Your FREE CDCES Flashcards 2026 – 250+ Cards

CDCES Flashcards

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.