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Practice Exam: Pharmacologic Glycemic Management (2024 Update)

You have reviewed the study guide for the Diabetes Canada 2024 Pharmacologic Update, and now it is time to test your knowledge.

This is arguably the most critical section of the CDE exam. The 2024 Guidelines have cemented a paradigm shift in diabetes care: we are no longer treating “sugar” in isolation; we are treating risk. The exam will require you to look beyond the A1C number and identify patients who need Cardiorenal Protection regardless of their glycemic control.

What to expect in this quiz: This practice exam focuses on the complex decision trees introduced in the latest update. You will be tested on:

  • The “Cardiorenal Path”: Identifying patients with ASCVD, Heart Failure, or CKD who require an SGLT2 inhibitor or GLP-1 RA, even if their A1C is already at target.

  • The “1.5% Rule”: Knowing when to bypass monotherapy and initiate Metformin + a second agent immediately at diagnosis.

  • Symptomatic Decompensation: Recognizing the clinical signs (weight loss, severe hyperglycemia) that mandate the immediate start of Insulin.

  • Heart Failure Nuances: Specifically recalling that SGLT2 inhibitors are the only class proven to reduce hospitalizations for heart failure.

1. Case: A patient asks about tirzepatide compared to GLP1-RAs. According to the User’s Guide, what does the evidence show?

2. Case: A patient using a GLP1-RA is scheduled for elective surgery. According to the User’s Guide, what is the concern?

3. According to the UKPDS, what was demonstrated with metformin monotherapy in newly-diagnosed participants who had overweight?

4. What is the recommended target dose of metformin when initiating therapy?

5. According to the guidelines, what is the recommended approach for initiating bolus insulin in type 2 diabetes?

6. According to the guidelines, what is the level of evidence supporting the use of basal-bolus injection therapy or CSII for cardiorenal protection in type 2 diabetes?

7. According to the guidelines, which SGLT2 inhibitors have demonstrated reduction in MACE outcomes in people at high CV risk?

8. Case: A healthcare team is considering using a TZD for a patient. According to the User’s Guide, what potential benefits and risks should be considered?

9. According to the User’s Guide, what is the concern with using oral semaglutide compared to subcutaneous semaglutide?

10. Case: A patient with type 2 diabetes has GI intolerance to immediate-release metformin. According to the User’s Guide, what strategies can be used?

11. Case: A patient with type 2 diabetes and heart failure with preserved ejection fraction (HFpEF) needs therapy intensification. Which medications have demonstrated benefit?

12. Case: A diabetes educator is discussing NPH insulin with a patient. According to the User’s Guide, what is a major challenge with NPH insulin?

13. According to the evidence, what is the effect on A1C when combining metformin with another agent at the outset compared to metformin alone?

14. According to the guidelines, when should insulin be initiated immediately with or without metformin?

15. According to the User’s Guide, what is the dose-response relationship for SGLT2 inhibitors regarding glucose lowering and cardiorenal benefits?

16. According to the guidelines, what should be done when bolus insulin is introduced into a treatment regimen?

17. Case: A patient asks whether using both a GLP1-RA and SGLT2 inhibitor together will provide additional cardiorenal benefit. What does the evidence show?

18. According to the guidelines and User’s Guide, why should GLP1-RAs NOT be used together with DPP4 inhibitors?

19. Case: A patient is concerned about the risk of DKA with SGLT2 inhibitors. According to the User’s Guide, when should SGLT2 inhibitors be held?

20. According to the evidence, what is the A1C threshold above target where combination therapy is recommended as initial pharmacologic therapy?

21. Case: A diabetes educator is counselling a patient about sulfonylureas. What are the key concerns with this drug class?

22. Case: A 58-year-old patient with newly diagnosed type 2 diabetes has an A1C of 9.5% (target 7.0%). According to the guidelines, what is the recommended initial pharmacotherapy approach?

23. Case: A patient with type 2 diabetes experiences declining kidney function. According to the guidelines, at what eGFR level is metformin contraindicated?

24. Case: A diabetes educator is evaluating a patient with type 2 diabetes who is not meeting glycemic targets. Before intensifying pharmacologic therapy, what should be assessed according to the guidelines?

25. What is the recommended starting dose of metformin to minimize gastrointestinal side effects?

26. Case: A patient with type 2 diabetes and chronic kidney disease (CKD) needs intensification of therapy. According to the guidelines, which SGLT2 inhibitors have demonstrated evidence of benefit for CKD?

