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CDE Diabetes

Study Guide: Physical Activity and Diabetes (Chapter 10)

1. Chapter Overview

Physical activity is not just “good advice”—it is a therapeutic intervention with specific dosages and safety protocols. For the CDE exam, move beyond general encouragement. You need to know the specific frequency, intensity, and type of exercise recommended, as well as the evidence-based strategies to prevent hypoglycemia in Type 1 diabetes (which often appear as clinical scenarios on the exam).

2. Key Messages (The "Gold Nuggets")

  • The “Dose”: The target is 150 minutes of moderate-to-vigorous aerobic exercise per week.

  • Consistency Matters: There should be no more than 2 consecutive days without exercise to maintain insulin sensitivity benefits.

  • Combination is Key: Performing both aerobic and resistance exercise is optimal for glycemic control.

  • Sedentary Behaviour: Habitual sitting is an independent health risk. Even if a patient exercises daily, prolonged sitting the rest of the day increases mortality risk.

  • T1D Hypoglycemia: Specific strategies, such as performing resistance training before aerobic training, can stabilize blood glucose.

3. Types of Exercise & Benefits

A. Aerobic Exercise

  • Definition: Continuous, rhythmic movement of large muscle groups (e.g., walking, cycling).

  • Benefit (T2D): Improves A1C, triglycerides, and blood pressure.

    • Evidence: >150 min/week reduces A1C by ~0.89%; ≤150 min/week reduces A1C by ~0.36%.

  • Benefit (T1D): Lowers mortality and complications; improves fitness.

B. Resistance Exercise

  • Definition: Brief repetitive exercises with weights, bands, or body weight.

  • Benefit (T2D): Improves A1C, insulin resistance, and muscular strength.

  • Optimal Prescription: 3 sets of 8 repetitions, 3 times per week.

C. Interval Training (HIIT)

  • Definition: Alternating short periods of vigorous effort with recovery.

  • Benefit: Greater gains in fitness; in Type 1 diabetes, it is associated with less risk of hypoglycemia compared to continuous aerobic exercise.

4. Safety and Screening

Who needs an ECG/Stress Test?

  • Asymptomatic: Most people do not require medical clearance for low-to-moderate intensity activity.

  • High Risk: Assessment (resting ECG and possibly stress test) is recommended for people ≥40 years old (or with diabetes duration >15 years T1D / >10 years T2D) who want to undertake very vigorous or prolonged exercise (e.g., competitive racing).

Complications & Exercise

  • Retinopathy: Proliferative retinopathy should be treated/stabilized before vigorous exercise (risk of hemorrhage).

  • Neuropathy: Moderate weight-bearing exercise is safe and does not increase ulcer risk (provided there are no active ulcers). Daily inspection of feet is mandatory.

5. Managing Glucose in Type 1 Diabetes (High Yield)

Managing blood glucose around exercise for T1D is a frequent exam topic.

A. Preventing Hypoglycemia

  • Carbohydrates: Ingest carbs before/during/after exercise.

  • Insulin Adjustment:

    • Reduce prandial (bolus) insulin by 25% to 75% for meals preceding exercise.

    • Reduce basal rates (CSII) or suspend basal (only if the activity is ≤45 minutes).

    • Reduce overnight basal by ~20% to prevent nocturnal lows.

  • Exercise Order: Perform Resistance exercise BEFORE Aerobic exercise. This sequence keeps blood glucose more stable than the reverse.

  • Sprinting: A brief (10-second) maximal sprint can raise blood glucose (via counter-regulatory hormones) to counter a drop.

B. Hyperglycemia & Ketones

  • The Rule: If BG >16.7 mmol/L + Unwell? -> Test Ketones.

    • Positive Ketones: Postpone vigorous exercise; administer insulin.

    • Negative Ketones: Exercise is generally safe (ensure hydration).

6. Diabetes Canada Clinical Practice Guidelines Recommendations

These are the “Must Memorize” graded recommendations for the exam.

