This CDE is All About Type 2 and You

4/22/19
WRITTEN BY: Megan Munoz
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Megan Muñoz is a Certified Medical Surgical Registered Nurse and a Certified Diabetes Educator based in Cedar Rapids, Iowa. She works with a wide range of people living with all types of diabetes in both the inpatient and outpatient setting. Megan recently started a blog for people with Type 2 diabetes to provide a common sense, actionable resource for those living with Type 2 diabetes. Strength and resiliency are two qualities she recognizes and admires in all people living with diabetes. Read more about how Megan uses her work to improve the lives of those with diabetes, including some changes you can make today.

Tell us about your work as a certified diabetes educator. What inspired you to get help people with Type 2 diabetes?

I’ve been a nurse going on 8 years now, and have worked as a diabetes educator most of my career. This includes both inpatient (hospital) and outpatient (clinic) work. I have the privilege of working with people with Type 1 or Type 2 diabetes, as well as those with gestational diabetes. I see a range of people, from newly diagnosed to those using the full extent of diabetes technologies like insulin pumps and continuous glucose monitors.  We also use protocols in our clinic and hospital that allow me and the other certified diabetes educators (CDEs) I work with to adjust insulin and other diabetes medications. This helps people with diabetes achieve the doses they need much more quickly.

I am inspired by those living with all types of diabetes. I chose to focus my blog on those living with Type 2 diabetes because I believe Type 2 diabetes has its own unique set of challenges. People with Type 2 diabetes are less likely to get Diabetes Self-Management Training (DSMT). Which means they often — struggle in understanding the disease, create unrealistic expectations of themselves and Type 2 diabetes, and believe the stigmas that surround Type 2 diabetes. In addition, there’s a wide spectrum of Type 2 diabetes. Some people manage their diabetes with healthy eating and physical activity, some take diabetes pills while others use shots of medication, like insulin. This makes it difficult for people with Type 2 diabetes to relate even to each other and leads to isolation even though diabetes is common enough it affects 1 in 11 people.

Does diabetes run in your family? Do you have friends with Type 2 diabetes?

Diabetes does run in the family. My grandmother, who was one of my favorite people in the whole world, developed Type 2 in her 60s. She ended up on dialysis the final years of her life but it was related to long-term high blood pressure which she struggled with from a very young age. I also have aunts and uncles who developed Type 2 diabetes in the last 5-10 years. But these were not the driving factor in my decision to become a CDE. I remember observing a nurse practitioner CDE work with a young man with diabetes in nursing school. I fell in love with the interaction I saw between the two—there was respect, understanding, joint input, and troubleshooting.  I thought, “I want to do that.”

What do you usually encounter in your day-to-day work? What’s your unique approach to diabetes education and counseling?

Day to day:

I work both in a clinic and hospital setting.  

In the hospital setting, I see a large variety of patients, both with and without diabetes. I primarily do medication management with a physician overseeing my work. I do some diabetes education, but a hospital is a hard place for anyone to retain much information!  I typically focus on identifying homegoing needs someone may have, assess for low blood sugar frequency at home, and work to understand what barriers someone may have to take their medication regularly.

In a typical clinic day, I spend approximately one hour with a patient. Much of my work in the clinic setting is partnering closely with people to help them reach their diabetes goals. I may be training someone on new technology like a continuous glucose monitor, facilitating a group class for those newly diagnosed with diabetes, or sitting with someone who is facing medication changes and needs support and information about the risks and benefits of their options.

My approach:

There are underlying principles to my approach to diabetes education and counseling:

  1. No one wants diabetes complications. Seems common sense, but we’re pretty good at beating someone down when they’ve developed a complication of diabetes. And I suspect most people with a diabetes complication have already beat themselves down enough, so no need to compound it.  In reality, they’ve just had barriers to managing their diabetes well.
  2. There’s a lot of work, without much visible payoff. I think of this in the same context as saving for retirement. All the work of diabetes is largely an investment in the future. A hope that you’ve reduced your risk of complications enough that you’ll never develop one. But while all the work is day-to-day, month-to-month, the payoff is years down the road. There’s a reason it’s called a silent disease.  
  3. People with diabetes have competing priorities, just like everyone else. Jobs, kids, financial stressors, other health needs, and so on. We have to consider the amount of time each day it takes for someone to manage their diabetes because it directly impacts the time they have available to address other important responsibilities.  

