A) Incorrect – The personal burden of diabetes is enormous and, obviously, this patient does not need additional stressors placed on him by other health care professionals
B) Incorrect – While technically correct, this is not the best answer as it ignores the patient. Unless the patient is drinking very heavily and there are other co-morbidities, the risk of lactic acidosis is very low
C) Correct – This is the best answer as there is empathy, screening, acknowledgement of patient difficulty and counseling. There will be similar questions on the exam that test empathy
D) Incorrect – While technically correct, this is not the best answer as it ignores the patient

A) 4-7 mmol/L Incorrect- this is the target for most people with diabetes but not for children under 18 years of age
B) 6-10 mmol/L Incorrect- this is the target if the child has recurrent hypoglycemia or hypoglycemia unawareness which the child does not have. Also this is the old 2013 clinical guideline for children under 6
C) 4-8 mmol/L Correct- the 2018 guidelines now have a single target for children under 18 years of age. In the 2013 guidelines the targets were different based on different age groups such as 0-6, 6-12 and over 12 years of age. This is is not the case anymore.
D) 6-9 mmol/L Incorrect- this is the target for elderly patients who are frail and/or have dementia
Please see pg S235 of the 2018 Diabetes Canada clinical practice guidelines for details on the targets for children. Also check out the Cheat Sheet I have created for you at the end of the quiz.

A) <8.5% Incorrect- this could be a A1c target for the frail elderly or patients with severe hypoglycemia and/or hypoglycemia unawareness
B) <8.0% Incorrect- this could be a A1c target for a functionally dependent elderly patient
C) ≤7.5% Correct- in the 2018 guidelines there is now only one age category for children. In the old 2013 guidelines there was specific targets for ages 0-6, 6-12 and 12-18. For patients under 18 years of age the target is ≤ 7.5% unless there is recurrent hypoglycemia or hypoglycemia unawareness
≤7.0% Incorrect- this is the A1c target for a child over 12 years of age an
Please see pg S235 of the 2018 Diabetes Canada clinical practice guidelines for details on the targets for children. Also check out the Cheat Sheet I have created for you at the end of the quiz.

A) 6-10 mmol/L Correct- this is the fasting blood sugar range for a child under 18 years of age with recurrent hypoglycemia or hypoglycemia unawareness.
B) 4-10 mmol/L Incorrect- this is the fasting blood sugar range for a child between 6 and 12 years of age in the old 2013 guidelines.
C) 5-10 mmol/L Incorrect- this is the blood sugar range for hospitalized patients who are peri-operative for surgeries other than CABG
D) 5.5-10 mmol/L Incorrect- this is the blood sugar range for hospitalized patients undergoing a CABG (coronary bypass artery graft)
Please see pg S235 of the 2018 Diabetes Canada clinical practice guidelines for details on the targets for children. Also check out the Cheat Sheet I have created for you at the end of the quiz.

A) ≤ 7.5% Incorrect- this is the A1c target for children under the age of 18
B) ≤6.5% or ≤6.1% if safe Incorrect- this is the A1c target for women who are already pregnant
C) ≤7% Incorrect- while technically correct there is a better answer. On the exam you should expect questions with multiple correct answers but your job is to choose the best answer. You will only get the question right if you choose the best answer.
D) ≤7% or ≤6.5% if safe- Correct this is the best answer.
For more information on the A1c targets in pregnancy please see pg S271-S273 of the 2018 Diabetes Canada clinical practice guidelines.

A) Incorrect- patients should wait at least 40 minutes before driving not 50 minutes
B) Incorrect- the target is 5 mmol/L and the wait time is 40 minutes
C) Correct- 5 mmol/L is the correct target and 40 minutes is the correct wait time
D) Incorrect- the correct target is 5 mmol/L not 6 mmol/L
Please see pg S152 of the 2018 Diabetes Canada clinical practice guidelines for more information.

