- Rule of 15 (hypoglycemia)
- Treat glucose < 70 mg/dL with 15 g fast-acting carbohydrate, recheck in 15 minutes, repeat if still < 70.
- A1C goal for most nonpregnant adults
- < 7% (individualize; ADA Standards of Care).
- Fasting/preprandial glucose target
- 80-130 mg/dL for most nonpregnant adults.
- Peak postprandial glucose target
- < 180 mg/dL (1-2 hours after the start of a meal).
- Time in Range (TIR) goal
- > 70% of readings in 70-180 mg/dL, with < 4% below 70 and < 1% below 54.
- Diagnostic A1C for diabetes
- >= 6.5% (confirmed with a repeat test unless clearly symptomatic with marked hyperglycemia).
- Prediabetes A1C range
- 5.7-6.4% (also FPG 100-125 mg/dL or 2-hr OGTT 140-199 mg/dL).
- Fasting plasma glucose diagnostic threshold
- >= 126 mg/dL (fasting = no caloric intake for >= 8 hours).
- 2-hour OGTT diagnostic threshold
- >= 200 mg/dL 2 hours after a 75 g oral glucose load.
- Random plasma glucose diagnosis
- >= 200 mg/dL WITH classic symptoms of hyperglycemia (polyuria, polydipsia, weight loss).
- What does the CDCES credential stand for?
- Certified Diabetes Care and Education Specialist (formerly CDE, renamed 2020).
- Who certifies the CDCES?
- The Certification Board for Diabetes Care and Education (CBDCE), formerly the NCBDE.
- Type 1 diabetes pathophysiology
- Autoimmune destruction of pancreatic beta cells → absolute insulin deficiency; requires exogenous insulin.
- Type 2 diabetes pathophysiology
- Insulin resistance plus progressive beta-cell dysfunction (relative insulin deficiency).
- Gestational diabetes (GDM)
- Hyperglycemia first recognized in pregnancy from placental hormones causing insulin resistance; usually 2nd-3rd trimester.
- LADA
- Latent Autoimmune Diabetes in Adults — a slow-onset autoimmune (type 1) diabetes in adults, often misdiagnosed as type 2.
- MODY
- Maturity-Onset Diabetes of the Young — a monogenic (single-gene), inherited diabetes; often non-insulin-dependent.
- Classic symptoms of hyperglycemia (the 3 Ps)
- Polyuria, polydipsia, polyphagia (plus weight loss and fatigue).
- What does A1C measure?
- Glucose attached (glycated) to hemoglobin in red blood cells — reflects average glucose over ~2-3 months.
- Estimated average glucose (eAG) for A1C of 7%
- ~154 mg/dL (each 1% A1C change ≈ 28-29 mg/dL).
- When can A1C be unreliable?
- Hemoglobinopathies, recent transfusion, hemolysis, pregnancy, anemia, or shortened RBC lifespan.
- Insulin resistance — key feature
- Cells respond poorly to insulin, so the pancreas compensates with higher insulin output until beta cells fail.
- Metabolic syndrome components
- Central obesity, high triglycerides, low HDL, hypertension, and elevated fasting glucose (>= 3 of 5).
- Diabetes autoantibodies (type 1 markers)
- GAD65, IA-2, ZnT8, and islet cell autoantibodies confirm autoimmune (type 1) diabetes.
- C-peptide — what it shows
- A marker of endogenous insulin production; low/absent in type 1, normal/high in early type 2.
- First-line oral medication for type 2 diabetes
- Metformin (a biguanide) — unless contraindicated.
- Metformin mechanism
- Decreases hepatic glucose production and improves insulin sensitivity; does NOT cause hypoglycemia alone.
- Metformin — most common side effect & counseling
- GI upset (nausea, diarrhea); take with meals and titrate slowly. Hold around iodinated contrast/renal impairment (lactic-acidosis risk).
- Sulfonylureas — mechanism & key risk
- Stimulate pancreatic insulin secretion; main risks are hypoglycemia and weight gain (e.g., glipizide, glimepiride).
- DPP-4 inhibitors
- 'Gliptins' (sitagliptin) increase incretin levels; weight-neutral, low hypoglycemia risk, modest A1C lowering.
- SGLT2 inhibitors — mechanism & benefit
- 'Flozins' (empagliflozin) block renal glucose reabsorption → glucosuria; benefit heart failure and CKD; cardiorenal protection.
- SGLT2 inhibitor key risks
- Genital mycotic infections, volume depletion, and euglycemic DKA (DKA with near-normal glucose).