If you consider these principles, how can anyone justify shaming, threatening, or berating someone struggling to manage their diabetes inside or outside a medical office?  

So, I work hard to not use those tactics on anyone.

My approach is about learning through experience. For example, I meet someone that is adamant about not starting insulin. Our appointment focuses on addressing concerns: if those concerns are about the side effects, we discuss benefits vs risks of insulin; if it’s fear of needles, we look at the equipment together and do a practice shot. I incorporate their personal health information like A1c and kidney labs in our discussion so they understand why insulin is the option being presented at this time.  

If someone is still resistant to the idea of insulin dosing, I ask them if they’d be willing to try it for a week, then come back and see me and give me “the good, the bad and the ugly.” I want to hear it all. This helps turn the overwhelming “this is the rest of my life” feeling into something short-term. The one-week follow-up gives the person with diabetes a voice and a place to be heard and supported. It also allows me to troubleshoot any problems or concerns they have regarding their medication.

Another example, I may meet someone that is not consistently taking their diabetes medications and does not check blood sugars. After our discussion, we may trial checking blood sugars before and after one meal of the day (ex: breakfast) for three days without taking their medication and for three days while taking medication. That allows them to see what effect their medicines are having on their blood sugars. And relieves them of the responsibility of trying to change everything at once.

What habits do you see in people with diabetes who don’t manage it well?

People struggling to manage their diabetes often aren’t checking blood sugars regularly. Checking is one of the only ways to make diabetes “real” and to truly gauge how someone’s diabetes management plan is working. Without checking blood sugars, diabetes remains more invisible and someone is less likely to take their medications, be physically active, or have healthy eating habits. But the root of the problem when someone isn’t managing their diabetes well is usually based in some kind of barrier, like:

  • Competing priorities
  • An ongoing struggle with high blood sugars (they stop believing it’s possible to get healthy blood sugars)
  • Fear or guilt about their diabetes
  • Cost of medications and glucose checking supplies
  • A sense of fatalism aka my family has it and they developed complications so I will too
  • The workload of diabetes self-care outweighs the benefits
  • Social barriers, like housing, food, money, etc

How do you get your clients to start making behavior changes after a diabetes diagnosis? What achievements have your clients made?

Often people that are newly diagnosed are at their most motivated to make changes. Which means information is a strong foundation for behavior change at this stage. I tend to see the most struggle when someone is in denial about the diagnosis. At times, making it more “real” (ex: comparing their lab work to the ranges we use for diagnosing diabetes), or talking about their personal risks in developing diabetes and the emotions that surround the diagnosis can help. Other times, it just takes good, old fashion time. We do give out “homework” in our classes for those newly diagnosed. This “homework” allows trialing of exercise and meal planning and how they relate to the blood sugars. This is a critical piece to behavior change and making diabetes “visible.”

I often see folks struggle with the idea of needing medication when they are newly diagnosed. Many want to trial healthy eating and activity before they start medication. If it’s safe, and someone is especially resistant to starting medication, I support them in this quest. Because one of two things will happen: they’ll be successful in managing their diabetes without medication, or they will identify that medication is needed. The key is helping the person with diabetes set a time limit (ex: 4 weeks) and a blood sugar/A1c goal (ex: A1c under 7.5%) for their trial. Otherwise, they tend to delay necessary treatment for too long, increasing the risk of diabetes complications.  

Accomplishments I’ve seen in the people I’ve had the privilege of working with:

  • Lower A1c levels, including less variability
  • Increased consistency in medication routine
  • Able to identify their medications and how they work
  • Being better advocates for themselves with their primary care provider
  • Increase in activity
  • Eating a more well-rounded diet
  • Using insulin pumps, CGMs, and medications to their max potential
  • Reduced number of low blood sugars
  • More social with friends and family
  • Report feeling less guilty about their diabetes
  • Reduced negative diabetes self-talk:  “I’m diabetic”, “cheat” meals, “bad food and good food” “Bad control”

Can you talk about the importance of Diabetes Self-Management Training?