A) Correct- this is the 2 hour PC blood glucose target for all children under the age of 18. The 2018 guidelines now have only one category for children with type 1 diabetes. The old 2013 guidelines had multiple categories based on age.
B) Incorrect- this is the 2 hour PC blood glucose target for elderly who are frail/and or have dementia
C) Incorrect- this is the 2 hour PC blood glucose target for a pregnant women with diabetes
D) Incorrect- this is the 2 hour PC blood glucose target for people unable to achieve an A1c of ≤ 7% or an elderly person who is functionally dependent

A) <5.3 mmol/L- Correct- this is the FBG for a pregnant women with diabetes
B) 7.8 mmol/L Incorrect- this is the 1 hour post prandial target for a pregnant women with diabetes
C) 4-7 mmol/L Incorrect- this is the FBG target for most people with diabetes
D) 4-5.5 mmol/L Incorrect- this is the FBG target for a patient who is unable to achieve an A1c ≤ 7% with the usual target of 4-7 mmol/L
For details on the blood glucose target of pregnant women with diabetes please see pg S271-S273 of the 2018 Diabetes Canada clinical practice guidelines

A) <6.7mmol/L Incorrect- this is the 2 hr PC BG target for a pregnant women with diabetes
B) <5.3mmol/L Incorrect- this is the fasting BG target for a pregnant women with diabetes
C) <7.8mmol/L Correct- this is the 1 hr PC BG target for a pregnant women with diabetes
D) 4-7 mmol/L Incorrect- this is the fasting BG target for most people but not pregnant women.
For details on the blood glucose target of pregnant women with diabetes please see pg S271-S273 of the 2018 Diabetes Canada clinical practice guidelines

A)  5-8 mmol/L Incorrect- this is the 2 hour  PC BG for patients unable to achieve  the ≤ 7% target using the usual 2 hour PC BG
B) <7.8mmol/L Incorrect- this is the 1 hr PC BG target for a pregnant women with diabetes
C) <6.7 mmol/L Correct- this is the 2 hr PC BG target for a pregnant women with diabetes
D)  5-10 mmol/L- Incorrect- this is the 2 hr PC BG target for most people but not pregnant women.
For details on the blood glucose targets of pregnant women with diabetes please see the summary on pg S271-273 of the 2018 Diabetes Canada guidelines

A) 6-9 mmol/L Incorrect- this is the FBG target for an elderly patient who is frail and/or have dementia
B) 4-8 mmol/L Incorrect- this is the FBG target for a child under 18 years of age with type 1 diabetes
C) <5.3 mmol/L Incorrect- this is the FBG for pregnant women with diabetes
D) 4-7 mmol/L Correct- this is the FBG target for most people with diabetes

Please see pg S43 of 2018 Diabetes Canada clinical practice guidelines for more details

A) Incorrect- This is too large of a starting dose and may lead to hypoglycemia
B) Incorrect- This is a default starting dose (10 units) for basal insulin but there is another answer that is also correct.
C) Incorrect- This is a acceptable lower starting dose for people who weigh under 50 kg (0.1-0.2 units per kg) but there is another answer that is also correct
D) Incorrect- This dose is too low
E) Correct- Both B and C are both correct

Please see Example A on Appendix 9 on pg S317 of 2018 Diabetes clinical practice guidelines and pg 2 of the Diabetes Canada insulin prescription tool at https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-My-Diabetes/Tools%20and%20Resources/insulin-prescription-fillable-EN.pdf?ext=.pdf (will open in new window) for more details

A) Correct- the usual starting dose for bolus insulin is 2-4 units. Studies have shown it has little effect on A1c whether you start with the biggest meal of the day or the largest post prandial rise in blood sugar of the day. So 2-4 units with either breakfast or dinner would be correct
B) Incorrect- this is too high of a starting dose given the information you are given
C) Incorrect- you could start bolus insulin at every meal but generally you start with one meal. Also the patient specifically asks for minimal injections. Studies show that you get the largest benefit in A1c reduction when adding bolus insulin to the first meal. You still get A1c reduction benefit when adding bolus insulin to the second and third meal but the reduction is less than the first one. So overall not the best answer therefore not the correct answer.
D) Incorrect- this is too high of a starting dose given the information you are given
E) Incorrect- only A) is correct

Please see Example B of Appendix 9 on pg S317 of the 2018 Diabetes Canada guidelines for more details for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

A) Incorrect- there was only one high post prandial reading after breakfast. Increasing insulin based on one reading is not ideal. Generally you treat hypoglycemia before you treat hyperglycemia
B) Incorrect- Generally you treat hypoglycemia before you treat hyperglycemia. Increasing the Toujeo (concentrated glargine) would likely lead to more lows after lunch
C) Correct- lowering the FIASP (aspart) would reduce the hypoglycemia after lunch
D) Incorrect- while lowering the Toujeo (concentrated glargine) would reduce hypoglycemia it would result in more fasting hyperglycemia. Reducing the lunch FIASP (aspart) is a much better answer

Please see Appendix 5 and 6 on pg S312 of the Diabetes Canada clinical practice guidelines for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

Like in real life you should expect that patients to miss taking readings. On the exam you will have to take your best guess even with incomplete information. You can complain about the “unfair” question after the exam to the CDECB but it wont help you pass the exam.

