Need help navigating life with diabetes? Ask D'Mine! That's our weekly advice column, hosted by veteran type 1, diabetes author and educator Wil Dubois.

This week, Wil attempts to settle a bet about high blood sugars and exercising, and also tells us what he really thinks about certified diabetes educators (CDEs). You won't want to miss this...

{Got your own questions? Email us at}

Andrew, type 2 from Utah, writes: There was a lively discussion at my church's diabetes support group that we could not resolve, and we agreed that your expertise will settle it for us. My side says that exercise can raise blood sugar because of the adrenaline release of a workout; the other idiots maintain it's physically impossible to go high during exercise because the muscles are supposed to use more glucose when in action. Who's right?

Wil@Ask D'Mine answers: You win, Andrew. The other idiots lose. I hope you bet heavily. (Oh and I'm tickled pink to be The Arbitrator of Diabetes Wisdom. I can't wait to add that to my next business card!)

Well... actually, you're both right... kinda sorta... in a way. Let me be clear: Working out does generally mop up excess blood sugar; so the net long-term effect of working out is to lower blood sugar. But where your other idiots went wrong was in being inflexible and not considering the other half of the equation: Before exercise lowers blood sugar, it commonly raises it first.

Here's how it works: Moving muscles need more sugar than muscles sitting on the couch watching Dr. Oz. But when you start working out, depending on the amount of insulin available, the intensity of the workout, and your blood glucose level, your body may not have access to sugar in the blood and will tap into its sugar reserves. To do this, your bod turns to its "fight or flight" fuel, using adrenaline as you correctly noted, to signal the liver to produce sugar.

But wait a minute, doesn't the body know how much sugar to release for the job at hand? Sure. But one half of the diabetic body is working just fine and dandy, while the other half is kaputt, as we know. The kidneys and the liver working together are great fuel producers, but you've still got that whole pancreas problem. Your exercising diabetic body can no more handle a flood of sugar from your internal organs than it can from a cupcake-eating contest. The spike in sugar triggered by exercise commonly out-paces the utilization of sugar at the beginning. When you start working out, your blood glucose can spike, then drop again downstream.

But you are waaaaaay more right than the other guys, because it's not only physically possible for exercise to raise blood sugar, but it's actually pretty common. So they have to pay up.

And in case the other guys accuse you of rigging the bet, you can see what the Joslin and Hopkins Arbitrators say. They agree with me, but they aren't as entertaining as I am.

I guess that new business card had better read Entertaining Arbitrator of Diabetes Wisdom.

Trent, type 1 from New Hampshire, writes: I read with interest the "conversation" about the AADE and diabetes educators following a recent post by MikeH on Diabetes Mine. Wil, I saw you briefly quoted in the article, but I wanted your take on the follow-up conversation, which began to evolve into an argument over what it takes to be a diabetes educator, and in particular how much pure medical knowledge it should require. I'm guessing you have a lot of perspective on this issue. What's your opinion?

Wil@Ask D'Mine answers: It's true that I have a lot of perspective on the issue. But it may not be an objective perspective, so I hesitate to give you my opinion at all... but what the hell, it's my column, so why not occasionally say what I really think?

So this is just my opinion (but I do have science on my side to prove I'm right). Read on.

First, with respect to everyone who likes to argue that a lot of knowledge of medicines and medical subjects is required to be a CDE, I have only one thing to say: If that's true, why do we let registered dietitians become CDEs?

I submit it's because dietitians bring something valuable to the table, namely a deep understanding of how food affects the human body. You could argue that food is as important to controlling diabetes as medications are.

So that begs the question: Does anyone else have something valuable to bring to the table? They used to let social workers be CDEs. Interesting. Could it be because your social environment affects your diabetes?

Hmmmmm...  Medications and anatomy. Diet and nutrition. Social environment and resources. What else would be useful? How about perspective? This is what PWDs bring. This is what we have that can't be taught. Meds, food, social work—these things can be learned. Living diabetes has to be experienced.

But backing up all the way to the beginning, let's think about what CDE stands for: Certified Diabetes EDUCATOR. So really, a CDE is a teacher. Do you need deep medical knowledge to teach? I guess it depends on what you are teaching. Look, "CDE" isn't a job description. What CDEs actually do for a living varies vastly from site to site and region to region in the country. Some do work a great deal with medicines. Others, no so much. Some, not at all. Some CDEs work in hospitals. Some work for private practices. Others for independent firms. Many work for pharma and device companies manning "help lines," never seeing a patient face-to-face, never seeing a patient's medical chart.

So as the educational role of CDEs varies a great deal, so too, I think, can the people who should have access to the title. But I also think this whole notion of "what does it take" is looking at the problem from the wrong angle. I don't think we should be asking who doesn't know something, but rather who does know something.

And PWDs know a thing or two about diabetes. That includes PWDs without medical backgrounds. In fact, those same non-medical PWDs are clinically proven to be highly effective as diabetes educators. My evidence? Consider the power and

success of the A1C Champions program. Or better yet, for you out there who are obsessed about medication knowledge, look at a recent study by Dr. David Thom and his colleagues at UCSF. It scientifically proved that peer educators (garden variety PWDs helping each other) lowered the A1Cs in patients they work with by 1.1%. Meanwhile, the study's control group, with no access to peer support and education—just receiving the standard medical interventions—only dropped 0.3%.

That means that peer educators are better at lowering A1C than most diabetes pills, as most of the pills on the market will only lower A1Cs between a half point and one point.

Hey, and not only that, the same study showed that nearly a quarter of the peer-coached group got their A1Cs under seven-and-a-half percent, while less than eight out of a hundred of the PWDs in standard therapy group achieved that. Anyone ever see a study that shows "certified" educators lowering A1Cs by that much?

Oddly, there are fewer studies than you'd expect showing that CDE interventions are effective, and this one of the reasons why diabetes education is so poorly reimbursed by many insurance companies. That said, the American Diabetes Association still recommends diabetes education in their latest standards of care, although the evidence grade they give for its effectiveness is far from the strongest possible score. And the studies cited by ADA as the evidence base for the recommendation are a decade old. One meta-analysis of 31 studies showed that formal diabetes education lowered A1C scores by 0.76% out of the gate, but the effect was short-lived. A second study cited by the ADA shows a drop of 0.43%, and a third by only 0.32%, a paltry effect termed by the authors as "modestly" improved glycemic control.

So wait a sec, why would peer educators generally out-perform the better-educated, qualified, certified, licensed professionals? The ones with all the knowledge of medicine and the human body?

Because peer educators "get" it. And often, "others" don't. Because we walk in diabetes shoes. Because we can better relate to PWDs, and PWDs, in turn, can better relate to us. It's something called empathy.

Should it be easier for PWDs to become CDEs? I don't know. Maybe. Maybe not. But we peer educators have an important role to play. And there should be some sort of way to formalize that role, provide the needed training to back up the life experience, and to ensure quality and consistency. We need a path to becoming a CDPE—a Certified Diabetes Peer Educator. We also need another path for family members, as they have much to teach as well. What mom of a newly dx'd type 1 couldn't benefit from talking with a veteran D-Mom with both training and personal experience?

And if the AADE doesn't want to lead the charge to create these new certifications, someone else should. That's my opinion.


This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.


This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.