- GLP-1 receptor agonists — mechanism & benefits
- '-tides' (semaglutide, liraglutide) enhance glucose-dependent insulin, slow gastric emptying, promote weight loss & cardiovascular benefit.
- GLP-1 agonist common early side effect
- Nausea (often improves with gradual dose escalation); also delayed gastric emptying.
- Tirzepatide drug class
- Dual GIP/GLP-1 receptor agonist — strong A1C lowering and weight loss.
- Thiazolidinediones (TZDs)
- Pioglitazone improves insulin sensitivity; risks: weight gain, edema, heart-failure exacerbation, fracture.
- Rapid-acting insulin — onset/peak/duration
- Lispro, aspart, glulisine: onset ~15 min, peak ~1-2 hr, duration ~3-5 hr; dose at the meal.
- Short-acting (regular) insulin
- Onset ~30 min, peak ~2-3 hr, duration ~5-8 hr; give ~30 min before meals.
- Intermediate-acting insulin (NPH)
- Onset ~1-2 hr, peak ~4-12 hr, duration ~12-18 hr; the cloudy insulin — roll to mix.
- Long-acting (basal) insulin
- Glargine, detemir, degludec: relatively peakless, duration ~24 hr (degludec > 42 hr); covers background needs.
- Basal-bolus regimen
- Long-acting insulin for background needs PLUS rapid-acting insulin at each meal — mimics physiologic secretion.
- When mixing NPH and regular insulin, which is drawn first?
- Clear before cloudy — draw up regular (clear) first, then NPH (cloudy), to avoid contaminating the regular vial.
- Insulin-to-carbohydrate ratio (ICR)
- Units of rapid insulin per grams of carb (e.g., 1 unit per 10 g); covers the meal carbohydrate.
- Correction (sensitivity) factor
- How many mg/dL one unit of insulin lowers glucose; correction dose = (current - target) / factor.
- Carb + correction dosing example
- ICR 1:10, factor 1u/50, eat 50 g at 200 mg/dL (target 100): 5 u (carb) + 2 u (correction) = 7 units.
- Insulin pump — basal vs bolus
- Delivers continuous rapid-acting insulin (basal) plus user-triggered meal/correction boluses; no long-acting insulin used.
- Insulin storage
- Store unopened insulin in the refrigerator; in-use vials/pens can stay at room temperature ~28 days; never freeze.
- Lipohypertrophy & site rotation
- Repeated injection at one spot causes fatty lumps that erratically alter absorption; rotate sites within a region.
- Which non-insulin injectable lowers weight and CV risk?
- GLP-1 receptor agonists (and dual GIP/GLP-1 tirzepatide).
- Amylin analog (pramlintide)
- Slows gastric emptying and suppresses glucagon; used with mealtime insulin; risk of hypoglycemia.
- 1 carbohydrate choice / serving =
- ~15 grams of carbohydrate.
- The Diabetes Plate Method
- Fill half the 9-inch plate with nonstarchy vegetables, one quarter lean protein, one quarter carbohydrate foods.
- Carbohydrate counting purpose
- Match mealtime insulin to grams of carbohydrate eaten for flexible, accurate dosing.
- Glycemic index
- Ranks carbohydrate foods by how quickly they raise blood glucose; lower-GI foods cause a slower rise.
- Fiber and diabetes
- Slows glucose absorption, improves satiety and lipids; aim for whole grains, legumes, vegetables, and fruit.
- Medical nutrition therapy (MNT)
- Individualized, evidence-based nutrition care from a registered dietitian; a core DSMES component.
- Alcohol and hypoglycemia
- Alcohol can cause delayed hypoglycemia by suppressing hepatic glucose output; consume with food and monitor.
- Aerobic exercise recommendation
- >= 150 min/week of moderate-intensity activity spread over >= 3 days, with no more than 2 consecutive days off.
- Exercise & hypoglycemia risk
- Activity increases insulin sensitivity; those on insulin/secretagogues may need carbs or reduced insulin to avoid lows (including delayed/overnight).
- Exercise when glucose is very high with ketones
- Avoid vigorous exercise if glucose > 240-250 mg/dL with ketones — it can worsen hyperglycemia/ketosis.
- SMBG — self-monitoring of blood glucose
- Fingerstick capillary glucose; timing (fasting, pre/post-meal, bedtime) guides therapy adjustments.
- Continuous glucose monitoring (CGM)
- A sensor measures interstitial glucose continuously, showing trends, time in range, and alerts for highs/lows.
- CGM lag vs fingerstick
- Interstitial glucose lags blood glucose ~5-15 min, most noticeable when glucose is changing rapidly.