A) Correct- this is the best answer out of all the given answer, even though in real life you would only increase the lunch bolus.  You can complain about the “unfair” answer but the worst thing to do is get frustrated or angry during the exam. This will result in you losing your peace of mind and guaranteeing that you will fail the exam.
B) Incorrect-  Generally you do correct hypoglycemia before hyperglycemia but there is no hypoglycemia before breakfast. Even if there was, reducing the Apidra wont help as the Apidra doesnt peak for another 2 hours. If there was fasting hypoglycemia you would reduce the basal insulin, in this case Tresiba.
C) Incorrect- there is only one reading above 7 and its only 0.1 above target. The patient forgot to take his after supper reading so maybe he had a big birthday dinner and his post prandials were very high. You cant assume numbers.
D) Incorrect- there is no after lunch hypoglycemia. Decreasing the Tresiba would cause all the readings to increase causing hyperglycemia at other times.

Please see appendix 5 and 6 on pg S313 of the 2018 Diabetes Canada clinical practice guidelines for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

A) Incorrect- when adjusting insulin you must look at when it takes effect not when it is administered. We want to stop the hypoglycemia before breakfast, however stopping the morning NPH wont help. The NPH will peak in 5-8 hours and last for ~18 hours. He is taking the NPH at 8am so it will peak around 1pm-4pm and last till 2am at most. He is having lows around 7-8am so reducing the morning NPH will not help
B) Incorrect- when adjusting insulin you must look at when it takes effect not when it is administered. We want to stop the hypoglycemia before breakfast, however stopping the morning Humalog (lispro) wont help. The Humalog will peak in 1-2 hours and last for 4-5 hours. He is taking the breakfast Humalog at 8am so it will peak around 9am and stop working around 12 pm. This is nowhere close to the lows he is having at 7-8am
C) Incorrect- generally you treat hypoglycemia before you treat lows. Also the 10.1 is only 0.1 above target and there is no pattern.
D) Correct- to fix the morning hypoglycemia you reduce the evening NPH which is taking effect throughout the night and causing the lows

Please see Appendix 5 and 6 on pg S312 of the 2018 Diabetes Canada clinical practice guidelines for more details

The formula for calculating ISF or Correction Factor (CF) is 100 divided by Total Daily Dose (TDD) if using rapid acting insulin or 83 divided by TDD if using short acting insulin. This patient is on 60+60+40+20+20= 200 for TDD. 100/200= 0.5. Meaning 1 unit of insulin is expected to bring him down 0.5 mmol/L.

A) Correct- this is the correct ISF or CF
B) Incorrect- A 1:1 ratio means 1 unit brings down the patients sugars by 1 mmol/L which is incorrect
C) Incorrect- A 1:2 ratio means 1 unit brings down the patients sugars by 2 mmol/L which is incorrect
D) Incorrect- A 1:2.5 ratio means 1 unit brings down the patients sugars by 2.5 mmol/L which is incorrect

To calculate ICR you take 500/Total daily dose (TDD). So for this patient 15+15+5+10+5=50. 500/50= 1:10 ICR which means for every 10 grams of carbohydrate this patient consumes taking 1 unit of insulin should minimize her blood glucose rise.

A) Incorrect- An ICR of 1:1 means that the patient needs 1 unit of insulin for every 1 gram of carbohydrate they consume to minimize blood glucose rise
B) Incorrect- An ICR of 1:5 means that the patient needs 1 unit of insulin for every 5 gram of carbohydrate they consume to minimize blood glucose rise
A) Correct- this is the correct ICR
A) Incorrect- An ICR of 1:15 means that the patient needs 1 unit of insulin for every 15 gram of carbohydrate they consume to minimize blood glucose rise

The key to this question is to calculate the ICR the patient used for each meal. Remember to subtract fibre from the total carbohydrate (since fibre does not break down into glucose) the divide the available carbohydrate by the numbers of bolus units used.

