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

Question 47

AGP

Answer 47

Ambulatory Glucose Profile A standardized report with visual cues for those on CGM devices

Question 48

What is the AGP goal for most with T1 and T2DM? -Time in Range

Answer 48

>70% of readings within BG range of 70-180 mg/dL

Question 49

What is the AGP goal for most with T1 and T2DM? -Low BG

Answer 49

<4% of readings <54 mg/dL

Question 50

What is the AGP goal for most with T1 and T2DM? -Hyperglycemia

Answer 50

<25% of readings > 180 mg/dL

Question 51

What is the AGP goal for most with T1 and T2DM? -Very high BG

Answer 51

<5% of readings > 250 mg/dL

Question 52

For those with frailty or at high risk of hypoglycemia, what are appropriate AGP goals? (2)

Answer 52

1) Time in Range 50% 2) <1% time below range

Question 53

What key points included in the AGP?

Answer 53

1) Time in Ranges 2) Average glucose 3) GMI (Glucose Management Indicator) 4) Glucose variability

Question 54

What is the goal for glucose variability?

Answer 54

<36%

Question 55

What are the leading causes of morbidity and mortality in diabetes?

Answer 55

ASCVD and HF

Question 56

What 3 conditions are included in the term ASCVD?

Answer 56

1) CHD (Coronary Heart Disease) 2) CVD 3) PAD (Peripheral Artery Disease)

Question 57

(TRUE or FALSE) With more aggressive goals, rates of CVD have decreased over the past decade.

Answer 57

TRUE

Question 58

What are the 5 ways to reduce diabetes complications?

Answer 58

1) Lifestyle Modification and Diabetes Education 2) Glycemic Mgmt 3) BP Mgmt 4) Lipid Mgmt 5) Agents with CVD and Kidney Benefits

Question 59

(TRUE or FALSE) If a person has albuminuria they are at a higher risk for a cardiac and vascular event.

Answer 59

TRUE

Question 60

What factors increase ASCVD and HF risks?

Answer 60

-Duration of diabetes -BMI -HTN -Dyslipidemia -Smoking -Family hx of premature coronary disease -CKD or presence of albuminuria

Question 61

(TRUE or FALSE) If the systolic or diastolic BP number is elevated, it is considered HTN.

Answer 61

TRUE

Question 62

What is the BP goal for those with diabetes?

Answer 62

<130/80 If it can be safely attained

Question 63

List some HTN Lifestyle Treatment Strategies. When would this be appropriate?

Answer 63

If BP > 120/80, start: 1) DASH Diet 2) Weight loss, if indicated 3) Sodium intake <2,300 mg daily 4) Increase fruits and vegetables, aiming for 8-10 servings per day 5) Aim for 2-3 servings of low-fat dairy daily 6) Limit alcohol to 1-2 drinks per day 7) Increase exercise

Question 64

When is it appropriate to start a medication for HTN?

Answer 64

BP > 130/80

Question 65

What is albuminuria defined as?

Answer 65

Urinary albumin creatinine ratio (UACR) of 30 or higher

Question 66

If HTN with albuminuria or ASCVD, what medication classes would be appropriate?

Answer 66

Either ACE or ARB?

Question 67

If HTN withOUT albuminuria or ASCVD, what medication classes would be appropriate?

Answer 67

-ACE Inhibitors -ARBs? -Thiazide-like diuretics, or -Calcium channel blockers

Question 68

What do you need to monitor after starting BP medication?

Answer 68

Potassium Monitor 7-14 days after starting medication and then annually

Question 69

(TRUE or FALSE) It is appropriate to take an ACE and ARB at the same time.

Answer 69

FALSE

Question 70

When would it be appropriate to start multiple drugs for HTN?

Answer 70

If BP greater than or equal to 150/90

Question 71

What are high CVD risk factors?

Answer 71

1) LDL > 100 2) HTN 3) Smoking 4) CKD 5) Albuminuria 6) Family hx of ASCVD

Question 72

For people with diabetes, aged 40-75 at higher CVD risk, what type of statin therapy is recommended? To achieve what goal?

Answer 72

High intensity statin therapy Reduce LDL cholesterol by at least 50% of baseline AND a LDL < 70mg/dL

Question 73

What is the goal for LDL cholesterol in those with diabetes, who have had a CVD event?