- Automated insulin delivery (AID / hybrid closed loop)
- A CGM and insulin pump communicate via an algorithm to auto-adjust basal insulin (and some boluses).
- Glucose Management Indicator (GMI)
- A CGM-derived estimate of A1C based on average sensor glucose.
- Recommended A1C testing frequency
- At least twice a year if at goal/stable; quarterly if therapy changed or not meeting goals.
- Dawn phenomenon
- Early-morning hyperglycemia from a natural surge of counterregulatory hormones (cortisol, growth hormone).
- Somogyi effect (rebound)
- Overnight hypoglycemia triggering rebound morning hyperglycemia; check ~3 a.m. glucose to distinguish from dawn phenomenon.
- Hypoglycemia Level 1
- Glucose < 70 mg/dL (>= 54) — an alert value requiring fast-acting carbohydrate.
- Hypoglycemia Level 2
- Glucose < 54 mg/dL — clinically significant; sufficient to cause neuroglycopenic symptoms.
- Hypoglycemia Level 3 (severe)
- Severe cognitive/physical impairment requiring assistance from another person to recover.
- Glucagon — when and how
- For severe hypoglycemia when the person cannot safely swallow; give injectable/nasal glucagon and call for help; position on side.
- Hypoglycemia unawareness
- Loss of warning symptoms from frequent lows; managed by raising targets and avoiding lows for several weeks to restore awareness.
- After treating a low, if the next meal is > 1 hr away
- Eat a snack with carbohydrate and protein to sustain glucose until the meal.
- DKA — who and what
- Diabetic ketoacidosis: mainly type 1; absolute insulin deficiency → hyperglycemia, ketosis, and metabolic acidosis.
- DKA hallmark labs
- Glucose usually > 250 mg/dL, ketones present, pH < 7.3, low bicarbonate, anion-gap acidosis.
- DKA classic signs
- Kussmaul (deep rapid) breathing, fruity (acetone) breath, abdominal pain, dehydration, and altered mental status.
- DKA management priorities
- IV fluids first, then IV insulin, and potassium replacement/monitoring (insulin drives K+ into cells).
- HHS — hyperosmolar hyperglycemic state
- Mainly type 2; extreme hyperglycemia (often > 600 mg/dL), severe dehydration, very high osmolality, minimal/no ketones.
- DKA vs HHS — key difference
- DKA has significant ketosis/acidosis; HHS has profound hyperglycemia and dehydration with little/no ketosis.
- Sick-day rule — insulin
- Never stop insulin when ill; illness raises glucose (stress hormones). Keep taking basal insulin even if not eating.
- Sick-day rules — what to do
- Check glucose & ketones more often, stay hydrated, continue insulin, and seek care for persistent ketones/vomiting.
- Diabetic retinopathy
- Damage to retinal blood vessels — the leading cause of new adult blindness; screen with annual dilated eye exam.
- Diabetic nephropathy screening
- Annual urine albumin-to-creatinine ratio (UACR) and eGFR; ACE inhibitors/ARBs and SGLT2 inhibitors slow progression.
- Diabetic neuropathy — most common form
- Distal symmetric peripheral neuropathy (numbness/tingling/pain in feet); raises ulcer and amputation risk.
- Autonomic neuropathy examples
- Gastroparesis, orthostatic hypotension, erectile dysfunction, hypoglycemia unawareness.
- Foot-care teaching
- Daily inspection, well-fitting shoes, never barefoot, no soaking, lukewarm water, cut nails straight, annual comprehensive foot exam.
- Cardiovascular disease & diabetes
- ASCVD is the leading cause of death in diabetes; manage BP, lipids (statins), glucose, and smoking cessation.
- Blood pressure target in diabetes
- Generally < 130/80 mmHg for most adults with diabetes (individualize).
- Statin therapy in diabetes
- Recommended for most adults 40-75 with diabetes for ASCVD risk reduction, regardless of baseline LDL.
- DSMES — what it stands for
- Diabetes Self-Management Education and Support.
- Four critical times for DSMES referral
- At diagnosis, annually/when not meeting goals, when complicating factors develop, and during care transitions.
- The ADCES7 Self-Care Behaviors
- Healthy Eating, Being Active, Monitoring, Taking Medication, Problem Solving, Healthy Coping, Reducing Risks.
- Healthy Coping (ADCES7)
- The self-care behavior addressing diabetes distress, burnout, depression, and emotional well-being.
- Problem Solving (ADCES7)
- Applying skills to handle hypo/hyperglycemia, sick days, and barriers as they arise.