  1. Aerobic Target: Accumulate a minimum of 150 minutes of moderate-to-vigorous aerobic exercise per week, spread over at least 3 days, with no more than 2 consecutive days without exercise.

    • Grade B, Level 2.

  2. Resistance Target: Perform resistance exercise at least 2 times per week (preferably 3).

    • Grade B, Level 2.

  3. Sedentary Time: Minimize sedentary time and periodically break up long periods of sitting (e.g., every 20-30 mins).

    • Grade C, Level 3.

  4. T1D Strategies: To reduce hypoglycemia in Type 1 diabetes:

    • Reduce bolus/basal insulin.

    • Perform brief (10s) maximal sprints.

    • Perform resistance exercise before aerobic exercise.

    • Grade D, Level 4.

  5. Screening: People ≥40 years wishing to undertake very vigorous exercise should be assessed for adverse event risk.

    • Grade D, Consensus.

Reference:

Sigal RJ, Armstrong MJ, Bacon SL, et al. Physical Activity and Diabetes. Canadian Journal of Diabetes. 2018;42:S54-S63. doi:10.1016/j.jcjd.2017.10.008
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CDE Diabetes

Flashcards: Blood Glucose Monitoring (Chapter 9 & 2021 Update)

Master the terminology and targets of modern glucose monitoring with these rapid-review flashcards.

The 2021 Update to the Clinical Practice Guidelines introduced significant changes to the language we use—shifting from SMBG to Capillary Blood Glucose (CBG)—and established new recommendations for using Real-Time and Intermittently Scanned Continuous Glucose Monitoring (rtCGM and isCGM). These flashcards are designed to help pharmacists and healthcare professionals quickly recall these new standards alongside the foundational principles of glycemic monitoring.

 

Key Topics Covered:

  • New Terminology: differentiating between Capillary Blood Glucose (CBG), Real-Time CGM (rtCGM), and Intermittently Scanned CGM (isCGM).
  • Glycemic Metrics: Memorizing the new international consensus targets, such as Time in Range (TIR >70%) and Time Below Range (TBR <4%) for most individuals.
  • Testing Frequency: Reviewing when to measure A1C (every 3 months vs. 6 months) and the recommended frequency of CBG testing for different treatment regimens.
  • Technology & Pregnancy: Understanding the specific recommendations for using rtCGM in pregnant women with type 1 diabetes to reduce NICU admissions and LGA infants.
  • Troubleshooting: Identifying factors that render A1C inaccurate (e.g., iron deficiency, hemoglobinopathies) and knowing when to use ketone testing.
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CDE Diabetes

Practice Exam: Blood Glucose Monitoring (Chapter 9 & 2021 Update)

Welcome to the practice exam for Chapter 9: Monitoring Glycemic Control and the 2021 Guideline Update.

Glucose monitoring remains a cornerstone of diabetes management, but the landscape has evolved significantly with the rapid uptake of new technologies. This exam tests your knowledge of the foundational principles from the 2018 Guidelines as well as the critical changes introduced in the 2021 Update, specifically regarding terminology, technology, and new glycemic metrics.

Key Concepts Covered in This Exam:

  • Updated Terminology: Mastering the shift in language, including Capillary Blood Glucose (CBG) instead of SMBG, and the distinction between Real-Time CGM (rtCGM) and Intermittently-Scanned CGM (isCGM)
  • Glycemic Metrics: Understanding new targets beyond A1C, such as Time in Range (TIR), Time Below Range (TBR), and Glucose Management Indicator (GMI).
  • Technology Recommendations: Identifying the evidence-based indications for rtCGM and isCGM in specific populations, including adults with type 1 and type 2 diabetes, and pregnant women.
  • Standard Monitoring Protocols: Reviewing the recommended frequency for A1C testing and CBG testing based on treatment type and glycemic stability.
  • Limitations & Accuracy: Recognizing factors that affect A1C accuracy (e.g., hemoglobinopathies) and when to verify CBG results against laboratory venous plasma glucose.