Answer 73

<55 mg/dL

Question 74

What is the goal for LDL cholesterol in those with diabetes, who are at risk for a CVD event?

Answer 74

<70 mg/dL

Question 75

Define moderate intensity statin therapy.

Answer 75

Lowers LDL by 30-50%

Question 76

Define high intensity statin therapy.

Answer 76

Lowers LDL by 50%

Question 77

What medications with what doses would be considered moderate intensity statin therapy?

Answer 77

-Atorvastatin 10-20 mg -Rosuvastatin 5-10 mg -Simvastatin 20-40 mg -Pravastatin 40-80 mg -Lovastatin 40 mg -Fluvastatin XL 80 mg -Pitavastatin 1-4 mg

Question 78

What medications with what doses would be considered high intensity statin therapy?

Answer 78

Atorvastatin 40-80 mg Rosuvastatin 20-40 mg

Question 79

When is it appropriate to add Ezetimibe or a PCSK9 inhibitor?

Answer 79

For those with ASCVD who have not reached the LDL targets* with maximum tolerated statin therapy *goal = reduce LDL by 50% from baseline, achieving <55 mg/dL

Question 80

What is the lipid therapy recommendation for -All ages 20+, with diabetes and ASCVD

Answer 80

Add high intensity statin therapy

Question 81

What is the lipid therapy recommendation for -20-39 y/o and additional ASCVD risk factors

Answer 81

May be reasonable to initiate statin therapy in addition to lifestyle modification

Question 82

What is the lipid therapy recommendation for -40-75 y/o

Answer 82

Moderate to high intensity statin therapy based on risk

Question 83

What is the lipid therapy recommendation for -75 y/o and already on statin

Answer 83

Reasonable to continue statin tx

Question 84

What is the lipid therapy recommendation for -75 y/o

Answer 84

May be reasonable to initiate moderate intensity statin therapy after discussion of potential benefits and risks

Question 85

What is the percent reduction in mortality with each 39 mg/dL reduction in LDL cholesterol?

Answer 85

13%

Question 86

When is it appropriate to use aspirin therapy?

Answer 86

1) As a secondary prevention strategy in those with diabetes and a hx of ASCVD 2) As a primary prevention strategy in those with diabetes and a risk of ASCVD

Question 87

What needs to be monitored for those in aspirin therapy?

Answer 87

Stools for GI bleeds, given increased risk of bleeding

Question 88

Which 2 classes of diabetes meds reduce CVD risk?

Answer 88

1) SGLT-2s 2) GLP-1s

Question 89

Name the 3 SGLT-2 meds that significantly decrease CVD events?

Answer 89

1) Empagliflozin (Jardiance) 2) Canagliflozin (Invokana) 3) Dapagliflozin (Farxiga)

Question 90

Name the 3 GLP-1 RA meds that significantly decrease CVD events?

Answer 90

1) Semaglutide (Ozempic) 2) Liraglutide (Victoza) 3) Dulaglutide (Trucility)

Question 91

When should you add on an ACE or ARB?

Answer 91

Those with previous ASCVD events

Question 92

(TRUE or FALSE) Treat HTN with ACE or ARB and for elevated albumin-to-creatinine ratio of 30-299.

Answer 92

TRUE

Question 93

What is the goal for UACR?

Answer 93

<30 mg/g

Question 94

What are the recommendations to protect the kidneys with those who have diabetes and GFR >20 and UACR > 200mg/g?

Answer 94

Start SGLT-2

Question 95

What is the recommendation to protect the kidneys with those who have T2DM and CKD?

Answer 95

Start nonsteroidal mineralocorticoid receptor antagonist (finerenone) and/or GLP-1

Question 96

When is Finerenone indicated?

Answer 96

Those with CKD associated with T2DM Reduces the risk of kidney function decline, kidney failure, CVD death, non-fatal MIs, and hospitalization for HF. The mineralocorticoid receptor antagonist blocks the effects of aldosterone

Question 97

(TRUE or FALSE) There is new information on the GLP-1 RAs that seem to have some renal protection and reducing ASCVD risk.

Answer 97

TRUE

Question 98

What are the ABCs of Diabetes?

Answer 98

A) A1c <7.0% B) BP <130/80 C) Cholesterol