27. According to the guidelines, what is the timeframe goal for reaching target A1C after dose adjustments or additions of medications?

28. Which drug class is associated with negligible risk for hypoglycemia and leads to weight loss?

29. According to the guidelines, what are the benefits of adding insulin to non-insulin antihyperglycemic agents compared to using insulin alone?

30. What is the typical A1C reduction with non-insulin antihyperglycemic agent monotherapy?

31. According to the 2024 guidelines, what is the recommended first-line antihyperglycemic medication for most people with type 2 diabetes who require pharmacotherapy?

32. Case: A patient with type 2 diabetes develops heart failure with reduced ejection fraction (HFrEF). According to the guidelines, which medication class should be prioritized?

33. According to the evidence comparing metformin with other agents as monotherapy, what are the relative advantages of metformin?

34. According to the guidelines, which long-acting basal insulin analogues may be considered to reduce the risk of nocturnal hypoglycemia?

35. Which GLP1-RAs have demonstrated reduction in major adverse cardiovascular events (MACE) in people at high CV risk?


 

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CDE Diabetes

Study Guide: Pharmacologic Glycemic Management (2024 Update)

1. Chapter Overview: The "Organ Protection" Shift

The 2024 update reinforces a major paradigm shift: we are no longer just treating “sugar”; we are treating risk. The guidelines prioritize agents with proven cardiovascular and renal benefits (Cardiorenal Protection) for high-risk patients, often independent of their A1C levels.

For the CDE exam, you must distinguish between the “Glycemic Path” (lowering A1C) and the “Cardiorenal Path” (reducing heart failure, kidney disease progression, and stroke).

2. Key Messages (The "Gold Nuggets")

  • Metformin is (Usually) First: Metformin remains the initial agent of choice for most people due to safety, low cost, and efficacy.

  • The “Symptomatic” Exception: If a patient presents with metabolic decompensation (e.g., significant weight loss, severe hyperglycemia, ketosis), Insulin should be initiated immediately.

  • Cardiorenal Trumps A1C: In patients with Atherosclerotic CVD (ASCVD), Heart Failure (HF), or Chronic Kidney Disease (CKD), use an agent with proven benefit (SGLT2i or GLP-1 RA) even if their A1C is already at target.

  • Early Combination: If the A1C is >1.5% above target at diagnosis, start with Metformin + a second agent immediately (don’t wait 3 months).

3. Cardiorenal Protection (The "Big Three")

A. Atherosclerotic CVD (ASCVD)

  • Definition: History of MI, stroke, or revascularization.

  • Recommended Agents:

    • GLP-1 RA (with proven CVD benefit).

    • SGLT2i (with proven CVD benefit).

  • Goal: Reduce Major Adverse Cardiovascular Events (MACE).

B. Heart Failure (HF)

  • Definition: Reduced Ejection Fraction (HFrEF) or Preserved Ejection Fraction (HFpEF).

  • Recommended Agent: SGLT2 Inhibitor

C. Chronic Kidney Disease (CKD)

  • Definition: eGFR <60 mL/min or Albuminuria (ACR >2 mg/mmol).

  • Recommended Agents:

    • SGLT2 Inhibitor: Primary choice to slow progression.

    • GLP-1 RA: Alternative if SGLT2i is contraindicated or additional lowering is needed.

4. Drug Classes & Characteristics

ClassKey
Examples		BenefitsConsiderations
SGLT2 InhibitorsEmpagliflozin, Dapagliflozin, CanagliflozinHF & CKD protection, Weight loss, BP reduction.Risk of Genital Infections, DKA (rare), Amputation (Canagliflozin).
GLP-1 RASemaglutide, Liraglutide, DulaglutideASCVD protection, Significant Weight loss, No Hypo.GI side effects (nausea/vomiting), Cost, Injection (mostly).
GIP/GLP-1 RATirzepatideHighest efficacy for A1C and Weight loss.GI side effects.
DPP-4 InhibitorsSitagliptin, LinagliptinWeight neutral, Well tolerated.No CV/Renal benefit (neutral). Do not combine with GLP-1.
SulfonylureasGliclazide, GlimepirideLow cost, High efficacy.Weight Gain, Hypoglycemia risk.