A) Incorrect- the time he used a 1:2 ratio his post prandial sugars dropped from 5.6 to 3.4 causing hypoglycemia. This ratio is too aggressive
B) Correct- the times he used this ratio (6 to 6.5 and 6 to 6.8) his post prandial sugars did not increase by more than 3 mmol/L and kept him at target. This ratio should be used for the rest of his meals.
C) Incorrect- the time he used a 1:10 ratio his post prandial sugars spiked significantly from 6.4 to 10.9 causing hypoglycemia. This ratio is too aggressive
D) Incorrect- the time he used a 1:2 ratio his post prandial sugars dropped from 5.6 to 3.4 causing hypoglycemia. This ratio is too aggressive

A) Incorrect- As a general rule when you switch from twice daily insulin to once daily insulin you reduce to dose by 20% to avoid hypoglycemia. Tresiba (degludec) is equally effective in the morning and the evening
B) Incorrect- As a general rule when you switch from twice daily insulin to once daily insulin you reduce to dose by 20% to avoid hypoglycemia. Tresiba (degludec) is equally effective in the morning and the evening
C) Correct- a 20% reduction in dose is the general rule. The timing of morning or evening is irrelevant
D) Incorrect- there should be a 20% reduction not a 20% increase

Note that the exam often uses older insulins so my Practice Exams often have many questions on older insulins even though I don’t typically use them in my real life practice.

A) Correct- strawberries and blackberries contain little sugar compared to other fruits. I recommend them to patients looking for a snack since you can eat a lot of them but not have a lot carbohydrate
B) Incorrect- this is for blueberries and melon
C) Incorrect- this is for juice and canned fruit
D) Incorrect- this is for cherries and grapes

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is for strawberries and blackberries
B) Incorrect- this is for melons and blueberries
C) Correct- this is the same amount as juice and canned fruit in juice, so that is how I remember it for the exam
D) Incorrect- this is for jam, jellies, honey and sugar

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is for strawberries and blackberries
B) Incorrect- this is the answer for regular low fat milk
C) Correct- the way I remember this is that chocolate milk, flavored soy milk, evaporated milk and juice all have the same carbohydrate content
D) Incorrect- this is for jam, jellies, honey and sugar

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is for tacos where two pieces of taco is 15 grams
B) Correct- this is the same as whole grain bread
C) Incorrect- this is for hotdog buns, burger buns, small bagels and pitas
D) Incorrect- this is for large bagels

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is for tacos where two pieces of taco is 15 grams
B) Incorrect- this is for white and whole grain bread
C) Incorrect- this is for small bagels not large bagels
D) Correct- this is for large bagels

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is about 45 grams
B) Incorrect- this is more than 15 grams
C) Correct- this is 15 grams as per the Beyond the Basics poster
D) Incorrect- this is less than 15 grams

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Incorrect- this is for strawberries and blackberries
B) Incorrect- this is for melons and blueberries
C) Correct- this is the same as canned fruit in juice
D) Incorrect- this is for soy yogurt

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

A) Correct- a large peach is equivalent to 15 grams of carbohydrate
B) Incorrect- medium oranges or pears are equivalent to 15 grams of carbohydrate
C) Incorrect- small bananas are equivalent to 15 grams of carbohydrate
D) Incorrect- 15 cherries or grapes are equivalent to 15 grams of carbohydrate

A) Incorrect- that is the amount for pancakes and waffles for 15 grams of carbohydrate
B) Incorrect- two 5-inch tacos are 15 grams of carbohydrate
C) Correct- this is 15 grams of carbohydrate for chapati, naan bread and white and multigrain pita bread
D) Incorrect- this is for pizza crust

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

Incorrect- 1 teaspoon is equivalent to 5 grams of carbohydrate
Incorrect- 2 teaspoons is equivalent to 10 grams of carbohydrate
Correct- 3 teaspoons is equivalent to 15 grams of carbohydrate. This is the same for sugar, jam, jelly and honey
Incorrect- 4 teaspoon is equivalent to 20 grams of carbohydrate

Please see the Beyond the Basics meal planning guide in the cheat sheet section for details

