and that helped us ramp up quickly. All of what she said would have been useful to you.

Difficult decision for you I understand. Wish I could help more:( If you want to discuss further the content we got, feel free to PM and we can chat!

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You can read more about this study over at my blog.

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Sturgeon’s Law

Theodore Sturgeon, one of the leading lights of the golden age of science fiction, was at a convention when he was buttonholed by an angry, pugnacious would-be literary critic. The guy got about eight inches from Sturgeon’s face and declared, defiantly, “Ninety percent of science fiction is crap!”

Without missing a beat, Sturgeon quietly and calmly replied, “Of course. Ninety percent of everything is crap.”

One can debate what constitutes the correct percentage, but the incident illustrates a universal rule. Whether we’re talking about doctors, lawyers, auto mechanics, computer programmers—or CDEs—there will always be a bell curve with good ones, bad ones, and the great mass of “ordinary” ones. It’s true of all professions in all times and places.

Point being, you got a CDE who doesn’t fit your needs. Keep looking. As Sam says, they’re out there.

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Unfortunately this is probably true, especially since the concept of “eat to your meter” is often never even presented as an option and properly explained. In these cases extra testing probably is a waste of time. I just wish more CDE’s would take the time to explain this simple concept.

I had a professor in college (Computer Science degree…) that added a practical corollary (probably not his, but if he said who said it, I’ve forgotten): Out of every thousand programmers out there, ten are good - the other nine hundred ninety are out there making work for the ten! I think the same can be applied to certain other professions without modification.

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They should change the title of their profession: CDE implies that they are out there trying to educate people - Effective education does not begin by assuming abject idiocy on the part of the student.

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They can’t present this concept when all they’re expecting is for you to test once a day. It’s a circular problem.

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“Eat to your meter” is a blockbuster concept when treating diabetes. It’s odd how some of the most effective ideas are lost in the noise created by the drive for profits and organizational prestige.

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Yeah, no one told me to do this. Not the hospital, not my doctor (an admitted diabetes novice), not the CDE, and not the dietician. The hospital told me to test before meals to determine how much to bolus (I was discharged with a basal-bolus regimen). The CDE thought I could get all that information by testing once a day if I staggered the time. That’s not eating to the meter, it’s eating to the A1C. The dietitian didn’t even offer anything but an argument on how many carbs are required per day (we “compromised” at 105).

This sort of blanket approach should be malpractice, but instead it’s accepted and expected procedure. Telling people they can still eat the same foods

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This context is why the diabetes online community and peer support plays such a valuable role. For a time I was angry with some doctors, dietitians, and CDEs for not passing such valuable info on to me. Now I realize that it is the patients that are the pros in this setting and I see the health professionals as complementary with good peer support and learning from books.

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As stated by many here, there are good and bad in all professions. And I am very sorry the CDE you worked with was not what you needed.
That being said, there are a lot of very good ones out there. You just need to find the right fit. I currently have 2 that I see when I feel the need. New change in treatment, questions about diet. How to do the calculations that my old pump did for me and my new one doesn’t etc. I have had diabetes for a very long time and still find everytime I go in I learn something new. Of the 2 I use, one does have type 1 and is a RD and never pushes any kind of diet on me. Both have said whatever works for you and makes things easier for you, we can make it work. That was through my trying to get Smylin to work and now Victoza. They have been great and very helpful.
If you are at a clinic and there are a few there, keep trying until you find one that helps you and doesn’t just talk to you.they need to listen to you. Conversations are a two way street, both talking and listening to each other. Don’t give up, there are very good ones out there. And I try and see mine every few years, unless there is something I think I need more time than my doctor can give me.

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