Are you ready to test your knowledge on the evolving standards of blood glucose monitoring?

1. According to the 2021 update, what is the recommended target for Time Above Range (TAR) Level 2 (>13.9 mmol/L) for most individuals?

2. Case: A diabetes educator is counselling a patient about A1C accuracy. Which of the following factors would cause a DECREASED A1C that may not reflect true glycemic status?

3. Case: A child aged 8 years with type 1 diabetes is using rtCGM inconsistently. According to the evidence, what factor predicts better A1C outcomes with rtCGM in children?

4. Case: A diabetes educator is counselling a patient about CGM accuracy during pregnancy. According to the accuracy study, which sensor site had the lowest MARD (best accuracy)?

5. According to the 2021 update, for older/higher risk individuals, what is the Time in Range target?

6. Case: A woman with gestational diabetes is managing with diet alone after 1 week of daily CBG testing (4 times/day). According to the 2021 update, what testing frequency is reasonable?

7. According to the 2021 update, what is the updated terminology for “self-monitored blood glucose (SMBG)”?

8. According to the 2021 update, what is the updated terminology for “flash glucose monitoring (FGM)”?

9. What glucose range defines Time in Range (TIR) for most individuals with diabetes (excluding pregnancy)?

10. Case: A diabetes educator is reviewing glucose metrics with a patient. According to the International Consensus, each 10% change in Time in Range equates to approximately what change in A1C?

11. Case: A patient with type 2 diabetes on basal-bolus insulin therapy has not achieved A1C target. According to the 2021 update, what monitoring may be used to reduce A1C and duration of hypoglycemia?

12. Case: A patient with type 1 diabetes using multiple daily injections has impaired awareness of hypoglycemia. According to the 2021 update, which monitoring modality should be used?

13. What is the recommended percentage of Time Below Range (TBR) for Level 1 hypoglycemia (3.8-3.0 mmol/L) in most individuals?

14. At what A1C level is approximately equivalent to 70% Time in Range?

15. Case: A clinician is comparing blood ketone testing to urine ketone testing. According to the guidelines, why might blood ketone testing be preferred?

16. What is the recommended Time in Range target for pregnant women with type 1 diabetes according to the glucose metrics consensus?

17. What percentage of the A1C result comes from the mean blood glucose level in the 30 days immediately preceding the blood sampling?

18. According to the 2021 Diabetes Canada update, in adults with type 1 diabetes comparing rtCGM to isCGM, which finding was demonstrated?

19. What is the recommended Time in Range (TIR) target for most individuals with type 1 or type 2 diabetes according to the International Consensus?

20. Case: A patient with type 1 diabetes is experiencing unexplained hyperglycemia and nausea. According to the guidelines, when should ketone testing be performed?

21. Glycated hemoglobin (A1C) is a reliable estimate of mean plasma glucose levels over what time period?

22. Case: A patient with type 2 diabetes has an A1C of 6.8% on metformin. According to the guidelines, what is the recommended frequency of CBG testing?

23. According to the glucose metrics recommendations, what is the target for glycemic variability (%CV)?

24. At what A1C level is approximately equivalent to 70% Time in Range?

25. In a patient with type 1 diabetes using CSII, for what additional period can the FGM/isCGM sensor be worn continuously?


 

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CDE Diabetes

Study Guide: Monitoring Glycemic Control (Chapter 9 & 2021 Update)

1. Chapter Overview: The "Language" Update

The 2021 update fundamentally changed the vocabulary of glucose monitoring. The CDE exam will likely test your knowledge of these new terms and the specific indications for each technology.

  • CBG (Capillary Blood Glucose): Formerly “SMBG.” The traditional finger-stick method.

  • isCGM (Intermittently-Scanned CGM): Formerly “Flash” (e.g., FreeStyle Libre). Requires scanning to see data.