5. Clinical Decision Algorithm (Summary)

Step 1: Assessment

  • Is the patient symptomatic/decompensated? -> Insulin +/- Metformin.

  • No? -> Proceed to Step 2.

Step 2: Baseline Therapy

  • Lifestyle Modifications + Metformin.

  • Exam Tip: If A1C is >1.5% above target, start Metformin + Second Agent.

Step 3: Cardiorenal Assessment (The Critical Junction)

  • Does the patient have ASCVD, HF, or CKD?

    • YES: Add SGLT2i or GLP-1 RA with proven benefit. (Do this regardless of A1C).

    • NO: Choose second agent based on goals:

      • Need Weight Loss? -> Tirzepatide, Semaglutide (GLP-1).

      • Avoid Hypo? -> DPP-4, SGLT2i, GLP-1.

      • Cost/Access Issues? -> Sulfonylurea, Insulin (NPH/Regular), TZDs.

Step 4: Monitoring

  • If not at target in 3–6 months, add another agent from a different class.

6. 2024 Diabetes Canada Clinical Practice Guidelines Recommendations

These are the “Must Memorize” graded recommendations.

  1. First Line: Metformin should be the initial agent of choice in most people with type 2 diabetes.

  2. Cardiorenal Risk: In adults with T2D and ASCVD, CKD, or HF, an agent with proven benefit (SGLT2i or GLP-1 RA) should be added to metformin.

    • Note: This decision is independent of A1C.

  3. Heart Failure: SGLT2 inhibitors are specifically recommended for patients with a history of Heart Failure to reduce hospitalization.

  4. Combination: In patients with A1C >1.5% above target, antihyperglycemic agents should be initiated concurrently (Metformin + Second Agent).

Reference:

Shah B, Bajaj HS, Butalia S, et al. Pharmacologic Glycemic Management of Type 2 Diabetes in Adults: 2024 Update. Canadian Journal of Diabetes. 2024;48:415-424. doi:10.1016/j.jcjd.2020.08.001
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CDE Diabetes

Flashcards: Glycemic Management in Adults with Type 1 Diabetes (Chapter 12)

Achieving optimal glycemic control in Type 1 diabetes requires a sophisticated balance of insulin regimens, monitoring technologies, and lifestyle management. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the Diabetes Canada Clinical Practice Guidelines recommendations for basal-bolus therapy, pump usage, and the integration of new technologies like continuous glucose monitoring.

Key Topics Covered:

  • Insulin Regimens: Differentiating between Multiple Daily Injections (MDI) and Continuous Subcutaneous Insulin Infusion (CSII) as standards of care.

  • Pharmacotherapy: Understanding the advantages of rapid-acting and long-acting insulin analogues over older formulations for reducing hypoglycemia and improving A1C.

  • Technology & Monitoring: Identifying the specific benefits of Real-Time Continuous Glucose Monitoring (rtCGM) and Sensor-Augmented Pumps (SAP) for high-risk individuals.

  • Hypoglycemia Prevention: Reviewing strategies for patients with hypoglycemia unawareness, including standardized education and technology.

  • Adjunctive Therapies: Recalling the current evidence and limitations regarding non-insulin agents like metformin, GLP-1 receptor agonists, and SGLT2 inhibitors.

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CDE Diabetes

Practice Exam: Glycemic Management in Adults with Type 1 Diabetes (Chapter 12)

Effective management of Type 1 diabetes requires a complex balance of insulin replacement, monitoring, and lifestyle adaptation. This exam tests your understanding of the Diabetes Canada Clinical Practice Guidelines regarding insulin pharmacotherapy, delivery systems, and the prevention of hypoglycemia.

Key Concepts Covered in This Exam:

  • Insulin Regimens: Differentiating between basal-bolus injection therapy and continuous subcutaneous insulin infusion (CSII), and understanding why these are the preferred standards of care.
  • Pharmacotherapy: Identifying the advantages of long-acting analogues (glargine, detemir, degludec) over NPH for reducing nocturnal hypoglycemia , and the role of rapid-acting analogues.
  • Hypoglycemia Prevention: Recognizing strategies for patients with hypoglycemia unawareness, including the use of sensor-augmented pumps (SAP) and standardized education programs.
  • Technology Integration: Understanding the indications for Real-Time Continuous Glucose Monitoring (rtCGM) to improve A1C and reduce severe hypoglycemia.
  • Adjunctive Therapies: Knowing the current limitations and risks (e.g., DKA) associated with non-insulin agents like SGLT2 inhibitors and GLP-1 receptor agonists in Type 1 diabetes.

