Questions may not always match the order of those online. Please be sure to read the questions when completing the online test.

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1 Module 13 Part 1 Questions may not always match the order of those online. Please Case #1 Fred W. Fred W. is in to see you for a referral from his family physician. In the referral letter, the family physician mentions that he has diagnosed Fred with prediabetes. He asks if you can provide him some education to reduce his risk of progression to type 2 diabetes. From his referral letter you see the following information: Patient - Fred W. Age 48 years old Weight 225 lbs, BMI 32 kg/m 2 Blood pressure = 148/94 mmhg LDL cholesterol = 3.8 mmol/l HDL cholesterol = 0.7 mmol/l Current medications: o Perindopril 8 mg daily started 1 week ago o Rosuvastatin 10 mg daily started 1 week ago Fasting blood glucose: o 6.3 mmol/l 2 hour 75-g oral glucose tolerance test: o 8.6 mmol/l Fred has some questions regarding why he is having this problem with sugar control. You start to provide him some information on the pathophysiology of diabetes. 1. You discuss the role of insulin in the body. Which of the following statements regarding insulin is TRUE? a. Insulin is an anabolic hormone b. When food is ingested insulin decreases glycogen levels c. Insulin levels are increased during low glucose levels to suppress glyconeogenesis d. Insulin suppresses lipid formation in the adipocytes 2. You start discussing glucagon. Which of the following statements regarding glucagon is TRUE? a. It promotes the conversion of glycogen to glucose b. It prevents gluconeogenesis c. After 1 hour of fasting, it promotes the formation of glucose from non-carbohydrate substrates d. It suppresses ketogenesis 3. You decide to review the other main hormones involved in glycemic control. Which of the following statements is TRUE? a. Gastric inhibitory peptide (GIP) inhibits the release of insulin b. Catecholamines has a similar effect to insulin c. Glucocorticoids stimulate gluconeogenesis 1

2 d. Growth hormone promotes the effect of insulin 4. Fred asks about what causes type 2 diabetes. Which of the following is linked to the development of type 2 diabetes? a. An increase in the number of β-cells in the pancreas b. High levels of insulin secretion after food ingestion c. Decreasing levels of insulin resistance d. Genetic predisposition for glucose intolerance 5. Fred asks if there could be other causes of diabetes. You review his medication history for drugrelated causes of diabetes. Which of the following agents have been linked to the development of hyperglycemia? a. Cyclosporine b. Phenytoin c. Thiazide diuretics 6. You discuss other options to reduce Fred s risk of developing type 2 diabetes. Which of the following medications does NOT decrease the risk of developing type 2 diabetes in patients with prediabetes? a. Orlistat b. Acarbose c. Rosiglitazone d. Repaglinide 7. You review impact of lifestyle modifications on Fred s risk of developing type 2 diabetes. In the Finish diabetes prevention study, what was the reduction in the risk of developing type 2 diabetes from a low calorie, low fat, low saturated fat, high fibre diet, combined with moderate intensity exercise of at least 150 minutes per week? a. 10% b. 26% c. 58% d. 72% 8. You start to review the diagnosis criteria for prediabetes with Fred. Which of the following readings would be classified in the prediabetes range? a. Fasting blood glucose of 7.2 mmol/l b. Fasting blood glucose of 6.4 mmol/l c. 2 hour plasma glucose in the 75 g OGTT of 7.2 mmol/l d. 2 hour plasma glucose in the 75 g OGTT of 11.4 mmol/l 9. Fred asks at what blood sugar level would he be diagnosed with type 2 diabetes. Which of the following readings is in the range for diagnosis of a patient with type 2 diabetes? a. A1C of 6.7% b. 2 hour plasma glucose in the 75 g OGTT of 9.2 mmol/l c. Fasting plasma glucose of 6.8 mmol/l 2

