Level 1 - Goals of Care 2024 (Class 5)

Question 1

(TRUE or FALSE)

PWD are not protected under the American Disabilities Act.

Answer 1

FALSE

they ARE

Question 2

(TRUE or FALSE)

Those living near fast food restaurants have a higher risk of weighing more.

Answer 2

TRUE

Question 3

How are population health outcomes measured?

Answer 3

1) Mortality, Morbidity, Health, & Functional status

2) Disease burden (prevalence, incidence)

3) Behavioral & Metabolic Factors (exercise, diet, A1c, etc.)

Question 4

What percentage of PWD are meeting all three risk factors?

Answer 4

22.2%

Question 5

What are the 3 risk factors we measure in those with diabetes?

Answer 5

1) A1c < 7.0%

2) BP < 130/80

3) Lipids: LDL < 130 mg/dL

Question 6

What are the 6 ‘Chronic Care Model’ elements? **

Answer 6

1) Proactive care delivery system, where planned visits are coordinated through a team-based approach

2) Clinical info systems (Registries that can provide patient-specific and population-based support to the care team)

3) Self-management support

4) Community Resources and polices (identifying or developing resources to support healthy lifestyles)

5) Decision Support (basing care on evidence-based, effective care guidelines)

6) Health systems (to create a quality-oriented culture)

Studies show that using chronic care delivery model decreases death and disease, and improves outcomes.

Question 7

What percentage of PWD are food insecure?

Answer 7

20%

Question 8

What concerns would you have with a PWD who is homeless?

Answer 8

~8% of unhoused people have diabetes

-Medication storage
-Foot health

Question 9

LS has T1DM and reports to a clinic with unusually frequent hypos and some weight loss. LS appears distraught and says that since the pandemic, their work hours have been dramatically reduced and paying bills has been a struggle. Based on this information, which of the following topics would be the CDCES most want to explore further?

A. Disordered eating
B. Food insecurity
C. Insulin rationing
D. Diabetes distress

Answer 9

B

-He could be taking insulin without sufficient PO intakes
-He does likely have diabetes distress but this question is giving us more information to lead to a better answer
-Refer to social services and local food pantry

Question 10

What are additional risk factors for prediabetes and diabetes that need to be considered when screening ADULTS?

Answer 10

1) First degree relative with diabetes
2) Member of high risk ethnic population
3) Habitual physical inactivity
4) Prediabetes
5) Hx of heart disease
6) Taking high risk medications (antiretrovirals, 2nd generation antipsychotics or steroids)
7) Hx of pancreatitis

Screen for prediabetes or diabetes at ANY age, if BMI > 25 (Asians > 23) + 1 of the risk factors above
Everyone else - screen at age 35

Question 11

Who is at risk of diabetes?

Answer 11

1) HTN
2) HDL < 35 or TG > 250
3) Hx GDM
4) PCOS
5) Other conditions associated with IR: elevated BMI, acanthosis nigricans

Question 12

What tests are appropriate to screen for prediabetes or diabetes?

Answer 12

1) A1c
2) FBG
3) OGTT

Question 13

Who is appropriate to be screened for prediabetes or diabetes in PEDIATRICS?

Answer 13

1) With excess weight (BMI > 85% percentile)
2) PLUS, ONE of the following:
a. Maternal diabetes or GDM during their gestation
b. FH of T2DM in 1st or 2nd degree relative
c. High risk ethnic population
d. Signs of IR (acanthosis nigricans, HTN, dyslipidemia, PCOS, or small for gestational age)

Question 14

What is the frequency of screening for prediabetes or diabetes in PEDIATRICS?

Answer 14

Test at 10 y/o OR puberty (whichever is first)

At least every 3 years or more frequently if indicated.

Consider earlier screening if multiple risk factors

Question 15

In those who are pregnant, at what A1c and what FBG would increase the risk for adverse outcomes and are more likely to experience GDM and need insulin?

Answer 15

A1c 5.9% or higher

FBG 110 mg/dL or higher

Question 16

What does the ADA Standards of Care say about screening pregnant women?

Answer 16

They do not say to absolutely screen all women before 15 weeks gestation, but they do SUGGEST screening at the FIRST PRENATAL VISIT

If normal - recheck at 24-28 weeks for GDM

Question 17

Which two tests are approved for GDM screening and recognized as evidence-based?

Answer 17

1) “One-Step” 75 gram OGTT

2) “Two-Step”

Question 17

What is the protocol for the “One Step” OGTT?

Answer 17

Consume 75grams glucose load while fasting, checking BG after 1 hour and after 2 hours

GDM is diagnosed when ANY one of the BG exceeds:
-FBG: > 92 mg/dL
-1 hour: > 180 mg/dL
-2 hour: > 153 mg/dL

(don’t really need to memorize for exam)

Question 18

What is the protocol for the “Two Step” OGTT?

Answer 18

STEP 1: 50 gram glucose load while non-fasting with plasma BG test after 1 hour.
-If BG is > 130-140 mg/dL then proceed to Step 2

STEP 2: 100 gram glucose load (fasting)

GDM is diagnosed when 2 out of the 4 BG measurements exceed:
-FBG: > 95
-1 hour: > 180
-2 hour: > 155
-3 hour: > 140

(don’t really need to memorize for exam)

Question 19

How can we prevent or delay diabetes for those with prediabetes? **

Answer 19

1) Screen yearly for diabetes
2) For adults with BMI 23/25:
a. Refer to DPP
b. Include intensive behavioral lifestyle interventions with a 7-10% weight reduction
c. Exercise for at least 150 minutes per week
d. Provide in-person or certified assisted programs

(MEMORIZE for exam**)

Question 20

What does DPP stand for?