- Transtheoretical (Stages of Change) Model
- Precontemplation, Contemplation, Preparation, Action, Maintenance — match the intervention to the stage.
- Action stage — example behavior
- Already checking glucose daily and actively asking how to improve the routine.
- Motivational interviewing
- A collaborative, person-centered style that elicits the person's own motivation to change; uses open-ended questions and reflective listening.
- Health literacy
- A person's capacity to obtain, understand, and use health information; teach plainly, use teach-back, avoid jargon.
- Teach-back method
- Have the person explain the instruction in their own words to confirm understanding — not 'Do you understand?'
- Person-centered care
- Care built on the person's values, preferences, and goals through partnership and respect for autonomy.
- Diabetes distress
- The emotional burden of living with diabetes; distinct from clinical depression, common, and addressed under Healthy Coping.
- Assessing a low-literacy or kinesthetic learner
- Emphasize hands-on practice and return demonstrations rather than written or verbal instruction alone.
- SMART goals
- Specific, Measurable, Achievable, Relevant, Time-bound — the framework for setting behavior-change goals.
- National Standards for DSMES
- Quality criteria a program must meet to deliver effective, evidence-based diabetes education and support (used for recognition/accreditation).
- Pediatric type 1 diabetes — A1C goal
- ADA recommends an A1C < 7% for most children/adolescents with type 1 (individualize).
- Diabetes in pregnancy — glucose targets
- Fasting < 95 mg/dL, 1-hr postprandial < 140, 2-hr postprandial < 120 mg/dL.
- GDM first-line therapy
- Medical nutrition therapy and activity; insulin is the preferred medication if targets aren't met.
- Older adults — A1C individualization
- Healthy older adults < 7-7.5%; complex/frail < 8-8.5%; prioritize avoiding hypoglycemia (deintensify when needed).
- Why hypoglycemia is dangerous in older adults
- Higher risk of falls, cognitive impairment, and unawareness; favor agents with low hypoglycemia risk.
- Glucagon's role in glucose regulation
- Secreted by pancreatic alpha cells; raises blood glucose by stimulating hepatic glycogenolysis and gluconeogenesis.
- Insulin's role
- Secreted by beta cells; lowers glucose by promoting cellular uptake and storage (glycogenesis), and inhibiting hepatic glucose output.
- Incretin hormones (GLP-1, GIP)
- Gut hormones released after eating that stimulate glucose-dependent insulin secretion and suppress glucagon.
- Counterregulatory hormones
- Glucagon, epinephrine, cortisol, growth hormone — raise glucose and oppose insulin (e.g., during stress/illness).
- Why illness raises blood glucose
- Stress hormones (cortisol, epinephrine) increase hepatic glucose production and insulin resistance.
- Ketones — what they signal
- Fat breakdown for fuel when insulin is insufficient; elevated ketones warn of impending DKA.
- When to check ketones
- When glucose is persistently > 240 mg/dL, during illness, or with DKA symptoms (especially in type 1).
- Whipple's triad (hypoglycemia)
- Symptoms of hypoglycemia, a low measured glucose, and relief of symptoms when glucose is raised.
- Early (adrenergic) hypoglycemia symptoms
- Shakiness, sweating, palpitations, hunger, anxiety — from epinephrine release.
- Neuroglycopenic hypoglycemia symptoms
- Confusion, difficulty concentrating, slurred speech, behavior change, seizures — brain glucose deprivation.
- 15 g fast-acting carb examples
- 4 glucose tablets, 4 oz (1/2 cup) regular juice or soda, 1 tablespoon honey/sugar — avoid fat (slows absorption).
- Why not treat a low with chocolate or nuts?
- Their fat slows carbohydrate absorption, delaying glucose recovery.
- Glucagon kit teaching points
- Check expiration periodically; ensure family knows where it is and how to use it; replace after use.
- DKA prevention in type 1 illness
- Continue insulin, check ketones when glucose is high or ill, hydrate, and seek care for persistent ketones.
- Euglycemic DKA cause
- SGLT2 inhibitors can cause DKA with near-normal glucose; check ketones even when glucose isn't very high.
- Honeymoon phase (type 1)
- A temporary period after diagnosis when residual beta-cell function lowers insulin needs; not a cure.
- Polydipsia mechanism
- High glucose pulls water osmotically and causes osmotic diuresis, leading to thirst.
- Why type 1 causes weight loss
- Without insulin, cells cannot use glucose, so the body breaks down fat and muscle for energy.
- Screening for type 2 diabetes — who
- Adults with overweight/obesity plus a risk factor, and all adults beginning at age 35 (ADA).