Most people with Type 2 diabetes visit their primary care provider for diabetes checkups about 2-4 times a year, at 15-20 minutes a pop. At most, that’s 80 minutes (or less than 0.01%) out of the whole year! Which means the person with diabetes is in the driver’s seat in what kind of care they demand and receive. Diabetes Self-Management Training (DSMT) helps people with diabetes develop the skills to advocate for themselves and live a long, healthy life with diabetes.  

Diabetes Self-Management Training (DSMT), focuses on:

  • Increasing confidence and knowledge about diabetes
  • Alleviating fears and misconceptions
  • Building coping and troubleshooting skills
  • Gaining overall wellness while living with diabetes.

DSMT addresses questions like:

  • When should I be concerned about my blood sugars and what do I do about it?
  • What am I supposed to eat?
  • Will I develop or die of complications of diabetes?
  • What are the benefits and risks of my medications?
  • How do I handle holidays, travel, etc now I have diabetes?
  • How do I manage diabetes with competing priorities?

DSMT has been shown to:

  • Decrease diabetes costs
  • Decrease the risk of diabetes complications
  • Improve blood sugar levels
  • Help someone with diabetes feel confident about caring for their diabetes
  • Lower the rate of diabetes distress/diabetes burnout

The world of diabetes is changing quickly in regards to medications, technologies, research and so on. A person’s body and diabetes change over time as well. Diabetes Self-Management Training can help connect someone’s new diabetes needs to new diabetes options. Even if your blood sugars are in a healthy range, there may be a new medication or a new technology that help reduce the burden of your day to day routines.

Tell us why you created your blog, “Type 2 and You”? What do you think is missing in the Type 2 community?

I think an open conversation about Type 2 diabetes is missing in the Type 2 community. Almost everyone I see has an internal conflict surrounding Type 2; what they know to be true of themselves and the picture society paints of them. Most people can identify positive qualities in themselves (hardworking, kind, generous, etc). But when they try to mesh those with preconceived notions about people with Type 2 diabetes (“lazy, overweight, etc”), it’s a clash of positive internal dialogue with negative. Add to that the social response from others, continuous judgments like “should you be eating that?,” and you could see why many folks remain quiet about Type 2 diabetes. I remember working with a gentleman who was shocked to find out generations of his family members had Type 2 diabetes. “It was like a club I couldn’t get into until I was diagnosed.” It bodes the question: How can we change the way society thinks about and reacts to Type 2 diabetes if we can’t even talk about it in our own families?

I was inspired to start a blog for those with Type 2 diabetes for a number of reasons:

  1. Many of the people I meet in DSMT are using unreliable sources online to guide their self-care.
  2. Many of the resources online are focused on research or general information about Type 2 diabetes. There’s little, what I would call, “actionable” information out there to help people think critically about their diabetes.
  3. People with Type 2 diabetes are often not offered the same information and resources as those with Type 1 diabetes.  Pumps, continuous glucose monitors, even insulin training is limited if even offered.
  4. Less than 10% of people with Type 2 diabetes ever receive Diabetes Self-Management Training to learn about reducing complication risks and slowing the progression of Type 2.
  5. There are a number of stigmas with Type 2 diabetes.  Many of the people I meet face criticism from friends, family, physicians, or coworkers about their diabetes.
  6. I often meet people with Type 2 diabetes who have unrealistic expectations of their diabetes, so they resort to extreme eating or exercising patterns to try to meet those goals.

How do you keep up with the latest diabetes research and apply it to your practice?

I am usually an active member of the American Diabetes Association(ADA) and the American Association of Diabetes Educators. Both organizations send magazines and have online resources with new research. They also give access to continuing education. I also enjoy listening to ADA’s podcasts. Occasionally, I get the opportunity to go to a national conference, which is a great opportunity to network with other people around the country. I work with a great team of CDE nurses and dietitians and we send around new research and information during our work week.

I usually have a number of emails that come to my inbox weekly about new diabetes research. It’s a challenge to keep up, as diabetes research, medication options, and technologies have skyrocketed in the past 5-10 years! The more I learn about diabetes, the more I realize how much I don’t know — if that makes sense!

