A) Incorrect- ASA is no longer used in primary prevention. Research have found the benefits to not outweigh the risks of gastric bleeds and other side effects
B) Incorrect- SGLT-2 inhibitors do not have significant evidence of reducing MACE in primary prevention
C) Incorrect- SGLT-2 inhibitors do not have significant evidence of reducing MACE in primary prevention
D) Correct- GLP-1 analogs, particularly  dulaglutide, have the best evidence of reducing MACE in primary prevention

Please see Figure 2A on pg 577 of 2020 Pharmacologic Glycemic Management of Type 2 Diabetes in Adults and pg 418 of the 2024 Pharmacological Glycemic Management of type 2 Diabetes in Adult for more 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 my pathphysiology lectures

On the exam there may be questions with very long answers. The key to these answers is to look for the item that is incorrect to eliminate the entire long answer. For example if I know that insulin in an anabolic hormone then I can already eliminate B and D right off the bat. That saves time (your most precious resource on the exam). Even if you cant decide between A and C at least you have a 50% chance of guessing the right answer instead of a 25%

A) Incorrect – 4 hours is too short
B) Incorrect – 18 hours is too short
C) Correct – Alcohol can cause hypoglycemia up to 24 hours after consumption. Alcohol interferes with the liver’s ability to create glucose, which can lead to hypoglycemia
D) Incorrect – 48 hours is too long

For more information please see pg S73 of the 2018 Diabetes Canada clinical practice guidelines

For alcohol consumption tips and a patient handout, please check out the Diabetes Canada website at https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-My-Diabetes/Tools%20and%20Resources/alcohol-and-diabetes.pdf?ext=.pdf will open in a new window

A) Correct- this is a process indicator
B) Incorrect- this is a outcome indicator
C) Correct- this is a outcome indicator
D) Incorrect- this is a structure indicator

Please see the Standard for Diabetes Education in Canada 2014 in the After Practice Exam for details

A) Correct- this is the TIR for older people and/or people with a high risk for hypoglycemia
B) Incorrect- this is a made up TIR
C) Incorrect- this is the TIR for most people with diabetes
D) Incorrect- this is a made up TIR

Please see Table 3 on pg 583 of the 2021 Blood Glucose monitoring update for details

A) Incorrect – The patient has had a stroke and should be on a number of medications to manage his CV (cardiovascular) 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.

As per the 2020 Pharmacological update, you could also consider medications for CV protection (such as certain SGLT-2 inhibitors or GLP-1 analogs).

This is an “EXCEPT” question. On older exams there were a lot of trick questions which ask what “not” to do or what is “incorrect” or “except”. In the latest exams there does not seem to be any of these trick questions but I decided to keep some in my Practice Exams to force people to read the question carefully. After talking to people who failed the exam I have found one of the most common reasons for failing the exam is not reading the question carefully. So remember to read the question carefully.
A) Incorrect – Distraction therapy can be useful to make injections more tolerable in children
B) Incorrect – Play therapy, as long as it doesn’t involve trickery and loss of trust, can be useful to make injections more tolerable in children
C) Incorrect – Parents who are well prepared beforehand will transmit less anxiety to a child. In fact, the presence of a calm and reassuring parent is the most effective support for a distressed child.
D) Correct – Cognitive behavioral therapy should be reserved to older children and adolescents. A 3 year old will not understand the concepts discussed in cognitive behavioral therapy and is unlikely to cooperate.

Please see pg 32 of the 2020 FIT guidelines for more details in the After Practice Exam section

A) ≤7% Correct- this is the A1c target for most people with diabetes
B) ≤7.5% Incorrect- this is the A1c target for children under 18 years of age
C) <8% Incorrect- this could be a A1c target for an elderly patient who is functionally dependent
D) ≤6.5% Incorrect- this may be targeted in some patients with type 2 diabetes to further lower the risk of nephropathy and retinopathy, but this must be balanced against the risk of hypoglycemia

For more information please see pg S43 of the 2018 Diabetes Canada clinical practice guidelines for more details

A) Incorrect- generally (but not always) tropical fruits tend to have a higher GI
B) Incorrect- ripe and over ripe bananas have the highest GI
C) Correct- apples have the lowest GI of the fruits listed
D) Incorrect- generally (but not always) tropical fruits tend to have a higher GI

Please see the Diabetes Canada resource on glycemic index for details. You do not need to memorize everything but you do need to have a good idea of what foods fall into high, medium and low glycemic index. Here is the link https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-My-Diabetes/Tools%20and%20Resources/glycemic-index-food-guide.pdf (will open in new window)

A) ≤7%- Correct- a more relaxed target should be used for a patients who are prone to hypoglycemia. Hypoglycemia can be severe and life threatening. Thus preventing it takes precedence over achieving stringent blood sugar targets in most cases
B) ≤7.5% Incorrect- this is a reasonable target for a patient with a history of severe hypoglycemia and/or hypoglycemia unawareness
C) ≤8% Incorrect- this is a reasonable target for a patient with a history of severe hypoglycemia and/or hypoglycemia unawareness
D) ≤8.5% Incorrect- this is a reasonable target for a patient with a history of severe hypoglycemia and/or hypoglycemia unawareness

For more information on target please see pg S43 of the 2018 Diabetes Canada clinical practice guidelines and pg 551 of the 2023 Hypoglycemia chapter update

This is an “EXCEPT” question. On older exams there were a lot of trick questions which ask what “not” to do or what is “incorrect” or “except”. In the latest exams there does not seem to be any of these trick questions but I decided to keep some in my Practice Exams to force people to read the question carefully. After talking to people who failed the exam I have found one of the most common reasons for failing the exam is not reading the question carefully. So remember to read the question carefully.