Please go to Practice Exam: Glycemic Management in Adults with Type 1 Diabetes (Chapter 12) to view this quiz

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Study Guide: Glycemic Management in Adults with Type 1 Diabetes (Chapter 12)

1. Chapter Overview

This chapter establishes the standard of care for Type 1 Diabetes (T1D): Basal-Bolus injection therapy (MDI) or Continuous Subcutaneous Insulin Infusion (CSII/Pump).

For the CDE exam, the focus is rarely on “how to inject,” but rather on insulin pharmacokinetics (why we choose analogues over human insulin) and the indications for advanced therapies (when to switch from MDI to Pump or Sensor-Augmented Pump). You must also understand the emerging, though cautious, data on non-insulin adjunctive therapies.

2. Key Messages (The "Gold Nuggets")

  • The Standard: Basal-bolus (MDI) or CSII are the only preferred regimens. Premixed insulins are generally not suitable for adults with T1D.

  • Safety First: The primary driver for choosing long-acting basal analogues (e.g., glargine, detemir, degludec) over NPH is the reduction of hypoglycemia, specifically nocturnal hypoglycemia.

  • Rapid is Better: Rapid-acting insulin analogues (RAIA) are preferred over short-acting (regular) insulin because they improve postprandial glucose and lower A1C without increasing hypoglycemia.

  • The Pump Candidate: CSII is not just for people with high A1C. It is specifically indicated for those with severe hypoglycemia, hypoglycemia unawareness, or a significant “Dawn Phenomenon.”

3. Insulin Pharmacotherapy

A. Basal Insulins

  • Goal: Control glucose in the fasting state and between meals.

  • Long-Acting Analogues (Detemir, Glargine U-100): Lower fasting glucose and less nocturnal hypoglycemia compared to NPH.

  • Ultra-Long Acting (Glargine U-300, Degludec):

    • Glargine U-300 (Toujeo): Longer duration (>30 hours) and flatter profile than U-100.

    • Degludec (Tresiba): Duration of ~42 hours. Associated with less nocturnal hypoglycemia and lower total insulin dose compared to glargine or detemir. Allows for flexible dosing timing.

B. Bolus Insulins

  • Goal: Control glycemic rise at meals.

  • Rapid-Acting Analogues (Aspart, Lispro, Glulisine): Administer 0–15 minutes before meals.

  • Faster-Acting Aspart (Fiasp): Can be administered at the start of the meal or up to 20 minutes after starting. Demonstrated superior postprandial control vs. insulin aspart.

4. Advanced Technologies: CSII and SAP

A. Continuous Subcutaneous Insulin Infusion (CSII / Pump)

  • Indications: Consider CSII if MDI is optimized but targets are not met, OR if the patient has:

    • Significant glucose variability.

    • Frequent severe hypoglycemia or hypoglycemia unawareness.

    • Significant “Dawn Phenomenon” (rise in BG early morning).

    • Very low insulin requirements (requiring micro-dosing).

    • Women contemplating pregnancy.

  • Outcomes: Lowers A1C by ~0.3% compared to MDI; improves Quality of Life (QOL) and Treatment Satisfaction.

B. Sensor-Augmented Pump (SAP)

  • Definition: Insulin pump combined with Continuous Glucose Monitoring (CGM).

  • Benefit: A1C reduction is superior to MDI or Pump alone.

  • Low Glucose Suspend: Pumps equipped with this feature (stopping insulin when low) significantly reduce nocturnal hypoglycemia without raising A1C or causing ketoacidosis.

5. Adjunctive Therapies (Non-Insulin)

The guidelines reviewed using Type 2 medications in Type 1 diabetes. Note: These are generally off-label uses.

  • Metformin: May reduce insulin requirements and lead to modest weight loss, but does NOT result in sustainable A1C improvement.

  • GLP-1 Receptor Agonists (e.g., Liraglutide): Associated with weight loss and insulin dose reduction, but inconsistent A1C results.

  • SGLT2 Inhibitors:

    • Showed reduction in A1C and weight.

    • Major Warning: Significant risk of Diabetic Ketoacidosis (DKA), including “euglycemic DKA” (DKA with normal blood sugars). Currently, they do not have an indication for T1D in Canada.