  • rtCGM (Real-Time CGM): (e.g., Dexcom, Medtronic). Continuously pushes data to a device/phone with alarms.

  • mCGM (Masked CGM): Formerly “Professional CGM.” Data is hidden from the patient and analyzed retrospectively by the clinician.

2. Key Messages (The "Gold Nuggets")

  • A1C Limitations: A1C is a retrospective average (last 2–3 months) and cannot detect daily hypoglycemia or glycemic variability.

  • A1C Weighting: 50% of the A1C value comes from the last 30 days.

  • Monitoring is Not Treatment: Monitoring devices (CBG, isCGM, rtCGM) do not lower A1C on their own; they must be paired with education and therapeutic action.

  • Pregnancy: rtCGM is now the standard of care for Type 1 diabetes in pregnancy to improve neonatal outcomes.

3. A1C Testing

  • Frequency: Measure every 3 months when targets are not met or therapy is adjusted. Consider every 6 months if stable.

  • Limitations: A1C may be inaccurate in conditions affecting red blood cell turnover (e.g., iron deficiency anemia raises A1C; hemolysis lowers A1C).

  • Point-of-Care A1C: Not approved for diagnosis of diabetes in Canada, only for monitoring.

4. Glucose Monitoring Technologies

A. Real-Time CGM (rtCGM)

  • How it works: Pushes data continuously; has alarms for highs/lows.

  • Benefits (Type 1):

    • Reduces A1C and increases Time in Range (TIR).

    • Reduces duration and incidence of hypoglycemia.

    • Reduces severe hypoglycemia in those with impaired awareness.

  • Benefits (Type 2): May be used to improve glycemic levels in those on basal-bolus insulin.

  • Pregnancy (Type 1): Should be used. Reduces Large for Gestational Age (LGA) infants, neonatal hypoglycemia, and NICU admissions >24 hours (CONCEPTT trial).

B. Intermittently-Scanned CGM (isCGM)

  • How it works: User must scan sensor to see data; no automatic alarms (in older versions).

  • Benefits:

    • Reduces time spent in hypoglycemia for Type 1 and Type 2 (on insulin).

    • Increases Time in Range (TIR).

    • Note: Does not consistently reduce A1C in trials compared to CBG, but improves other metrics.

  • Comparison to rtCGM: rtCGM is superior for reducing hypoglycemia and fear of hypoglycemia in high-risk Type 1 patients (impaired awareness).

C. Capillary Blood Glucose (CBG)

  • Insulin Users: Essential for self-management. Test at least 3 times/day for those on multiple injections.

  • Non-Insulin T2D:

    • Daily testing is not recommended if targets are met and meds don’t cause hypo.

    • Structured Testing: (e.g., 7-point profiles) is beneficial when A1C is off-target to guide therapy changes.

  • Pregnancy (GDM):

    • Initial: 4x daily (fasting + post-meals) for 1 week.

    • Diet-controlled: Can reduce to 4x daily on alternate days.

    • Insulin-treated: Continue 4x daily.

5. Glucose Metrics & Targets (The "New Numbers")

The 2021 Update emphasizes “Time in Range” (TIR) alongside A1C.

MetricTarget
(Most T1D/T2D)		Target
(Older/High Risk)		Pregnancy
(T1D)

Time in Range (TIR)


(3.9–10.0 mmol/L)

> 70%> 50%

> 70%


(3.5–7.8 mmol/L)

Time Below Range (TBR)


(< 3.9 mmol/L)

< 4%< 1%< 4%

Time Above Range (TAR)


(> 10.0 mmol/L)

< 25%< 10% (>13.9)< 25% (>7.8)

6. 2021 Clinical Practice Guidelines Recommendations

Key Recommendations to Memorize:

  1. Type 1 & rtCGM: rtCGM should be used to reduce A1C, increase TIR, and reduce hypoglycemia in adults/children willing to use it daily. (Grade A, Level 1A).