- Why a single random glucose isn't used in asymptomatic people
- Without symptoms it lacks specificity, so fasting glucose or A1C is preferred for diagnosis.
- Confirming a diabetes diagnosis
- Repeat the same test (or two different tests) above threshold, unless clearly symptomatic with marked hyperglycemia.
- OGTT load for nonpregnant adults
- 75 g oral glucose; diagnostic sample at 2 hours.
- GDM screening (one-step)
- 75 g 2-hr OGTT at 24-28 weeks; any one abnormal value (fasting >= 92, 1-hr >= 180, 2-hr >= 153) diagnoses GDM.
- Comprehensive assessment domains
- Medical history, medications, psychosocial/behavioral factors, readiness to learn, literacy, culture, and support systems.
- Assessing readiness to learn
- Identify the stage of change, learning preferences, barriers, and what matters most to the person before teaching.
- Long-acting basal — degludec duration
- Ultra-long: > 42 hours, allowing flexible dosing times.
- Premixed insulin (e.g., 70/30)
- Combines intermediate + rapid/short insulin in fixed ratio; convenient but less flexible for carb matching.
- Insulin pen storage after first use
- Most pens stay at room temperature for a labeled number of days (commonly 28); never freeze.
- Rotating injection sites — absorption order
- Abdomen (fastest), then arm, thigh, buttock (slowest); keep the body region consistent for a given time of day.
- Which drug classes do NOT cause hypoglycemia alone?
- Metformin, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, TZDs (low risk); sulfonylureas and insulin DO.
- Metformin and B12
- Long-term metformin can lower vitamin B12; monitor periodically, especially with neuropathy or anemia.
- SGLT2 inhibitor sick-day caution
- Hold during acute illness/dehydration/surgery to reduce euglycemic DKA risk ('SADMANS' / sick-day medication guidance).
- GLP-1 / SGLT2 priority in CV/kidney disease
- ADA recommends them (independent of A1C) for established ASCVD, heart failure, or CKD.
- Aspirin in diabetes
- Considered for secondary prevention (established ASCVD); not routine for primary prevention due to bleeding risk.
- Nonstarchy vegetables
- Low-carb vegetables (leafy greens, broccoli, peppers) that fill half the plate and minimally raise glucose.
- Reading a nutrition label for carbs
- Use Total Carbohydrate (includes fiber and sugars), serving size, and servings per container for carb counting.
- Glycemic load vs glycemic index
- Glycemic load accounts for both the GI and the amount of carbohydrate in a typical serving.
- Sugar alcohols
- Sweeteners (sorbitol, xylitol) with less glycemic impact; excess can cause GI upset/diarrhea.
- Resistance exercise recommendation
- 2-3 sessions/week on nonconsecutive days, in addition to aerobic activity.
- Pre-exercise glucose check
- If on insulin/secretagogues and glucose is low/borderline, have carbohydrate available to prevent exercise-induced hypoglycemia.
- Ambulatory Glucose Profile (AGP)
- A standardized one-page CGM report summarizing time in range, variability, and glucose patterns.
- Coefficient of variation (CV) on CGM
- A measure of glucose variability; target <= 36% (lower = more stable glucose).
- When fingerstick confirmation is still needed with CGM
- When symptoms don't match the reading, during rapid changes, or per device instructions before dosing.
- Gastroparesis & glucose control
- Delayed stomach emptying causes unpredictable post-meal glucose; consider timing insulin and smaller, low-fat meals.
- Charcot foot
- Progressive joint/bone destruction in the neuropathic foot; a podiatric emergency needing offloading.
- Why tight control matters early (legacy effect)
- Early good control reduces long-term microvascular and macrovascular complications (DCCT/UKPDS legacy effect).
- Microvascular complications
- Retinopathy, nephropathy, and neuropathy — small-vessel damage from chronic hyperglycemia.
- Macrovascular complications
- Coronary artery disease, stroke, and peripheral artery disease — large-vessel atherosclerosis.
- Annual diabetes monitoring checklist
- A1C, BP, lipids, UACR & eGFR, dilated eye exam, comprehensive foot exam, and vaccinations.
- Smoking and diabetes
- Greatly increases cardiovascular and microvascular risk; cessation counseling is a core part of care.
- Cultural competence in DSMES
- Adapt nutrition, language, and goals to the person's culture, food traditions, and beliefs.
- Reducing Risks (ADCES7)
- Behaviors that prevent complications: monitoring, screenings, foot/eye care, immunizations, smoking cessation.
- Taking Medication (ADCES7)
- Safe, effective, consistent use of medications, including barriers like cost, access, and adherence.