Lactose, fructose and sucrose are all carbohydrates which increase blood sugars, so insulin may be adjusted based on these nutrients. Sorbitol and isomalt are sugar alcohols which have erratic absorption and affect blood sugars minimally. Insulin should not be adjusted for these sugar alcohols. Fibre does not break down into glucose, so insulin should not be dosed for fibre. Cyclamate is an artificial sweetener and has little effect on blood sugars; thus, insulin should not be adjusted for this sweetener either. A person taking 4 units of insulin with a carb ratio of 1:17.5 means he is consuming 4×17.5 g carbohydrates = 70 carbohydrates
A) Incorrect –  Only the 35 grams from lactose counts for adjusting insulin
B) Correct – The 70 grams of fructose counts, while the fibre does not. 4 x 17.5= 70 grams of carbohydrate. Note: when carbohydrate-counting off a food label, you subtract the fibre from the TOTAL amount of carbohydrate to get to carbohydrate portions.
C) Incorrect – Neither would break down into glucose
D) Incorrect- 15 grams of sucrose counts, but the isomalt does not

Please see pg S72-73 of the 2018 Diabetes Canada clinical practice guidelines and the Sugar and Sweeteners webpage at https://guidelines.diabetes.ca/docs/patient-resources/sugars-and-sweeteners.pdf (will open in new window) for more information.

A) Correct – Adding fat increases the amount of time required for digestion and, therefore, lowers the glycemic index. In general, switching consumption from higher glycemic-index carbohydrates to lower glycemic-index carbohydrates is beneficial for glycemic control, but it is not always the case
B) Incorrect- In general, decreasing fibre increases the glycemic index. As well, decreasing acidity can also increase the glycemic index. Sourdough breads, generally, have a lower index than other breads.
C) Incorrect- In general, the easier it is  to digest the the food, the higher the glycemic index. This is because it spends less time in digestion and is more rapidly absorbed, causing higher post-prandial sugars. I counsel patients to cook their pasta al dente to lower the glycemic index.
D) Incorrect- For the same reason above and also gross

Please see the Diabetes Canada glycemic index webpage at https://guidelines.diabetes.ca/docs/patient-resources/glycemic-index-food-guide.pdf (will open in new window) for more details

A) Correct – Patients should keep their insulin on their carry on luggage and not in their checked baggage, which goes into the plane’s baggage area. Checked-in luggage may be lost or be placed on the wrong plane. Also, insulin may freeze in the baggage area if it is depressurized, rendering the insulin useless. The insulin will then thaw out while waiting to be picked up. You patient will not be aware that the insulin had froze
B) Incorrect – Patients should carry extra insulin on trips
C) Incorrect – Though its likely an airline will have juice or snacks, there may be delays in attaining it, especially if the plane is experiencing turbulence. It’s better to be well prepared
D) Incorrect – That is a good idea to prepare for the trip

Please check the Diabetes Canada webpage “Travel Tips for People with Diabetes” at https://www.diabetes.ca/learn-about-diabetes/your-rights/air-travel  (will open in new window) for more details

A) Incorrect – Patients at this stage do not intend to start the behavior change in the near future (greater than 6 months), and may be unaware of the need to change at all
B) Correct – The pros outweigh the cons for this patient and he intends to start within 6 months
C) Incorrect – Patients at this stage are ready to start taking action soon, generally within the next 30 days. He is not ready for 5 months
D) Incorrect – He has not yet taken action

Please see pg 2-39 of Building Competency: The Essentials for more information on the transtheoretical model

A) Incorrect – That is below the maximum limit
B) Incorrect – That is below the maximum limit
C) Correct – The Diabetes Canada guidelines recommends 30-50 grams of dietary fibre intake daily because of the benefits of fibre for glycemic control. This is higher than what is recommended for people without diabetes ( 25 g and 38 g for women and men, and 21 g and 30 g for women and men over 51 years.).
D) Incorrect- That is above the maximum limit

Please see Recommendation 10 pg S74 of the 2018 Diabetes Canada clinical practice guidelines for details

Insulin is a hormone that stimulates the body to build things up and is, therefore, anabolic. Catabolic hormones, like cortisol, do the opposite to stimulate the body to break things down. Free fatty acids are the building blocks of triglycerides. Glucose is the building block of glycogen. Amino acids are the building blocks of proteins. Therefore, insulin stimulates building free fatty acids into triglycerides, glucose into glycogen and amino acids into protein for storage in the body or other functions. Catabolic hormones do the reverse by stimulating the body to break apart more complex molecules into simpler molecules, usually to burn for energy.