  2. Type 1 & isCGM: isCGM may be used to increase TIR and reduce hypoglycemia. (Grade B, Level 2).

  3. Hypo Awareness: In adults with T1D and impaired awareness, rtCGM is recommended over isCGM to reduce time in hypoglycemia. (Grade B, Level 2).

  4. Pregnancy (T1D): rtCGM should be used to reduce risk of LGA infants and NICU admissions. (Grade A, Level 1A).

  5. Ketones: T1D patients should test for ketones during acute illness or if BG >14.0 mmol/L. Blood ketone testing is preferred over urine. (Grade B, Level 2).

References:

Cheng AYY, Feig DS, Ho J, et al. Blood Glucose Monitoring in Adults and Children with Diabetes: Update 2021. Canadian Journal of Diabetes. 2021;45(7):580-587. doi:10.1016/j.jcjd.2021.07.003
Berard LD, Siemens R, Woo V. Monitoring Glycemic Control. Canadian Journal of Diabetes. 2018;42:S47-S53. doi:10.1016/j.jcjd.2017.10.007
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CDE Diabetes

Flash Cards: Targets for Glycemic Control (Chapter 8)

Welcome to the Flash Card section for Chapter 8: Targets for Glycemic Control.

In this chapter, the “devil is in the details.” While the general A1C target of ≤7.0% is well known, the CDE exam tests your knowledge of the exceptions and the specific evidence that drives them. You need to be able to instantly recall which patient needs a target of ≤6.5% versus who requires a relaxed target of 8.5%.

Why use flash cards for this chapter? Glycemic targets are numeric and specific. Flash cards are the most effective way to memorize the rigid criteria for “tight” versus “relaxed” control, as well as the outcomes of the major landmark trials that established these rules.

Key concepts covered in this deck:

  • Target Ranges: Memorizing the specific criteria for A1C targets of ≤6.5% (to reduce CKD/retinopathy) vs. 7.1%–8.5% (for the frail elderly or those with limited life expectancy).

  • A1C Composition: Recalling when Fasting Plasma Glucose (FPG) is the main contributor to A1C and when Postprandial Glucose (PPG) takes over.

  • Safety Triggers: Identifying the clinical signs (like hypoglycemia unawareness) that mandate a change in target.
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CDE Diabetes

Practice Exam: Targets for Glycemic Control (Chapter 8)

You have reviewed the study guide, now it is time to test your mastery of Chapter 8: Targets for Glycemic Control.

For the CDE exam, simply knowing that “7 is the magic number” is not enough. You must demonstrate the ability to individualize care. The guidelines emphasize that while optimal control reduces complications, the “legacy effect” and safety concerns (especially hypoglycemia) dictate different targets for different people. This exam will test your ability to balance these competing priorities in complex clinical scenarios.

 

What to expect in this quiz: This practice exam focuses on the nuances of target setting and the evidence behind the numbers. You will be tested on:

  • The Hierarchy of Targets: Identifying exactly which patients qualify for a target of ≤6.5% (to reduce CKD/retinopathy) versus those who need a relaxed target of 7.1%–8.5% (e.g., frail elderly or high functional dependence).
  • A1C Composition: Understanding when Fasting Plasma Glucose (FPG) is the main driver of A1C versus when Postprandial Glucose (PPG) takes over.
  • Safety First: Recognizing the specific triggers for relaxing targets, such as hypoglycemia unawareness or limited life expectancy.

Use this quiz to ensure you can confidently answer the question “How low should we go?” for any patient profile the exam presents.

Please go to Practice Exam: Targets for Glycemic Control (Chapter 8) to view this quiz
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CDE Diabetes

Study Guide: Targets for Glycemic Control (Chapter 8)

1. Chapter Overview

This chapter answers the critical question: “How low should we go?” It balances the benefits of intensive glycemic control (reduced microvascular and long-term cardiovascular complications) against the risks (hypoglycemia and mortality, particularly in high-risk groups).