- Being Active (ADCES7)
- Incorporating physical activity safely into daily life, individualized to ability and goals.
- Monitoring (ADCES7)
- Tracking glucose, A1C, BP, weight, and other markers, and using the data to guide decisions.
- Healthy Eating (ADCES7)
- Making informed food choices, understanding portions and carbohydrate, and meal planning.
- Empowerment model of education
- The person is the primary decision-maker; the specialist provides knowledge, skills, and support.
- Evaluating a DSMES program's effectiveness
- Use aggregated outcome data (behavioral and clinical) to evaluate and guide program improvement.
- Scope of practice for the CDCES
- Education, support, and care coordination within the specialist's licensure; collaborate for prescribing/diagnosis.
- Documentation in DSMES
- Record assessment, goals, education provided, the person's response, and the follow-up plan.
- Insulin onset comparison — fastest
- Inhaled and rapid-acting analogs act fastest; regular is slower; basal insulins act slowest and longest.
- Hyperglycemia symptoms beyond the 3 Ps
- Blurred vision, fatigue, slow-healing wounds, recurrent infections, and weight loss.
- Secondary diabetes causes
- Pancreatitis/pancreatectomy, Cushing syndrome, acromegaly, glucocorticoids, and certain medications.
- Steroid-induced hyperglycemia pattern
- Glucocorticoids most raise post-lunch and afternoon glucose; often need added/adjusted insulin.
- Why potassium is monitored in DKA treatment
- Insulin and correction of acidosis shift potassium into cells, risking dangerous hypokalemia.
- Fluid replacement first in DKA
- IV isotonic fluids restore volume and improve perfusion before/with insulin therapy.
- DKA in children — cerebral edema risk
- A serious complication; fluids/correction are managed cautiously to avoid rapid osmotic shifts.
- Hypoglycemia in pregnancy
- More common with tight targets; treat promptly and adjust insulin; severe lows risk maternal/fetal harm.
- Postpartum follow-up after GDM
- Screen with a 75 g OGTT at 4-12 weeks postpartum; lifelong increased type 2 risk warrants periodic screening.
- Insulin needs across pregnancy
- Requirements rise through the 2nd-3rd trimester (placental insulin resistance) and drop sharply after delivery.
- Behavioral goal vs clinical goal
- Behavioral: an action the person will take (walk 20 min daily). Clinical: a measurable outcome (A1C < 7%).
- Self-efficacy
- A person's confidence in their ability to perform a behavior; building it improves self-management.
- Open-ended question for diabetes distress
- 'What is the hardest part of living with diabetes for you?' invites the person to share concerns.
- Health Belief Model
- Behavior depends on perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy.
- Social determinants of health (SDOH)
- Conditions like food access, income, housing, and transportation that strongly affect diabetes outcomes.
- Food insecurity & diabetes
- Limited access to affordable healthy food worsens glycemic control; screen and connect to resources.
- Numeracy in carb counting
- Low numeracy impairs dosing/carb math; simplify with visual portions, plate method, or fixed-dose plans.
- Group vs individual education
- Both are effective; choose by the person's needs, complexity, learning style, and resources.
- Continuing the care relationship (DSMS)
- Diabetes self-management SUPPORT provides ongoing help to sustain behaviors after initial education.
- Person-first language
- Use 'person with diabetes,' not 'diabetic'; avoid judgmental terms like 'noncompliant' (use 'barriers').
- A1C target in pregnancy
- Aim for < 6% if achievable without significant hypoglycemia (individualize up to < 7%).
- Continuous subcutaneous insulin infusion (CSII)
- Insulin pump therapy delivering rapid-acting insulin continuously with mealtime boluses.
- Hybrid closed-loop benefit
- Improves time in range and reduces hypoglycemia by automating basal adjustments using CGM data.
- Glucose target for hospitalized noncritical patients
- Generally 140-180 mg/dL for most hospitalized patients (avoid tight control that risks hypoglycemia).
- Why basal insulin shouldn't be held when NPO
- Basal covers background hepatic glucose; stopping it (especially in type 1) risks DKA.
- Insulin pump failure / DKA risk
- Pumps use only rapid insulin, so any interruption can quickly cause hyperglycemia/DKA — have a backup plan.
- Glycemic variability — why it matters
- Wide swings increase hypoglycemia and may worsen complications independent of average glucose.
- When to refer to mental health
- For significant diabetes distress, depression, anxiety, disordered eating, or severe coping difficulty.
- Diabetes and depression
- About twice as common as in the general population; screen and treat, as it impairs self-care.