A) Incorrect – Anabolic hormones, like insulin, stimulates conversion from glucose to glycogen and amino acids into proteins. Converting free fatty acids to triglycerides is correct.
B) Incorrect – Insulin is an anabolic hormone, not a catabolic one
C) Correct – All of the information is correct
D) Incorrect – Insulin is an anabolic hormone, not a catabolic one. Insulin stimulates conversion from glucose to glycogen, amino acids to proteins and free fatty acids to triglycerides

For more information, please see pg 3-6 of Building Competency: The Essentials

A) Incorrect – Invokana (canagliflozin) has shown cardiac benefit in the CANVAS trial. Bydureon (extended release exanatide) and Trajenta (linagliptin) has not yet shown cardiac benefit.
B) Correct – All three of these medications have shown cardiac benefit.
C) Incorrect – Victoza (liraglutide) did show cardiac benefit in the LEADER trial. However both Januvia (sitagliptin) and Trulicity (dutaglutide) did not
D) Incorrect – Jardiance (Empagliflozin) did show cardiac benefit in the EMPA-REG trial and Invokana (canagliflozin) in the CANVAS trial. However Mounjaro (tirzepatide) has not yet shown CV benefits. Mounjaro’s CV trials are expected to come out at the end of 2024 or early 2025.

Please see Figure 1 on pg S92 of the 2018 Diabetes Canada clinical practice guidelines for more details. Also see the 2020 Pharmacological update for more details on which medications have cardiac benefits. There are typically many questions on the 2018 Guidelines updates (2019 cannabis, 2020 medications, 2021 blood glucose monitoring, 2019 Ramadan, 2022 Remission, 2023 Mental Health) so make sure you read those in addition to the guidelines.

A) Incorrect – This is a neurogenic symptom
B) Correct – Out of the options, this is the only neuroglycopenic symptom
C) Incorrect – This is a neurogenic symptom
D) Incorrect – This is a neurogenic symptom
Hypoglycemia reactions are split into neurogenic (autonomic) and neuroglycopenic. Neurogenic symptoms are mostly caused by glucagon and epinephrine (adrenaline). Side effect of glucagon include nausea. Epinephrine causes trembling, anxiety, sweating etc. Think of autonomic symptoms as the fight or flight response. The state of neuroglycopenia is a lack of glucose for nerve cells to function properly. I like to think about it as being drunk, so symptoms of confusion, difficulty speaking, drowsiness etc. Autonomic symptoms  usually appear before neuroglycopenic symptoms. Counter regulatory responses start around 3.8 mmol/L and neuroglycopenic symptoms at 3.2 mmol/L. However, this is highly individual.

Please see Table 1 pg S104 of the 2018 Diabetes Canada clinical practice guidelines for more details

A) Correct- this patient is in remission to pre-diabetes
B) Incorrect- even though this patient is on Jardiance for heart failure and not diabetes the definition of remission includes not being on any antihyperglycemic medications. Therefore we wouldn’t classify this as remission but as pharmacologically managed diabetes.
C) Incorrect- remission is currently only possible for type 2 diabetes not type 1 diabetes
D) Incorrect- this patient is in remission to normal blood glucose levels

Please see pg 754 of the Remission of Type 2 Diabetes chapter for more details

A) Incorrect – The personal burden of diabetes is enormous and, obviously, this patient does not need additional stressors placed on him by other health care professionals
B) Incorrect – While technically correct, this is not the best answer as it ignores the patient. Unless the patient is drinking very heavily and there are other co-morbidities, the risk of lactic acidosis is very low
C) Correct – This is the best answer as there is empathy, screening, acknowledgement of patient difficulty and counseling. There will be similar questions on the exam that test empathy
D) Incorrect – While technically correct, this is not the best answer as it ignores the patient

The CCM model consists of:

1) Delivery systems designs – The system that the team (and the different roles in the team) uses to deliver care to patients
2) Self-management support – Involves active patient participation in self-monitoring and/or decision making
3) Decision support – Providing healthcare practitioners with best practice information at the point of care to help support decision making
4) Clinical information System – Electronic medical records or patient registries that that allow for a population-based approach to diabetes assessment
5) The Community – Environmental factors, such as food security, the ability to lead an active lifestyle, as well as access to care and social supports, also impact diabetes outcomes
6) Health systems – Support for diabetes care from the broader level of the healthcare system, such as the national and provincial systems, is essential.