For the CDE exam, you must master the individualization of targets. The “one size fits all” approach is outdated. You need to know exactly who qualifies for a target of ≤6.5% and who requires a more relaxed target of 7.1%–8.5%.

2. Key Messages (The "Gold Nuggets")

  • Fundamental Goal: Optimal glycemic control is fundamental to the management of diabetes.

  • The “Legacy Effect”: Early intensive control has long-lasting benefits. Even if control worsens later, the initial period of tight control reduces long-term complications (microvascular and CV).

  • Individualization is Mandatory: Glycemic targets should be individualized based on the individual’s frailty, functional dependence, and life expectancy.

  • A1C Composition: Both fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) contribute to the A1C value.

    • Clinical Pearl: As A1C gets closer to target (≤7.0%), PPG (post-meal glucose) becomes the dominant contributor. When A1C is high, FPG (fasting) is the main driver.

3. The Evidence: Major Clinical Trials

You may be asked which trial demonstrated specific outcomes.

  • DCCT (Type 1) & UKPDS (Type 2):

    • Established that intensive control significantly reduces microvascular complications.

    • Long-term follow-up revealed the “Metabolic Memory” or “Legacy Effect,” showing significant reductions in CV outcomes and mortality years after the trials ended.

  • ACCORD (Type 2):

    • Targeted A1C <6.0% in older patients with long-standing diabetes and CV risk.

    • Result: Prematurely terminated due to higher mortality in the intensive arm.

    • Lesson: Tight control may not be safe for high-risk, older individuals with established CVD.

  • ADVANCE (Type 2):

    • Targeted A1C ≤6.5%.

    • Result: Significant reduction in nephropathy (21% reduction). No benefit on mortality/CV events during the trial.

  • VADT (Type 2):

    • Targeted A1C reduction of 1.5% in veterans with poor control.

    • Result: No initial CV benefit, but long-term observational follow-up showed a significantly lower risk of major CV events.

4. Recommended Targets (The "Numbers")

A. A1C Targets

Target A1CPatient PopulationGoal/Benefit
≤ 6.5%Adults with Type 2 diabetes at low risk of hypoglycemia.To reduce the risk of CKD (Chronic Kidney Disease) and Retinopathy.
≤ 7.0%MOST adults with Type 1 or Type 2 diabetes.To reduce the risk of microvascular and (if achieved early) CV complications.
7.1% – 8.0%Functionally dependent adults.To avoid hypoglycemia and symptomatic hyperglycemia.
7.1% – 8.5%

1. Recurrent severe hypoglycemia or hypoglycemia unawareness.

 

2. Limited life expectancy.

 

3. Frail elderly and/or with dementia.

To minimize risk of hypoglycemia and symptomatic hyperglycemia.
No TargetEnd of Life.Avoid A1C measurement. Focus on avoiding symptomatic hyperglycemia and any hypoglycemia.

B. Glucose Targets 

To achieve an A1C ≤7.0%, patients should aim for:

  • Fasting/Preprandial PG: 4.0 to 7.0 mmol/L.

  • 2-Hour Postprandial PG: 5.0 to 10.0 mmol/L.

Intensified Targets: If A1C target is not met, consider tighter targets if safe:

  • Fasting/Preprandial: 4.0 to 5.5 mmol/L.

  • 2-Hour Postprandial: 5.0 to 8.0 mmol/L.

5. Diabetes Canada Clinical Practice Guidelines Recommendations

hese are the “Must Memorize” graded recommendations for the exam.

  1. General Target: In most people with type 1 or type 2 diabetes, an A1C ≤7.0% should be targeted to reduce the risk of microvascular complications and, if implemented early, CV complications.

    • Grade A, Level 1A (Microvascular); Grade B, Level 3 (CV).

  2. Tighter Target (T2D): In people with type 2 diabetes, an A1C ≤6.5% may be targeted to reduce the risk of CKD and retinopathy, if at low risk of hypoglycemia.

    • Grade A, Level 1A.