3 Case #2 Katie S. Katie S. is in to see you for diabetes education. She was referred to you by her family doctor as she was recently diagnosed with type 2 diabetes. She was started on metformin 500 mg BID and she has very little knowledge of how to properly manage her diabetes. She was also told to purchase a blood glucose meter to start testing her blood sugar. The referral letter reveals the following: Patient - Katie S. Age 52 years old Weight 160 lbs, BMI 27 kg/m 2 Blood pressure = 132/81 mmhg LDL cholesterol = 2.7 mmol/l HDL cholesterol = 1.2 mmol/l Current medications: o Metformin 500 mg BID Last A1C result = 8% You feel the best way to start is to provide her education on her glycemic targets. 10. Katie asks if her A1C reading is in the target range. Is Katie s current reading in the recommended range a. Yes, she is currently in the A1C target range b. No, she is not in the current A1C target range 11. Katie asks about how often she should have her A1C blood test. What does the CDA guidelines recommend for A1C testing frequency in patients who are having their therapy adjusted? a. Every month b. Every 3 months c. Every 5 months d. Annually 12. She says that she thought an A1C reading of 8% was equivalent to blood glucose reading of 8 mmol/l. You explain that this is not the case. What is the estimated average blood glucose for Katie with an A1C of 8%? a. 8.6 mmol/l b mmol/l c mmol/l d mmol/l 13. You demonstrate the use of a blood glucose meter for Katie. What is the recommended selfmonitoring of blood glucose (SMBG) testing frequency for Katie? a. Once daily b. Twice daily c. Four times daily d. Tailored based on the patient and their targets 3

4 14. You have worked with Katie to determine the optimal SMBG testing frequency. She asks what her readings should be. Which of the following readings would be a recommended target range for most patients with diabetes? a. 3.8 mmol/l fasting reading b. 7.6 mmol/l fasting reading c. 7.8 mmol/l 2 hour post-prandial reading d mmol/l 2 hour post-prandial reading 15. You move your discussion to the nutritional management of diabetes. You start with carbohydrates. Which of the following statements regarding carbohydrates is TRUE? a. They are the largest energy source in patients with diabetes b. Approximately 60% of ingested carbohydrates are converted to glucose in the blood stream c. The CDA recommends the carbohydrate intake to be 25-30% of the total energy intake d. The source of carbohydrates has little response in the conversion to glucose in the bloodstream 16. You start discussing the glycemic index with Katie. Which of the following foods would be classified as having a high glycemic index? a. Sweet potato b. Popcorn c. Rye bread d. Corn flakes 17. Katie asks about sugar free products. You start with a discussion of sugar alcohols. What is the recommended maximum intake of sugar alcohols per day? a. 1 gram/day b. 5 grams/day c. 10 grams/day d. 15 grams/day 18. Which of the following sweeteners is considered safe in patients like Katie? a. Sucrose b. Fructose c. Saccharin 19. You start discussing the role of fibre in Katie s diet. Which of the following statements regarding dietary fibre is TRUE? a. Patients with diabetes should be encouraged to eat a minimum of 10 g of fibre per day b. Wheat bran is an example of soluble fibre c. Soluble fibre may also help control blood glucose levels by slowing gastric emptying and delaying the absorption of glucose into the bloodstream d. It may increase the absorption of cholesterol from the gastrointestinal tract 20. You move the discussion to protein consumption. Which of the following statements regarding protein intake in diabetes is TRUE? a. 30% of the protein ingested is converted to glucose in the blood stream b. In the standard diet, it has a major impact on blood glucose levels c. There is no limitations on the intake of protein in patients with diabetes 4

5 d. Common sources include eggs, lentils and tofu 21. You discuss the role of dietary fat in diabetes with Katie. Which of the following statements regarding dietary fat in diabetes is TRUE? a. Fat consumption usually causes a significant increase in blood glucose levels b. Fat consumption increases the digestion of food c. Fat intake should be limited to < 35% of the total daily energy intake d. The main reason to limit fat consumption is its role in microvascular complications 22. Katie asks about alcohol intake in patients with diabetes. Which of the following statements is a suitable recommendation for patients with diabetes? a. Patients with diabetes should avoid alcohol b. Moderate alcohol consumption with food commonly causes hyperglycemia in patients with type 2 diabetes c. If Katie drinks alcohol she should she never drink alone d. The recommended weekly maximum for Katie would be 14 standard drinks per week 23. What is the recommended minimum amount of moderate intensity aerobic physical activity per week for Katie? a. 30 minutes b. 60 minutes c. 120 minutes d. 150 minutes 24. You move the discussion to her metformin therapy. Which of the following statements regarding metformin is TRUE? a. As monotherapy it will reduce A1C levels by 1-2% b. The maximum daily dose is 1000 mg per day c. It is not recommended in patients with a creatinine clearance of < 60 ml/min d. Lactic acidosis occurs in approximately 1 per 1,000 patient years Katie returns 6 months later. She is currently taking metformin 1000 mg BID. She is not reaching her A1C target. Her last A1C reading was 8.4%. Her family physician wants a suggestion on different therapies that could be added to her metformin therapy. 25. Which of the following therapies could be an option for Katie to add to her metformin therapy? a. Gliclazide b. Pioglitazone c. Liraglutide 26. You discuss the different options with Katie. Which of the following statements regarding insulin secretagogues is TRUE? a. Out of the sulfonylureas the risk of hypoglycemia is lowest with glimepiride b. The average weight gain with a meglitinides agent is kg c. If we were to initiate gliclazide MR therapy, the starting dose would be 60 mg daily d. Risk of hypoglycemia is less common in elderly patients due to increased elimination of these drugs 5