C) Correct – A reward/punishment system is not part of the CCM model. Patients are adults who can make their own decisions and we, as health care professionals, need to respect that. It is not our job to hand out punishments. Given our strained health care system, the rewards we can hand out are limited.

Please see pg S29 of the 2018 Diabetes Canada clinical practice guidelines for more information.

A) Incorrect – The patient has had a stroke and should be on a number of medications to manage his CV risk. His cholesterol being on target does not mean he does not need any medications.
B) Incorrect – He has already had a CV event (stroke) which puts him in the high risk category of experiencing another CV event. He should be on a statin as well as other medications to reduce his CV risk.
C) Incorrect – Several studies like HOPE, EUROPA and ONTARGET show the cardiovascular benefits of ACE inhibition. Subset analysis of patients with diabetes from the studies above show similar vascular protective effects. However he should still be on additional meds.
D) Correct – The patient is allergic to ASA, so clopidogrel which also inhibits platelets from aggregating and forming clots, is a reasonable alternative
E) Incorrect – Platelet aggregation plays a key role in atherothrombosis. Even though ASA seems to be less effective in patients with diabetes, ASA has been shown to reduce CVD events in patients with established CVD disease and diabetes. However, since this patient is allergic to ASA, clopidogrel is a reasonable alternative.

Please see the recommendations on pg S166 of the 2018 Diabetes Canada  clinical practice guidelines. Also see the Reducing Vascular Risk tool in the Diabetes Canada website (will open in new window) http://guidelines.diabetes.ca/health-care-provider-tools . Its under For Health Care Providers then Tool and Resources and then Macrovascular Complications.

Food labels usually contain the following three parameters: Total Carbohydrate, Fibre and Sugar. The available carbohydrate in a food is equal to Total Carbohydrate minus the Fibre content. Fibre is included in Total Carbohydrate but does not actually break down into sugar; therefore, it should not be included in calculations for bolus insulin. Sugar is part of the total carbohydrate and does not need to be counted separately.

A) Incorrect – This answer does not take into account the 10 grams of fibre, which should be subtracted from the total carbohydrate
B) Correct – 45 grams of total carbohydrate minus 10 grams of fibre =35 grams available carbohydrate for 1/2 cup serving. 35 grams x 2 (pt eating 1 full cup) =70 grams. 70 grams divided by 1-unit-of-insulin per 5-grams-of-carbohydrate = 14 units
C) Incorrect – This answer does not taking into account that the patient is eating one full cup
D) Incorrect – This answer is basing the amount of bolus insulin on the sugar content, not the carbohydrate content; hence, it is incorrect.

A) Incorrect – If unrecognized or left untreated, Charcot neuroarthropathy can result in a severely misshapen and unstable foot and ankle
B) Correct – Charcot foot (neuropathic osteoarthropathy) is a progressive condition characterized by joint dislocation, pathologic fractures, and severe destruction of the pedal architecture. It is not characterized by infection and unless an infection is also present, then antibiotics are not required.
C) Incorrect – Increased warmth is the first indicator of inflammation in an insensate foot
D) Incorrect – Total immobilization is required for the bones and joints to heal
For more information, please see pg S223 of the 2018 Diabetes Canada clinical practice guidelines and pg 36 of the Guidelines for the Diabetic foot at http://onlinelibrary.wiley.com/doi/10.1002/dmrr.848/abstract  (will open link in new tab)

A) Incorrect – The patient’s sugars are already quite low and he is about to start an exercise program which would push the sugars even lower. Increasing the Lantus would likely cause more hypoglycemia
B) Correct – For 2 reasons:   1) the patient’s blood sugars are already quite low and he is about to start an exercise program which would push the sugars even lower. Lowering the dose may prevent hypoglycemia. 2) As a general rule, when switching to from a twice-daily basal insulin to a once-daily insulin, the dose is reduced by 20% to avoid hypoglycemia. This general rule isn’t in the guidelines and doesn’t apply in all cases (such as when the patient’s blood sugars significantly above target) but it is commonly done in real life practice
C) Incorrect – Lantus does not have to be taken only at bedtime
D) Incorrect – Technically, long-acting analogues do cause a small amount of weight gain. However, so does NPH which the patient is already on. Lantus causes less weight gain than NPH. So, to tell a patient that he is going to gain weight on a new insulin (when he may actually lose weight) would not be correct.