  3. Relaxed Targets: A higher A1C target may be considered to avoid hypoglycemia and over-treatment in specific groups:

    • Functionally dependent: 7.1%–8.0%.

    • Recurrent severe hypoglycemia/unawareness: 7.1%–8.5%.

    • Limited life expectancy: 7.1%–8.5%.

    • Frail elderly/dementia: 7.1%–8.5%.

    • Grade D, Consensus for all above.

  4. End of Life: A1C measurement is not recommended. Avoid symptomatic hyperglycemia and any hypoglycemia.

    • Grade D, Consensus.

Reference:

Imran SA, Agarwal G, Bajaj HS, Ross S. Targets for Glycemic Control. Canadian Journal of Diabetes. 2018;42:S42-S46. doi:10.1016/j.jcjd.2017.10.030
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CDE Diabetes

Flash Cards: Self-Management Education and Support (Chapter 7)

Welcome to the Flash Card section for Chapter 7: Self-Management Education and Support.

While many educators feel comfortable with the “art” of teaching, the CDE exam focuses heavily on the “science” behind it. This chapter contains specific definitions and statistical evidence that are easy to confuse but essential to know.

Why use flash cards for this chapter? You might intuitively know that “support helps,” but the exam asks for specifics: How much does it help? Which type of support is best? These flash cards are designed to help you memorize the hard data points—such as specific A1C reduction percentages—and the precise definitions that differentiate “Education” from “Support.”

Key concepts covered in this deck:

  • SME vs. SMS: Drilling the definitions to ensure you can distinguish between the process of learning and the support required for maintenance.

  • Delivery Formats: Recalling the evidence grades for group vs. individual education and when to use peer support.

  • Intervention Types: Defining terms like “Cognitive Behavioural Interventions” and “Diabetes Coaching.”

Use these cards to lock in the statistics and definitions, ensuring you can answer evidence-based questions with confidence.

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CDE Diabetes

Practice Exam: Self-Management Education and Support (Chapter 7)

You have reviewed the study guide, now it is time to test your mastery of Chapter 7: Self-Management Education and Support.

For the CDE exam, it is easy to underestimate this chapter as “common sense,” but the guidelines are quite specific about the distinction between Self-Management Education (SME) and Self-Management Support (SMS). The exam will test your ability to differentiate between the initial transfer of knowledge (SME) and the ongoing scaffolding required to sustain it (SMS).

What to expect in this quiz: This practice exam focuses on the evidence-based strategies that drive patient behavior change. You will be tested on:

  • Definitions: Distinguishing between SME (a systematic intervention to gain knowledge/skills) and SMS (activities that support the maintenance of behaviors).

  • The “Numbers”: Recognizing the specific A1C reductions associated with different interventions, such as the 0.53% reduction seen with text messaging or the 0.9% reduction with telephone follow-up.

  • Delivery Formats: Knowing when group education is sufficient versus when a combination of group and individual follow-up is superior.

  • Tailoring: Identifying the correct approach for specific populations, such as using peer educators for minority groups or adding literacy-sensitive materials.

Use this quiz to ensure you can apply these educational principles to the clinical scenarios you will face on exam day.

Please go to Practice Exam: Self-Management Education and Support (Chapter 7) to view this quiz
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Study Guide: Self-Management Education and Support (Chapter 7)

1. Chapter Overview

This chapter marks a shift in terminology from simply “Diabetes Education” to Self-Management Education (SME) and Self-Management Support (SMS). The addition of “Support” recognizes that education alone is often insufficient for sustaining behavior change. For the CDE exam, you must distinguish between the process of learning (SME) and the ongoing support required to maintain it (SMS).

2. Key Messages (The "Gold Nuggets")

  • The Power of Education: Structured education doesn’t just lower A1C; in people with Type 2 diabetes, it has been associated with a 44% reduction in all-cause mortality and a 20% reduction in first cardiovascular events.

  • SME vs. SMS:

    • SME (Education): A systematic intervention involving active participation to gain knowledge and skills.