As far as applying the evidence-based practice to my work, I tend to adapt quite quickly. For example, I try to always recommend Metformin ER vs regular Metformin for women due to their higher risk of side effects. I recently started incorporating a new medication dosing routine in the hospital after watching a CEU on using Januvia (a diabetes pill) along with long-acting insulin, instead of 4 shots of insulin a day. Unless it’s a policy change where I need to write a proposal, or requires a new tool or piece of equipment, incorporating evidence-based practice is overall fairly easy to do in my day-to-day.

What’s your philosophy as a CDE? What do you think CDEs should always keep in mind while working with patients?

My core philosophy as a CDE is to decrease the burden of diabetes while improving or maintaining glucose stability. While each person with diabetes is unique and each person’s diabetes plan should be individualized, reducing barriers is the overarching goal.

The pieces that feed into this philosophy are:

  • A common sense and non-judgmental approach
  • Recognizing everyone with diabetes has a reason behind their actions
  • Listening more than talking
  • Seeing the person before the diabetes
  • Asking questions, seeking to understand and clarify
  • Not assuming
  • Understanding that I am the guide, not the ultimate decision maker

To other educators:

When you are a CDE, the most important thing to remember is you’re helping someone on their journey with diabetes, not yours. They’ve given you the privilege to come into their story, even for a brief moment of time. Be respectful and gracious with this invitation. Your job is to guide, support, challenge, empower, inform, and advocate so they have the tools and skills to be successful WITHOUT you.

What advice do you have for people who have been newly diagnosed who don’t know where to start, as well as people who have had diabetes for quite some time and don’t know how to address their condition? What are some easy diet and exercise changes they can make today?

I’m a strong believer in Diabetes Self-Management Training. Even for those who have had diabetes a number of years.

Easy changes to make right off the bat:

  • Use MyPlate as a guide for what your meals should look like
  • Cut back on your pop intake as much as you can
  • Eat three meals a day with small snacks in between
  • Focus on bursts of activity built in throughout your day
  • Exercise every other day, rather three days in a row (the benefits extend over your week better)
  • Walk 10 minutes after meals, which is when blood sugars tend to be highest (as long as you do not have heart disease)

Overall, focus on changing 1-2 things a time. Trying to change too much gets overwhelming and you’re more likely to give up!

What do you think are the biggest misconceptions about Type 2 diabetes?

That it’s reversible. Many people hold onto the hope that they can reverse diabetes if they just work hard enough. But Type 2 diabetes is progressive, meaning your body will make less insulin over time. 

Another misconception is that it’s your fault. If you look at the list of cancer risk factors, they’re similar. Yet, we don’t shame and blame people who develop cancer. Also, when you look at the list of risk factors for Type 2 diabetes closely, only a small percentage are controllable, most are not.

Another is that complications of diabetes are a given. As Dr. William Polonsky says, “Well-controlled diabetes is the leading cause of ….nothing.” Your risk for complications is significantly reduced with healthy blood sugars, blood pressure, and cholesterol.

Finally, another misconception is that someone eating a candy bar or a piece of cake is a poor manager of their diabetes. There are many ways we incorporate treats into someone’s diabetes plan. And healthy eating is only one component of diabetes care. There’s also activity and medication.

Tell our audience where they can connect with you.

I would love to hear from you!  I’m on Instagram @type2andyou_by_a_cde. You can also visit https://type2andyou.org. While you’re there, subscribe to get new posts sent directly to your inbox. I tend to write in a series format. Right now the focus is on blood sugars. Next will be medications for Type 2 diabetes. Finally, you can always reach me by email at type2andyoucontact@gmail.com. I welcome any feedback or questions.



Megan Munoz

Megan Muñoz holds a bachelor's and master's degree in nursing, along with certifications as a Certified Medical Surgical Registered Nurse and a Certified Diabetes Educator. She works with a wide range of people living with all types of diabetes in both the inpatient and outpatient setting. Megan recently started a blog for people with Type 2 diabetes to provide a common sense, actionable resource for those living with Type 2 diabetes. Strength and resiliency are two qualities she recognizes and admires in all people living with diabetes.