6 27. You start discussing other therapies for Katie to consider in addition to her metformin. Which of the following statements is TRUE? a. Katie is contraindicated to receiving pioglitazone as she is taking metformin therapy b. If we were to initiate Katie on acarbose the starting dose should be 100 mg TID c. If Katie s renal function was a concern she should avoid DPP-4 inhibitors d. If Katie was to initiate liraglutide therapy she could expect a 3 kg weight loss 28. You finish your review of the different options by discussing the efficacy of combination therapy. Which of the following therapies added to metformin is UNLIKELY to help Katie reach her A1C target? a. Insulin b. Sitagliptin c. Gliclazide d. Repaglinide 29. Katie s uncle recently had some pain in his feet and his doctor said it was associated with his diabetes. You explain that this is a condition called diabetic peripheral neuropathy. How common is detectable diabetic peripheral neuropathy in patients within 10 years of the onset of type 1 or type 2 diabetes? a. 5-8% b % c % d % 30. You discuss diabetic peripheral neuropathy with Katie. Which of the following statements is TRUE? a. As many as 50% of patients with the condition are asymptomatic b. The only affected areas are the feet and legs c. Pain occurs in approximately 50% of patients with diabetic peripheral neuropathy d. Patients with type 2 diabetes should start screening 5 years after diagnoses of diabetes 31. She wants to know if she is at a higher risk of this condition. Which of the following is NOT a risk factor for diabetic peripheral neuropathy? a. Hyperglycemia b. Duration of diabetes c. Short stature d. Hypertension 6

7 Case # 3 Carly Y. Carly Y. is in to see you for her quarterly appointment for her diabetes management. She was diagnosed with type 1 diabetes approximately 9 years ago when she was 10 years old. Over the last few appointments you have noticed a worsening of glycemic control. You decide to address this with Carly. She admits that she has been so busy at university that she has not focussed on the management of her diabetes. She says that she is having trouble remember all of the different aspects of diabetes care as her parents used to do almost everything and the bulk of her education occurred years ago when she was a child. You take a look at her chart and see that her regimen is: Insulin glargine 20 units at bedtime Insulin aspart sliding scale prior to each of her meals Her average daily prandial aspart dose is 16 units/day 32. You decide to review the key concepts of carbohydrate management with Carly. Which of the following statements regarding carbohydrate intake in type 1 diabetes is TRUE? a. Carly should choose products with a higher glycemic index b. Carly should attempt to ingest the same amount of carbohydrates at consistent times during the day c. She should be taught to eat the same carbohydrate sources each day d. Her current regimen offers little flexibility for varying carbohydrate intake 33. You review carbohydrate counting with Carly. Which of the following statements is TRUE? a. Carbohydrate counting allows for Carly to eat varying amounts of carbohydrate without causing glycemic excursions b. Carbohydrate counting is important as each carbohydrate affect blood glucose levels very differently c. Carbohydrate counting is only recommended for type 1 diabetes d. Every patient with diabetes has the same recommended amount of carbohydrate servings per meal 34. If her total intake of carbohydrates is 160 grams per day, what is her carbohydrate:insulin ratio based on the daily carbohydrate method? a. 2 b. 7 c. 10 d You decide to calculate Carly s carbohydrate:insulin ratio using the rule of 500. What is this value? a. 2 b. 14 c. 36 d