- Recertification of the CDCES
- Renewed periodically (every 5 years) by continuing education or re-examination through CBDCE.
- Beta-cell function in type 2 over time
- Declines progressively, so therapy is intensified over time (often adding insulin eventually).
- Insulin antibodies/allergy (rare)
- Local or systemic reactions can occur; analog insulins reduce immunogenicity vs older preparations.
- Dyslipidemia pattern in type 2
- High triglycerides, low HDL, and small dense LDL — atherogenic; managed with statins and lifestyle.
- ACE inhibitor/ARB in diabetes
- First-line for hypertension with albuminuria; protects kidneys; monitor potassium and renal function.
- Vaccinations recommended in diabetes
- Influenza, pneumococcal, hepatitis B, COVID-19, and others per CDC schedule.
- Hypoglycemia and driving
- Check glucose before driving; treat lows and wait until recovered; keep fast carbs in the vehicle.
- Insulin & weight gain counseling
- Insulin can cause weight gain; pair with nutrition/activity, and consider weight-favorable agents (GLP-1, SGLT2).
- Fingerstick technique teaching
- Wash hands, use the side of the fingertip, rotate sites, and don't reuse lancets; first drop may be wiped if dirty.
- When to test postprandial glucose
- 1-2 hours after the start of the meal, when post-meal targets are a concern (e.g., pregnancy).
- Bariatric/metabolic surgery and diabetes
- Can induce type 2 remission/improvement; an option for selected patients with obesity and diabetes.
- Insulin units measurement
- Standard insulin is U-100 (100 units/mL); always use an insulin syringe/pen matched to concentration.
- Concentrated insulins (U-200, U-300, U-500)
- Deliver more units in less volume for high-dose needs; dosing errors are dangerous — verify the device.
- Why rapid insulin is dosed at the meal
- Its onset matches meal absorption; dosing too early or late risks hypo- or hyperglycemia.
- Correction dose timing
- Avoid stacking — wait for the prior rapid-insulin dose to act (insulin-on-board) before re-correcting.
- Insulin on board (IOB)
- Active insulin still working from a prior dose; pumps track it to prevent dose stacking and lows.
- Target A1C when hypoglycemia is a major risk
- Relax the target (e.g., < 8%) to prioritize safety, especially in frail older adults.
- Glargine vs detemir
- Both long-acting basal analogs; glargine ~24 hr, detemir sometimes twice daily; relatively peakless.
- Why NPH peaks matter
- NPH's mid-action peak can cause hypoglycemia hours later; time meals/snacks accordingly.
- Insulin and potassium (acute care)
- Insulin (with glucose) is used to drive potassium into cells to treat hyperkalemia.
- Severe hyperglycemia symptoms requiring care
- Persistent vomiting, dehydration, confusion, Kussmaul breathing, or fruity breath — seek emergency care.
- Lifestyle change for prediabetes
- Intensive lifestyle (e.g., DPP): 7% weight loss + 150 min/week activity cuts progression to type 2 (metformin if high risk).
- Diabetes Prevention Program (DPP)
- A structured CDC-recognized lifestyle program proven to reduce progression from prediabetes to type 2 diabetes.
- Weight management role in type 2
- Modest weight loss (5-10%) improves glycemia, BP, and lipids; significant loss can drive remission.
- Mediterranean / DASH eating patterns
- Evidence-based patterns emphasizing vegetables, whole grains, lean protein, and healthy fats for diabetes.
- Counting carbs in mixed meals
- Add total grams from all carbohydrate foods; fat/protein can slow absorption and delay the glucose rise.
- Hypoglycemia after alcohol — teaching
- Eat carbohydrate with alcohol, monitor overnight, and know glucagon may be less effective after drinking.
- Foot ulcer warning signs
- Redness, warmth, drainage, calluses, or a non-healing wound — report promptly to prevent amputation.
- Monofilament test
- A 10-g monofilament screens for protective-sensation loss (peripheral neuropathy) on the feet.
- Erectile dysfunction in diabetes
- Common from autonomic neuropathy and vascular disease; assess and address sensitively.
- Hypertension screening in diabetes
- Measure BP at every routine visit; confirm elevated readings and treat to target.
- What confirms autoimmune type 1 vs type 2 in an unclear case?
- Positive islet autoantibodies (GAD65, etc.) and low C-peptide point to type 1/LADA.
- Hemoglobin variants & A1C alternatives
- If A1C is unreliable, use fructosamine, glycated albumin, or CGM/SMBG data for assessment.
- Fasting requirement for FPG
- No caloric intake for at least 8 hours before the fasting plasma glucose draw.