    • SMS (Support): Activities that support the implementation and maintenance of these behaviours (e.g., coaching, peer support).

  • The Winning Combination: Combining SME and SMS is most advantageous for improving glycemic control, self-efficacy, and reducing diabetes distress.

  • Cognitive Behavioural Interventions: Using cognitive restructuring, problem-solving, and goal setting is more effective than didactic (lecture-style) teaching alone.

3. Self-Management Education (SME)

A. Evidence of Benefit

  • Clinical: Reductions in A1C, CV risk factors, and foot complications.

  • Economic: Lower health-care expenditures observed after 12 months.

  • Psychosocial: Improvements in quality of life, self-efficacy, and reduced diabetes distress.

B. Delivery Formats

  • Group vs. Individual: Group settings are effective for short-term control, but combining group interventions with individual follow-up results in lower A1C than either setting alone.

  • The Team Effect: Interventions using a combination of health-care professionals are superior.

    • Nurse + Team: Most effective decrease in A1C (-1.84%).

    • Nurse only: -0.80% decrease.

    • Other personnel only: -0.77% decrease.

C. Technology in SME

  • Internet/Web-based: Effective for improving glycemic control and knowledge compared to usual care.

  • Mobile Apps/Texting:

    • General mobile apps show a small beneficial effect on A1C (-0.5%).

    • Text messaging interventions specifically reported an A1C difference of 0.53% compared to usual care.

4. Tailoring Education

One size does not fit all. Tailoring is paramount.

  • Cultural Tailoring: Culturally appropriate education (language, dietary advice, faith traditions) results in A1C reductions of -0.2% to -0.5%.

  • Minority Populations: Individual, face-to-face programs with peer educators often show larger A1C reductions than group-based programs in these populations.

  • Literacy: Content geared toward low literacy/numeracy can successfully improve A1C and self-efficacy.

5. Self-Management Support (SMS)

SMS is defined as strategies that augment an individual’s ability to self-manage.

A. Key SMS Interventions & Efficacy

  1. Peer Support:

    • Overall reduction in A1C: -0.57%.

    • Individual peer support is superior to group peer support (Individual reduction: -0.91%).

  2. Community Health Workers:

    • In minority populations, access results in A1C decrease of -0.37% to -0.75%.

  3. Diabetes Coaching:

    • Involves goal setting and frequent follow-up.

    • Associated with A1C reduction of -0.32%.

  4. Telephone Follow-up:

    • A study of 4 phone calls in one year by a nurse educator resulted in an A1C 0.9% lower than those who did not receive calls.

6. Diabetes Canada Clinical Practice Guidelines Recommendations

These are the “Must Memorize” graded recommendations for the exam.

  1. Timely Education: People with diabetes should be offered timely SME that is tailored to enhance self-care.

    • Grade A, Level 1A.

  2. Cognitive-Behavioural: SME should incorporate interventions like problem-solving, goal setting, and self-monitoring.

    • Grade B, Level 2.

  3. Format: SME interventions may be offered in small group and/or one-on-one settings.

    • Grade A, Level 1A for Type 2 Diabetes.

  4. Support Strategies: Support should be offered to assist in maintaining self-management (Grade B, Level 2), specifically via:

    • Peer-led support or community support workers (Grade B, Level 2).

    • Diabetes coaching (Grade B, Level 2).

    • Telephone follow-up (Grade B, Level 2).

  5. Technology: Internet-based programs, text messages, and mobile apps may be used to improve glycemic control.

    • Grade A, Level 1A for Type 2 Diabetes.

  6. Cultural Competence: Culturally appropriate SME/SMS should be used to improve glycemic control.

    • Grade A, Level 1A.

Reference:

Sherifali D, Berard LD, Gucciardi E, MacDonald B, MacNeill G. Self-Management Education and Support. Canadian Journal of Diabetes. 2018;42:S36-S41. doi:10.1016/j.jcjd.2017.10.006