8 36. You ask Carly what is her insulin sensitivity factor, she is unsure. Using the rule of 100, what is Carly s insulin sensitivity factor? a. 1 b. 3 c. 5 d Carly has some questions regarding her insulin regimen. Which of the following statements is TRUE regarding her insulin glargine? a. It is more effective than NPH insulin at reducing A1C b. It has a lower rate of nocturnal hypoglycemia but a higher rate of overall hypoglycemia compared to NPH insulin c. There is greater intra-patient variability with insulin glargine compared to NPH insulin d. Insulin glargine primarily targets Carly s fasting blood glucose readings 38. You start discussing insulin aspart with Carly. Which of the following is a property of insulin aspart? a. Onset of action 30 minutes b. Peak 30 minutes c. Duration 3-5 hours 39. When reviewing Carly s logbook you notice she is having a significant number of hypoglycemic episodes. You decide to review the proper management of hypoglycemia. You start by discussing symptoms. Which of the following is a neurogenic symptom of hypoglycemia? a. Confusion b. Sweating c. Headache d. Weakness 40. You decide to review some of the risk factors for hypoglycemia with Carly. Which of the following is NOT a hypoglycemia risk factor? a. Skipping a meal b. Physical activity c. Renal dysfunction d. Weight gain 41. You are concerned that Carly may be experiencing some nocturnal hypoglycemia. Which of the following is a symptom of nocturnal hypoglycemia a. Headache b. Nightmares c. Difficulty getting up in the morning 42. Carly explains that she does not commonly have many of the symptoms of hypoglycemia like tremor, palpitations and tingling. You feel she is experiencing hypoglycemia unawareness. Which of the following is a risk factor for hypoglycemia unawareness? a. Younger patients b. Obese patients with diabetes c. Those recently diagnosed with diabetes 8

9 d. Patients with infrequent bouts of hypoglycemia 43. If Carly has a severe hypoglycemic reaction, which of the following is an appropriate initial strategy? a. If conscious, ingest 15 grams of carbohydrates b. If conscious, ingest 20 grams of carbohydrates c. If unconscious, ingest 15 grams of carbohydrates d. If unconscious, be administered 1.5 mg of glucagon subcutaneously 44. You notice that Carly has not been adherent to her screening for microvascular complications. You decide to review this with Carly. Which of the following is screening frequency is recommend for patients with type 1 diabetes? a. Screening for chronic kidney annually from the time of diagnosis b. Screening for chronic kidney annually with duration of diabetes > 5 years c. Screening for retinopathy annually from the time of diagnosis d. Screening every 6 months in all patients > 15 years of age 45. You are concerned about her risk of diabetic nephropathy. Which of the following is NOT a recommendation to help to reduce her risk of diabetic nephropathy? a. Blood pressure control b. Lipid control c. High fluid intake d. Smoking cessation 46. You finish by reviewing contraception and sexual health with Carly. Which of the following statements are TRUE? a. Patients with type 1 diabetes are at higher risk of acquiring sexually transmitted infections b. Only oral contraceptives and condoms are recommended as methods of birth control in patients with diabetes c. Sexual dysfunction is common in women with type 1 diabetes 47. You review the importance of discussing any pregnancy plans with you before she starts trying to become pregnant. Which of the following is a recommendation for preconception care in patients with type 1 diabetes? a. A1C level should be less than 2% above target range b. She should be have an ophthalmologic exam as soon as she becomes pregnant c. She should be initiated on folic acid mg at least 3 months preconception and 12 weeks post-conception d. Medications should be evaluated for safety during the preconception stage 9

10 Case 4 Anil G. Anil G. is in to see you for an appointment for initiation of basal insulin. Anil was diagnosed with type 2 diabetes over 5 years ago and his current regimen of metformin 1000 mg BID and gliclazide MR 120 mg once daily is no longer allowing him to reach his glycemic targets. He was sent to you to discuss the initiation of basal insulin as well as he has some specific questions regarding diabetes management. You review his chart and see the following: Patient Anil G. Age 67 yo Weight 240 lbs, BMI 34 kg/m 2 Blood pressure 140/92 mmhg LDL cholesterol 3.6 mmol/l HDL cholesterol 0.8 mmol/l Current medications: o Telmisartan 80 mg daily o Atorvastatin 10 mg daily o ASA 81 mg daily o Citalopram 20 mg daily Last A1C reading: o 8.7% 48. You start by discussing the initiation of basal insulin. Which of the following would be the LEAST appropriate basal insulin choice for Anil? a. Insulin glargine b. Insulin glulisine c. Insulin detemir d. Insulin NPH 49. You discuss the starting dose and titration of insulin for Anil. Which of the following is the MOST appropriate insulin titration regimen for Anil? a. 1 unit once daily at bedtime and increase by 2 units each day until target is reached b. 5 units once daily at bedtime and increase by 3 units each day until target is reached c. 10 units once daily at bedtime and increase by 1 unit each week until target is reached d. 10 units once daily at bedtime and increase by 1 unit each day until target is reached 50. Through your conversation with Anil you feel that he is elevated risk of cardiovascular disease. You decide to counsel Anil about cardiovascular risk in patients with diabetes. Which of the following statements regarding cardiovascular disease in patients with diabetes is TRUE? a. Patients with type 2 diabetes have a 10 fold increase in cardiovascular disease risk compared to the general population b. The rate of cardiovascular mortality and morbidity in patients with diabetes exceeds by 50% the rate predicted by standard cardiovascular risk factors c. Anil would be classified as moderate risk of coronary artery disease 10

