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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.

1. Case: A diabetes educator is explaining interval training to a patient. What is the recommended duration for alternating intervals of higher and lower intensity exercise?

2. Case: A patient with type 2 diabetes asks about resistance bands for exercise. According to the meta-analysis, what effect did resistance band training have on A1C?

3. Case: A patient with type 1 diabetes on CSII plans evening exercise. According to the guidelines, by how much should the overnight basal insulin infusion rate be reduced to prevent nocturnal hypoglycemia?

4. What is the recommended frequency of resistance exercise for people with diabetes?

5. According to the guidelines, what is the recommended minimum duration of moderate- to vigorous-intensity aerobic exercise per week for people with diabetes?

6. Case: A diabetes educator is counselling a patient about sedentary behaviour. According to systematic reviews, what is the relationship between sedentary time and mortality in people with diabetes?

7. For how long can prolonged aerobic exercise increase insulin sensitivity in recovery?

8. According to the guidelines, what heart rate range defines moderate-intensity aerobic exercise?

9. According to the guidelines, what strategies should be collaboratively performed between the person with diabetes and health-care provider to increase physical activity?

10. According to the evidence from meta-analyses in children and youth with type 1 diabetes, what was the range of A1C reduction with aerobic training?

11. Case: A patient with type 1 diabetes experiences exercise-induced hyperglycemia after resistance training. According to the guidelines, how can this be addressed?

12. What blood ketone level indicates that vigorous exercise should be postponed in a person with type 1 diabetes?

13. According to the evidence on thermoregulation, which populations have a restricted capacity to lose heat during exercise?

14. Case: A 65-year-old with type 2 diabetes plans to start high-intensity interval training. According to the guidelines, what assessment should be performed?

15. How is aerobic exercise defined in terms of minimum duration for continuous activity?

16. What is defined as vigorous-intensity aerobic activity in terms of metabolic equivalents (METS)?

17. According to the guidelines, how often should people with diabetes break up prolonged sitting?

18. Case: A person with type 1 diabetes plans to exercise 2 hours after a meal. According to the guidelines, what prandial insulin reduction is effective in limiting hypoglycemia?

19. Case: A patient with type 1 diabetes asks about the order of exercise types to minimize hypoglycemia. According to the guidelines, what order is recommended?

20. Case: A diabetes care team is evaluating supervised vs. unsupervised exercise for a patient with type 2 diabetes. According to the meta-analysis, under what condition did unsupervised exercise improve glycemic control?

21. Case: A patient with type 1 diabetes is concerned about hypoglycemia during exercise. Which type of exercise is associated with less hypoglycemia risk compared to aerobic exercise?

22. Case: A person with type 1 diabetes wants to reduce hypoglycemia risk during moderate-intensity exercise. According to the guidelines, what brief intervention can be performed at the start of exercise?

23. According to the evidence, what is the optimal resistance training program for greatest A1C impact in type 2 diabetes?

24. According to systematic reviews, what effect does tai chi have on A1C in people with diabetes?

25. What is the definition of sedentary behaviour according to the guidelines?

26. Case: A patient with type 1 diabetes on insulin injections asks about reducing hypoglycemia on active days. According to the guidelines, by what percentage can total daily basal insulin be reduced?

27. Case: A 55-year-old with type 2 diabetes has peripheral neuropathy but no active foot ulcers. According to the guidelines, can they participate in moderate weight-bearing exercise?

28. Case: A patient with type 2 diabetes has a capillary blood glucose of 18.0 mmol/L before planned exercise. According to the guidelines, what should be done?

29. Case: A diabetes educator is counselling a patient with type 2 diabetes about exercise benefits. According to the meta-analysis, what additional A1C reduction was achieved with higher-intensity vs. lower-intensity aerobic exercise?


 

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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?

Please go to Practice Exam: Blood Glucose Monitoring (Chapter 9 & 2021 Update) to view this quiz
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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