6. Diabetes Canada Clinical Practice Guidelines Recommendations

Key Recommendations to Memorize:

  1. Regimen: Basal-bolus injection or CSII should be used to achieve glycemic targets. (Grade A, Level 1A).

  2. Basal Choice: A long-acting insulin analogue (Detemir, Glargine, Degludec) may be used in place of NPH to reduce the risk of nocturnal hypoglycemia. (Grade B, Level 2).

  3. Degludec Specifics: Degludec may be used instead of detemir or glargine U-100 to reduce nocturnal hypoglycemia. (Grade B/C).

  4. Bolus Choice: Rapid-acting analogues should be used over regular insulin to improve A1C and minimize hypoglycemia. (Grade B, Level 2).

  5. Hypoglycemia Unawareness: Strategies to restore awareness include:

    • Standardized education (Grade A, Level 1A).

    • Relaxed glycemic targets for up to 3 months (Grade C, Level 3).

    • Sensor-Augmented Pump with Low Glucose Suspend (Grade B, Level 2).

  6. Technology: In adults not achieving targets (on MDI or CSII), CGM should be considered to improve A1C. (Grade B, Level 2).

Reference: 

McGibbon A, Adams L, Ingersoll K, Kader T, Tugwell B. Glycemic Management in Adults With Type 1 Diabetes. Canadian Journal of Diabetes. 2018;42:S80-S87. doi:10.1016/j.jcjd.2017.10.012
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CDE Diabetes Uncategorized

Flashcards: Nutrition Therapy (Chapter 11)

Test your recall on the dietary strategies that drive diabetes management.

Nutrition therapy is a fundamental pillar of diabetes care, capable of lowering A1C by up to 2.0%. These flashcards are designed to help pharmacists and healthcare professionals quickly review the evidence-based recommendations for macronutrient distribution, dietary patterns, and specific food choices that improve metabolic outcomes.

Key Topics Covered:

  • Macronutrient Ranges: Memorizing the flexible distribution ranges for carbohydrates (45–60%), protein (15–20%), and fat (20–35%).

  • Dietary Patterns: Identifying specific benefits of Mediterranean, DASH, Vegetarian, and Portfolio diets for glycemic control and cardiovascular health.

  • Carbohydrate Quality: Understanding the role of Glycemic Index (GI) and the recommended daily target for dietary fibre (30–50 g).

  • Fat & Sugar Limits: Recalling the specific thresholds for saturated fat intake (<9% of total energy) and added sugars (<10% of total energy).

  • Clinical Considerations: Reviewing guidelines for alcohol consumption, non-nutritive sweeteners, and vitamin supplementation.

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CDE Diabetes

Practice Exam: Nutrition Therapy (Chapter 11)

Welcome to the practice exam for Chapter 11: Nutrition Therapy.

Nutrition therapy is a critical component of diabetes management, with the potential to reduce A1C by 1.0% to 2.0% and improve overall health outcomes. However, there is no “one-size-fits-all” diet; nutritional counselling must be individualized to the patient’s preferences, culture, and metabolic goals.

This practice exam tests your ability to apply the 2018 Clinical Practice Guidelines to real-world scenarios, covering macronutrient distribution, cardioprotective dietary patterns, and specific considerations for weight management and insulin therapy.

Key Concepts Covered in This Exam:

  • Dietary Patterns: Identifying evidence-based patterns that improve glycemic control and cardiovascular health, including the Mediterranean, DASH, Portfolio, and Vegetarian diets.

  • Macronutrient Distribution: Understanding the flexibility in macronutrient ranges (Carbohydrate 45–60%, Protein 15–20%, Fat 20–35%) and individualizing them based on patient needs.

  • Carbohydrate Quality: Differentiating between high and low Glycemic Index (GI) foods and the importance of consuming 30 to 50 g/day of dietary fibre.

  • Fat Intake: Recognizing the recommendation to restrict saturated fats to <9% of total energy and replace them with polyunsaturated and monounsaturated fats.

  • Special Considerations: Managing alcohol intake to prevent delayed hypoglycemia and using sugar substitutes safely.