A) Incorrect- one full cup of low fat milk is 15 grams and 3/4 cups of yogourt is 15 grams not a full cup
B) Incorrect- half a cup of chocolate milk is 15 gram and a full cup of juice is 30 grams
C) Incorrect- half a cup of evaporated milk is 15 grams and 3/4 cups of yogourt is 15 grams not a full cup
D) Correct- half a cup of chocolate milk is 15 grams and half a cup of juice is 15 grams for a total of 30 grams

Please see the Beyond the Basics guide on carbohydrates in the Chapter 11 Nutrition Therapy study guide for details

A) Incorrect – this is too much, metformin is excreted through the kidneys so adequate renal function is required or build up of metformin in the body will occur
B) Incorrect – still too much
C) Correct – 500 mg daily can be used.
D) Incorrect – you can still use a small dose of metformin

Please see Table 2 on pg 418 of the 2024 Pharmacological update for the latest renal adjustment table

A) 23 and yearly: Correct- Retinopathy screening for patients with type 1 diabetes should commence 5 years after onset of diabetes and be done yearly regardless if retinopathy is present or not
B) 15 and every 2 years: Incorrect- screening starts after 5 years after diagnosis so 5 years after 18 so screening should start at 23 years of age. For children with type 1 diabetes retinopathy screening should start at 15 years of age if duration of diabetes is more than 5 years.
C) 25 and every 2 years: Incorrect- people with type 1 diabetes are screened at least yearly for retinopathy while adults with type 2 diabetes can be screened 1-2 years if no retinopathy is present
D) 15 and yearly: Incorrect- for the reasons above

Please see pg S211 of the 2018 Diabetes Canada guidelines for more details

A) Incorrect – (15 grams of sugar – 5 grams of fibre) x 3 servings= 30 grams divided by 1:5= 6 units is not correct because you calculate insulin dosage based on available carbohydrate (total carbohydrate – grams of fibre), not sugar
B) Incorrect – (15 grams of sugars) x 3 servings = 45 grams divided by 1:5 = 9 units is not correct because you calculate insulin dosage based on available carbohydrate (total carbohydrate – grams of fibre), not sugar
C) Correct – (30 grams of carbohydrate – 5 grams of fibre) x 3 servings = 75 grams of available carbohydrate. 75 grams divided by 1 unit per 5 grams = 15 units which is the correct formula and answer
D) Incorrect – (30 grams total carbohydrate) x 3 servings = 90 grams divided by 1:5= 18 units is not the correct answer because you calculate insulin dosage based on available carbohydrate which total carbohydrate – grams of fibre)

A) Seven-standard field, stereoscopic-colour fundus photography: Correct- this is the gold standard for screening for retinopathy
B) Kaleidoscope vision ray: Incorrect- that is a bunch of words I made up
C) Indirect slit-lamp funduscopy through dilated pupil: Incorrect- commonly used but not the gold standard
D) Direct ophthalmoscopy: Incorrect- not the gold standard

Please see table 1 on pg S211 of the 2018 Diabetes Canada clinical practice guidelines for more details

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.

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) Incorrect- ß- cell dysfunction can’t precede hyperinsulinemia because if the ß- cells aren’t functioning how can they produce a hyper amount of insulin?
B) Correct- this is the correct sequence of events
C) Incorrect- if the ß cells are gone how can insulin deficiency precede hyperinsulinemia? And how can both precede ß-cell dysfunction? If the ß-cells are working fine then you won’t get the other two
D) Incorrect- same as C)

Please see my pathophysiology lectures for more details

A) Incorrect- counter regulatory hormone, stomach hormones that help lower sugars, counter regulatory hormone and a by product of insulin production
B) Incorrect- secreted by beta cells and helps lower sugars, counter regulatory hormone, counter regulatory hormone and a type of incretin
C) Incorrect- stomach hormones that help lower sugars, by product of insulin production, a type of incretin and a counter regulatory hormone
D) Correct- counter regulatory hormone, counter regulatory hormone, counter regulatory hormone and counter regulatory hormone

Please see the pathophysiology lectures for details

A) Correct- this patient is very fearful of starting. The most empathetic course of action is to explore her fears and to reassure her. On the exam and in real life the best course of action is usually the empathetic one.
B) Incorrect- while this option may reduce overnight lows, as rapid acting insulin doesn’t last long enough, this doesn’t solve the main problem of the patient’s fears
C) Incorrect- while a reduced dosage would reduce the likelihood of having overnight lows, this doesn’t solve the main problem of the patient’s fears
D) Incorrect- while this does acknowledge the patients fears it doesn’t address them. Also a history of bladder cancer is a contraindication to Actos (pioglitazone) so not the best answer.

Please see chapter 18 and table 5 on pg 326 the 2023 Diabetes and Mental Health update for details