A) Incorrect- skeletal muscle stores roughly 300-500 grams of glycogen and is the largest reservoir of glycogen in the body
B) Incorrect- the pancreas does not store significant amounts of glycogen
C) Correct- the liver stores roughly 75 grams of glycogen and is the principal reservoir where glycogen can be converted to glucose
D) Incorrect- adipose tissues stores its energy as lipids

A) Incorrect – Atypical antipsychotics are associated with significant weight gain, insulin resistance and impaired fasting glucose/type 2 diabetes. Please see pg S137 of the 2018 Diabetes Canada clinical practice guidelines for more information
B) Incorrect – Actos works by activating the PPAR system in cells to reduce insulin resistance. Please see Table 1 on pg S90 of the 2018 Diabetes Canada clinical practice guidelines for more information.
C) Correct – Eating more artificial sweeteners will not raise blood glucose but they do not generally improve insulin sensitivity. Substituting sugar already in the diet for artificial sweeteners will likely improve blood glucose but do little for insulin resistance. The best answer out of all the available answers. Please see pg S72 of the 2018 Diabetes Canada clinical practice guidelines.
D) Incorrect – Resistance exercise improves skeletal muscle insulin sensitivity. Please see pg S55 of the 2018 Diabetes Canada clinical practice guidelines for more information.

A) Incorrect- correct, incorrect, correct
B) Correct- all of these percentages are correct. Metformin reduces the progression to pre-diabetes by about 30%, pioglitazone about 70% (rosiglitazone the other thiazolidinedione reduces risk about 60%) and lifestyle interventions by about 60% with just 5% weight loss!
C) Incorrect- incorrect, incorrect- incorrect
D) Incorrect- correct, correct, incorrect

Please see pg S21 – S23 of the 2018 Diabetes Canada clinical practice guidelines for more information

A) Incorrect- he is not worried about threats from having diabetes such as “I am so worried that diabetes will rob of my vision”. He is expressing unfairness that his friends don’t have diabetes and he does. While cognitive behavioral therapy may help his anger this is not the best answer.
B) Incorrect- while technically correct this is not an empathetic answer and given the patients anger you will be unlikely to convince him to start insulin. This answer does not take into account his feelings of unfairness and is not the best answer.
C) Correct- he is expressing unfairness that he has diabetes while his friends who eat poorly do not. Acceptance and use commitment therapy could be used to relieve his anger
D) Incorrect- he is not expressing any loss from having diabetes such as “I guess I can never have ice cream with my grandchildren ever again, that’s so sad”. He is expressing unfairness that his friends don’t have diabetes and he does. Motivational interview may or may not help his anger but this is not the best answer.

Please see pg 311 of the 2023 Diabetes and Mental Health update for more details

The 2020 Pharmacologic Glycemic Management of Type 2 Diabetes in Adults update emphasizes primary prevention in diabetes. The main difference between Marcus and Zeno is that in Marcus we are aiming for secondary prevention as he has had a cardiovascular event and in Zeno we are aiming for primary prevention since he has never had a cardiovascular event. The medications used to prevent major adverse cardiovascular events (MACE) are different. For primary prevention only GLP-1 analogs have shown significant primary prevention benefits.

A) Incorrect- SGLT-2 inhibitors have not shown the highest evidence primary prevention cardiovascular benefit
B) Correct- GLP-1 analogs have shown to have significant primary prevention cardiovascular benefits especially Trulicity (dulaglutide)
C) Incorrect- DPP-4 inhibitors have not shown significant primary prevention or secondary prevention cardiovascular benefit
D) Incorrect- SGLT-2 inhibitors have not shown the highest evidence of primary prevention cardiovascular benefit

Please see Figure 2A on pg 577 of the Pharmacologic Glycemic Management of Type 2 Diabetes in Adults: 2020 Update for more details. There were a lot of questions on the 2018 Guidelines updates (2019 cannabis, 2020 medications, 2021 blood glucose monitoring, 2019 Ramadan, 2022 Remission, 2023 Mental Health) so make sure you read those in addition to the guidelines.