Please go to Practice Exam: Nutrition Therapy (Chapter 11) to view this quiz
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CDE Diabetes

Study Guide: Nutrition Therapy (Chapter 11)

1. Chapter Overview

Nutrition therapy is one of the most powerful tools in diabetes management, yet often the most challenging to implement. For the CDE exam, move away from the idea of a restrictive “Diabetic Diet.” The Diabetes Canada Guidelines emphasize individualization, dietary patterns (rather than single nutrients), and the crucial role of the Registered Dietitian (RD).

2. Key Messages (The "Gold Nuggets")

  • The Power of Food: Nutrition therapy can reduce A1C by 1.0% to 2.0%. This is comparable to, or greater than, the effect of many glucose-lowering medications.
  • The Role of the RD: People with diabetes should receive counselling by a Registered Dietitian (Grade B, Level 2 for T2D).
  • Weight Loss: For those with overweight/obesity, a modest weight loss of 5% to 10% of initial body weight can substantially improve insulin sensitivity and glycemic control.
  • No “One Size Fits All”: Macronutrient distribution is flexible. The “best” diet is the one the patient can adhere to long-term.

3. Macronutrients: The Evidence

A. Carbohydrates (45%–60% of Energy)

  • Quality over Quantity: Focus on low-Glycemic Index (GI) and high-fibre sources.

  • Glycemic Index (GI): Replacing high-GI foods with low-GI foods has a clinically significant benefit for glycemic control in both Type 1 and Type 2 diabetes.

  • Fibre:

    • Target: 30 to 50 g/day (higher than the general population recommendation of 25–38 g/day).

    • Viscous Soluble Fibre: (e.g., oats, barley, psyllium, legumes) is specifically effective for lowering LDL-C and improving glycemic control. Target: 10–20 g/day.

  • Sugars: Added sugars (sucrose, fructose) can be substituted for other carbs up to 10% of total energy, provided control is maintained. Sugar-Sweetened Beverages (SSBs) should be avoided due to the risk of weight gain and metabolic syndrome.

B. Fats (20%–35% of Energy)

  • Saturated Fat: Limit to <9% of total energy. Replace with polyunsaturated (PUFA) and monounsaturated (MUFA) fats.

  • Trans Fats: Avoid completely.

  • Omega-3 Supplements: Routine high-dose supplementation (fish oil capsules) is not recommended for glycemic control or CVD prevention (based on the ORIGIN trial). However, consuming oily fish (≥2 servings/week) is beneficial.

C. Protein (15%–20% of Energy)

  • Plant-Based: Replacing animal protein with plant protein (legumes, soy, nuts) improves glycemic control and lipids.

  • CKD: In chronic kidney disease, protein intake should not exceed 0.8 g/kg body weight/day.

4. Dietary Patterns (The "Menu" of Options)

The guidelines endorse specific dietary patterns that have evidence of benefit. On the exam, you may be asked to match a patient’s goals (e.g., CVD reduction) with the best dietary pattern.

Dietary PatternKey FeaturesSpecific Benefits
(Evidence Grade)
MediterraneanOlive oil, nuts, veggies, legumes, fish, moderate wine.Reduces Major CV Events (Grade A). Improves A1C (Grade B).
Vegetarian/VeganPlant-based.Improves A1C, Weight, and LDL-C (Grade B).
DASHHigh fruit/veg/dairy, low sodium.Reduces BP and Major CV Events (Grade B).
PulsesBeans, peas, chickpeas, lentils.Improves A1C, BP, and Weight (Grade B).
NutsTree nuts and peanuts.Improves A1C and LDL-C (Grade B).

5. Special Considerations

A. Alcohol

  • The Risk: Moderate alcohol consumption (with or 2–3 hours after an evening meal) may cause delayed hypoglycemia the next morning (up to 24 hours later).

  • Mechanism: Alcohol inhibits hepatic gluconeogenesis.

  • Prevention: Educate patients to eat carbohydrates when drinking and monitor BG frequently.

  • Limits: ≤2 drinks/day (women), ≤3 drinks/day (men).

B. Sweeteners

  • Safety: Approved non-nutritive sweeteners (aspartame, sucralose, stevia, etc.) are safe when consumed within Acceptable Daily Intake (ADI) levels.

  • Benefit: They may help with weight control if used to displace excess calories from added sugars.

C. Vitamin/Mineral Supplements

  • Routine Use: Not recommended for glycemic control.

  • Exceptions:

    • Vitamin D: 10 µg (400 IU) daily for adults >50 years.

    • Folic Acid: 0.4–1.0 mg daily for women who could become pregnant.