11 d. Resting ECG testing is only recommended for patients > 40 years of age 51. Anil mentions to you that he has been suffering from erectile dysfunction. Which of the following statements is TRUE? a. Erectile dysfunction occurs in 34-45% of men with diabetes. b. It is more common in men aged years of age c. Erectile dysfunction occurs 5-8 years earlier compared to men without diabetes d. Erectile dysfunction is much more common in men with type 2 diabetes compared to men with type 1 diabetes 52. Which of the following treatments could be considered for Anil s erectile dysfunction? a. Sildenafil b. Trimix of papaverine, alprostadil and phentolamine c. Vacuum constrictive device 53. Anil mentions that he will be travelling to India in the next few months. Which of the following recommendation is MOST appropriate for Anil? a. He is travelling East and should not require any adjustments of his medications b. Transport Canada will not allow insulin transport in carry-on baggage on the plain c. Insulin should be hand inspected as repeated exposure to x-rays may affect the overall potency d. Patients with diabetes should adjust to the time zone they are travelling to a week before travel 54. Anil mentions that he is travelling to India due to the death of his mother. He mentions the death occurred several months ago and he has been feeling down since then. His physician started him on citalopram to manage the way he is feeling. You discuss the impact of depression on diabetes control. Which of the following is associated with patients with diabetes and depressive disorders? a. Poorer self-care behaviour b. Decreased quality of life c. Increased family problems 55. When managing a senior with diabetes, which of the following should you consider? a. Assure that he reaches the target A1C level of 7.0% b. Use a similar approach for all seniors with diabetes c. Simplify the regimen as much as possible d. Initiate aggressive treatment as all seniors are at high risk of complications 56. You mention to Anil that he has to be involved in most of the decisions regarding his diabetes as he is the one that has to make the commitment to implement these changes in his life. What percentage of care decisions are made by the patient outside the clinical practice setting? a. 10% b. 25% c. 50% d. 90% 57. You want to empower Anil to take better care of his diabetes. Which of the following is NOT part of the 5 A s of the empowerment education model? 11

12 a. Acceptance b. Abstain c. Alliance d. Active participation 58. You feel through your assessment Anil has a basic Self-Management Education (SME) level. Which of the following best describes this SME level? a. This is the education level that patients with diabetes require for survival b. This is knowledge, skills and motivation to achieve optimal self-care c. This is the knowledge, skills and motivation for self-care that involves a full integration of care into the individual s life activities and goals d. None of the above 59. Which of the following is NOT a principle of adult education in patients with diabetes such as Anil? a. Lectured learning is the optimal teaching method b. Adult life experiences are rich resources for learning c. Information provided should have immediate application d. Adults want to know What s in it for me? 60. Anil mentions that he will start the insulin injections today. Based on the transtheoretical model, what stage of change is Anil currently in for initiating insulin therapy? a. Precontemplation b. Contemplation c. Preparation d. Action 61. If you are considering offering lectures to educate patients with diabetes. Which of the following should you consider? a. Avoid engaging the audience as this can inhibit learning b. Start with complex topics and end with simple topics c. Vary pace and delivery d. When designing lectures include large amounts of content as most adults will retain using this method. 62. Which of the following is NOT a key principle of motivational interviewing? a. Expressing empathy b. Help the patient develop discrepancy c. Insisting to the patient that your point of view is optimal d. Support self-efficacy 63. You ask Anil if he would prefer group learning. Which of the following is an advantage of group discussions? a. Allows for exploration, reflection and critical analysis of an issue b. Helps the patient develop effective and attentive listening skills c. Group discussion also helps to facilitate group cohesiveness and sharing 12