Answer 20

Diabetes Prevention Programw

Question 21

What is the eligibility criteria for DPP?

Answer 21

MUST:
1) 18 y/o or older
2) Overweight
3) Not diagnosed with T1 or T2DM (including not on any diabetic medications)
4) Not pregnant

PLUS, ONE OF THESE:
1) Diagnosed with prediabetes
2) Previously diagnosed with GDM
3) Receive a high risk result on the prediabetes risk test

Question 22

(TRUE or FALSE)

DPP has a standardized curriculum that anyone can access for free.

Answer 22

TRUE

Question 23

How effective are DPPs at reducing risk of diabetes?

Answer 23

Reduces risk by 58%

Question 24

(TRUE or FALSE)

Everyone who is diagnosed with prediabetes should be referred for DPP.

Answer 24

TRUE

Eligibility based on specific criteria

Question 25

(TRUE or FALSE)

There is no FDA approved medication for prevention of diabetes.

Answer 25

TRUE

Metformin used for prediabetes is considered an off-label use

Question 26

(TRUE or FALSE)

The ADA does not recommend Metformin for those with prediabetes.

Answer 26

FALSE

Recommended for:
-BMI > 35
-If A1c is 6.0% or FBG is 110 mg/dL
-Women with a hx of GDM **

Question 27

What vitamin should be addressed with long-term use of metformin.

Answer 27

Vitamin B12, especially for those with neuropathy and anemia

Recommend checking levels or supplementation

Question 28

(TRUE or FALSE)

Statins can increase BG.

Answer 28

TRUE

In a small percentage of people. It is recommended to stop if there is an elevation

Question 29

What medication would be appropriate to recommend in those who are prediabetic with a history of stroke, MI, or at risk of fluid retention and CHF?

Answer 29

Consider low dose Piolitazone (Actos)

Question 30

(TRUE or FALSE)

Daily minutes spent doing vigorous physical exercise reduced risk of progression of T1DM in the TEDDY study.

Answer 30

TRUE

Question 31

Which medication can delay symptomatic T1DM in stage 2?

Answer 31

Teplizumab-Tzield (CD3 monoclonal antibody)

Question 32

Which providers are within the diabetes care team?

Answer 32

CDCES
Doctors
RNs
RDNs
Exercise Physiologists
Pharmacists
Dentist
Podiatrist
Behavioral health professionals

Question 33

Why is bone health now a consideration for those with diabetes?

Answer 33

Diabetes is associated with increased fractures

Question 34

What preventative care can be recommended for healthy bone health?

Answer 34

1) DEXA scan (those > 65 y/o or younger PWD)
2) Avoid medications that increase fx
3) Problem solve to prevent falls
4) Adequate calcium and vitamin D intakes
5) Consider antiresorptive medications, osteoanabolic agents for those with low bone mineral density scores

Question 35

(TRUE or FALSE)

Insulin causes bone demineralization.

Answer 35

FALSE

PWD on insulin have a higher risk of hypoglycemia and therefore, an increased risk of FALLS

Question 36

What the general risk factors for fractures?

Answer 36

1) Prior osteoporotic fx
2) Age > 65 y/o
3) Low BMI
4) Sex
5) Malabsorption
6) Recurrent falls
7) Glucocorticoid use
8) FH
9) Alcohol/tobacco abuse
10) RA

Question 37

What are specific diabetes risk factors for fractures?

Answer 37

1) Lumbar spine or hip - T-score <2.0
2) Frequent hypo events
3) Diabetes duration > 10 years
4) Diabetes medications: insulin, sulfonylureas, thiazoidinediones
5) A1c > 8%
6) Peripheral and autonomic neuropathy
7) Retinopathy and nephropathy

Question 38

MASLD

Answer 38

Metabolic Dysfunction-Associated Steatotic Liver Disease

replacing NAFLD

Question 39

What term is replacing Fatty Liver Disease?

Answer 39

Steatotic Liver Disease

Question 40

What term is replacing NASH?

Answer 40

Metabolic Dysfunction-Associated Steatohepatitis (MASH)

Question 41

How common is NAFLD in adults with T2DM?

Answer 41

> 70% based on recent studies

Question 42

JL is 23 y/o and struggles with chemical addiction and mental health issues. JL takes 1000 mg metformin BIG when he remembers. Last A1c was 12.9%. What is the A1c target for JL?

A. Less than 6.5% since metformin doesn’t cause hypos.
B. Less than 7% based on the Legacy Trial results.
C. Focus on ongoing self-care and resources.
D. Ask JL to determine his A1c target.

Answer 42

C

We want to stay connected to JL; we do NOT want to put additional pressure on him

Question 43

What is the A1c goal for most people?

Answer 43

A1c < 7%

Question 44

What is the A1c goal for those who do not have significant risk of hypos?

Answer 44

A1c < 6.5%

Includes: those on CGMs, on GLP-1 RAs

Question 45

What is the A1c goal for those who have a history of hypos, limited life expectancy, or those with longstanding diabetes and vascular complications?

Answer 45

A1c < 8.0%

Question 46

How often is it recommended to check A1cs?

Answer 46

Twice a year, if stable

Check every 3 months (or 4x/year) if above goal