- Why two confirmatory tests matter
- A single abnormal value can be transient; confirmation (unless clearly symptomatic) avoids misdiagnosis.
- Initial education priorities at diagnosis (survival skills)
- Medication/insulin use, glucose monitoring, hypo/hyperglycemia recognition and treatment, and when to seek help.
- Ongoing (in-depth) education
- After survival skills: carb counting, sick-day rules, complication prevention, and lifestyle integration.
- Evaluating education effectiveness
- Assess behavior change and clinical outcomes (A1C, TIR), not just knowledge gained.
- Collaborative goal-setting
- Set goals WITH the person (shared decision-making), not for them, to improve adherence.
- When to adjust A1C goals upward
- Limited life expectancy, advanced complications, severe hypoglycemia history, or extensive comorbidity.
- Telehealth in diabetes education
- Expands access; effective for DSMES, CGM review, and follow-up support.
- Postprandial vs fasting hyperglycemia driver
- Fasting/basal driven by overnight hepatic output; postprandial driven by mealtime carbohydrate and bolus timing.
- Hypoglycemia and beta-blockers
- Beta-blockers can mask adrenergic warning symptoms (except sweating) — teach extra monitoring.
- DKA precipitating factors
- Infection, missed insulin, new-onset type 1, pump failure, MI, or certain medications.
- HHS precipitating factors
- Infection, dehydration, limited water access (often older adults), and certain medications.
- Why HHS has higher mortality than DKA
- Older, sicker patients with profound dehydration, comorbidities, and delayed recognition.
- Insulin pump infusion-set change
- Change the set and site every 2-3 days to prevent absorption problems and infection.
- Severe hypoglycemia recovery — after glucagon
- Once alert and able to swallow, give oral carbohydrate to replenish glycogen; monitor for recurrence.
- Cardiac autonomic neuropathy sign
- Resting tachycardia and orthostatic hypotension; raises silent-ischemia and arrhythmia risk.
- Annual eye exam rationale
- Retinopathy is often asymptomatic until advanced; early detection allows sight-saving treatment.
- Why glucose targets are individualized
- Balance complication prevention against hypoglycemia risk based on age, comorbidity, and life expectancy.
- Counterregulatory failure in long-standing type 1
- Blunted glucagon/epinephrine responses contribute to hypoglycemia unawareness.
- Pramlintide injection timing
- Given before meals, separate from insulin; reduces post-meal glucose spikes.
- Inhaled insulin
- A rapid-acting mealtime option (Afrezza); contraindicated in asthma/COPD; check lung function.
- When to escalate type 2 therapy
- If A1C remains above target after lifestyle + metformin, add agents based on comorbidities/cost/preference.
- Diabetes technology selection
- Match the device (CGM, pump, AID) to the person's needs, dexterity, literacy, and access.
- Hypoglycemia prevention with CGM alerts
- Set low/high alerts and use trend arrows to act before reaching dangerous levels.
- Glucagon nasal vs injectable
- Both treat severe hypoglycemia; nasal needs no reconstitution and is easier for caregivers.
- Diabetes burnout
- Emotional exhaustion from constant self-management; addressed under Healthy Coping with support and simplification.
- Family involvement in self-management
- Engage family for support, especially for hypoglycemia treatment and meal planning, with the person's consent.
- Cultural food adaptation example
- Modify portions and preparation of traditional foods rather than eliminating them, to support adherence.
- Latent vs overt diabetes onset
- LADA progresses slowly to insulin dependence; classic type 1 in youth presents abruptly with DKA risk.
- Glucose toxicity
- Chronic hyperglycemia further impairs beta-cell function and insulin sensitivity, worsening control.
- Postprandial target in nonpregnant adults
- < 180 mg/dL, measured 1-2 hours after the start of the meal.
- Continuous quality improvement in DSMES
- Programs review aggregate outcomes and processes regularly to improve education delivery.
- When insulin is required in type 2
- With very high A1C/glucose, symptoms of catabolism, or when other agents fail to reach goal.
- Adjusting basal insulin
- Titrate based on fasting glucose trends, raising/lowering by small increments to reach the fasting target.
- Adjusting mealtime insulin
- Use post-meal and pre-next-meal glucose; refine the carb ratio and correction factor over time.
- Hypoglycemia documentation
- Record frequency, severity, timing, and likely causes to guide regimen and target changes.
- Goal of glycemic management
- Prevent acute and chronic complications while minimizing hypoglycemia and preserving quality of life.
- Role of the CDCES on the care team
- An expert in DSMES who bridges the medical plan and the person's daily self-management.