6. Clinical Decision Algorithm (Summary of Figure 1 in the Guidelines)

  1. Assess: Refer to RD for assessment.

  2. Intervene: Initiate healthy behaviour interventions (diet + activity) to achieve healthy body weight.

  3. Individualize: Select a dietary pattern (e.g., Mediterranean, DASH) based on patient preference.

  4. Monitor:

    • If Target A1C is not met within 2 to 3 months of lifestyle intervention alone -> Add Pharmacotherapy.

    • If on meds -> Adjust every 3 to 6 months.

7. Diabetes Canada Clinical Practice Guidelines Recommendations

Key Recommendations to Memorize:

  1. Counselling: People with diabetes should receive nutrition counselling by a Registered Dietitian. (Grade B, Level 2).

  2. Weight Loss: In people with overweight/obesity, a nutritionally balanced, calorie-reduced diet should be followed to achieve a healthier body weight. (Grade A, Level 1A).

  3. Fibre: Aim for 30 to 50 g/day of dietary fibre, with 10–20 g from viscous soluble fibre. (Grade C, Level 3).

  4. Glycemic Index: Select carbohydrate food sources with a low-GI to optimize glycemic control. (Grade B, Level 2).

  5. Cardiovascular Protection: To reduce CVD risk, consider a Mediterranean-style dietary pattern. (Grade A, Level 1A).

  6. Alcohol: Educate patients using insulin/secretagogues about the risk of delayed hypoglycemia from alcohol. (Grade C, Level 3).

Reference:

Sievenpiper JL, Chan CB, Dworatzek PD, Freeze C, Williams SL. Nutrition Therapy. Canadian Journal of Diabetes. 2018;42:S64-S79. doi:10.1016/j.jcjd.2017.10.009
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CDE Diabetes

Flashcards: Physical Activity and Diabetes (Chapter 10)

Physical activity is a powerful therapeutic intervention that lowers morbidity and mortality, yet prescribing it effectively requires navigating specific guidelines for intensity, frequency, and safety. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the evidence-based recommendations for aerobic and resistance training, as well as the critical adjustments needed to prevent hypoglycemia in patients using insulin.

 

Key Topics Covered:

  • Exercise Targets: Memorizing the specific goals for aerobic exercise (minimum 150 minutes/week) and resistance training (at least 2 sessions/week).
  • Sedentary Behaviour: Understanding the impact of prolonged sitting and the recommendation to interrupt sedentary time every 20 to 30 minutes.
  • Hypoglycemia Prevention: Reviewing strategies for Type 1 diabetes, such as reducing bolus/basal insulin, consuming carbohydrates, or performing sprints.
  • Definitions: Differentiating between aerobic exercise, resistance training, and high-intensity interval training (HIIT).
  • Safety Screening: Identifying which patients (e.g., those 40 years old) require medical assessment before starting vigorous activity.
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CDE Diabetes

Practice Exam: Physical Activity and Diabetes (Chapter 10)

Physical activity is a cornerstone of diabetes management, associated with substantially lower morbidity and mortality in people with diabetes. While the benefits of exercise are well-established, prescribing the correct type, intensity, and duration, while managing risks such as hypoglycemia, requires specific clinical knowledge.

This practice exam tests your understanding of the evidence-based recommendations for aerobic and resistance training, strategies to reduce sedentary behaviour, and safety protocols for diverse patient populations.

Key Concepts Covered in This Exam:

  • Exercise Targets: Mastering the specific recommendations for aerobic exercise (minimum 150 minutes per week) and resistance training (at least 2 sessions per week).
  • Sedentary Behaviour: Understanding the risks of habitual prolonged sitting and the recommendation to interrupt sitting time every 20 to 30 minutes.
  • Type 1 Diabetes Management: Identifying strategies to prevent hypoglycemia during and after exercise, such as adjusting insulin doses, carbohydrate intake, and utilizing brief maximal-intensity sprints .
  • Safety Screening: Recognizing which individuals (e.g., those 40 years of age wishing to undertake vigorous exercise) require medical assessment prior to starting an exercise program.
  • Exercise Types: Differentiating between aerobic, resistance, and high-intensity interval training (HIIT) and their respective benefits for glycemic control and cardiorespiratory fitness.
Please go to Practice Exam: Physical Activity and Diabetes (Chapter 10) to view this quiz