Assessment
25%of exam
Diagnostic CriteriaAutoantibodies & C-PeptideReadiness & Literacy ToolsPsychosocial ScreeningDiagnosis Pathway Tree
Care and Education Interventions
70%of exam
ADCES7Insulin PharmacologyNon-Insulin AgentsMNT & Insulin MathGlycemic TargetsGlucose MonitoringAcute ComplicationsChronic ComplicationsPhysical ActivitySpecial Populations
Standards and Practices
5%of exam
Quick Facts
- Exam
- CDCES
- Body
- CBDCE
- Items
- 175 (150 scored)
- Time
- 4 hours
- Pass
- Scaled 70 of 99
- Pass rate
- 72% first-time
- Domains
- 3 weighted domains
- Fee
- $350
- Provider
- PSI, test center or LRP
- Validity
- 5 years
SMART Goals
Specific, Measurable, Achievable, Relevant, Time-bound goals
S: specific behaviorM: measurable targetA: achievable stepR: relevant to personT: time-bound deadline
Type 1 vs Type 2 Pathophysiology
Type 1
- Autoimmune beta-cell destruction
- Absolute insulin deficiency
- Islet autoantibodies present
- Low or undetectable C-peptide
Type 2
- Insulin resistance, muscle/liver/fat
- Relative, progressive deficiency
- Autoantibodies typically negative
- Normal to high C-peptide
Absolute deficiency vs insulin resistance
Diabetes Diagnosis Pathway
- A1C 6.5% or higher→Diabetes, confirm w/ repeat(Any one criterion suffices)
- FPG 126 mg/dL or higher→Diabetes, confirm w/ repeat(No caloric intake 8 hr)
- 2-hr OGTT 200+ mg/dL→Diabetes, confirm w/ repeat(75-gram glucose load)
- Random glucose 200+ w/ symptoms→Diabetes, no repeat needed(Classic hyperglycemia symptoms)
- A1C 5.7 to 6.4%→Prediabetes(Can meet multiple criteria)
- FPG 100 to 125 mg/dL→Prediabetes (IFG)(May overlap A1C criterion)
ADA Diagnostic Criteria
- Diabetes A1C
- 6.5% or higher
- Diabetes FPG
- 126 mg/dL or higher
- Diabetes 2-hr OGTT
- 200 mg/dL or higher
- Diabetes random glucose
- 200+ with symptoms
- Prediabetes A1C
- 5.7 to 6.4%
- IFG (prediabetes)
- FPG 100 to 125
- IGT (prediabetes)
- OGTT 140 to 199
Dawn Phenomenon vs Somogyi Effect
Dawn phenomenon
- 2-3 AM glucose normal/rising
- Hormone-driven surge
- Fix: adjust basal timing/dose
Somogyi effect
- 2-3 AM glucose low
- Rebound hyperglycemia after
- Fix: reduce evening insulin
Check 2-3 AM glucose to distinguish
Autoantibodies and C-Peptide
- GAD65
- Islet autoantibody, T1D/LADA
- IA-2
- Islet autoantibody, T1D
- IAA
- Insulin autoantibody
- ZnT8
- Islet autoantibody, T1D
- Low C-peptide
- Minimal endogenous insulin
- High C-peptide
- Insulin resistance, type 2
Readiness and Literacy Tools
- Teach-back
- Person restates in own words
- Transtheoretical Model
- Stages of change
- Precontemplation stage
- Not yet considering change
- Action stage
- Actively changing behavior
- Maintenance stage
- Sustained 6+ months
- Cost-adherence question
- Ask cutting back at every visit
ADCES7 Self-Care Behaviors
Coping, Eating, Active, Medication, Monitoring, Risk, Problem-solving
Healthy Coping: centerHealthy Eating: MNTBeing Active: exerciseTaking Medication: adherenceMonitoring: SMBG/CGMReducing Risk: screeningProblem Solving: sick days
DKA vs HHS
DKA
- Glucose usually over 250
- pH under 7.3, ketones positive
- Rapid onset, hours
- Typically type 1
HHS
- Glucose usually over 600
- pH normal, ketones minimal
- Gradual onset, days
- Typically type 2, older
Acidotic vs hyperosmolar crisis
Hypoglycemia Response Steps
- Glucose 54-69, conscious→15g fast carb, recheck 15 min(Level 1 alert value)
- Glucose under 54, conscious→15g fast carb, recheck 15 min(Level 2, treat urgently)
- Still under 70 after 15 min→Repeat 15g carb(Rule of 15)
- AID/pump user, mild low→5 to 10g carb(Pump already reducing insulin)
- Cannot swallow safely→Give glucagon(Not oral carbohydrate)
- Unconscious or seizing→Glucagon, position on side(Call EMS if no response)
ADCES7 Self-Care Behaviors
- Healthy Coping
- Center of the framework
- Healthy Eating
- MNT and carb counting
- Being Active
- Aerobic and resistance training
- Taking Medication
- Adherence and safe use
- Monitoring
- SMBG, CGM, ketones
- Reducing Risk
- Complication prevention, screening
- Problem Solving
- Sick days, hypo/hyper response
15-15 Rule
15 grams fast carb, wait 15 minutes, recheck glucose
Glucose under 70: treatGive 15g fast carbWait 15 minutesRecheck, repeat if low
Rapid-Acting vs NPH Insulin
Rapid-acting
- Onset 10 to 15 minutes
- No pronounced late peak
- Used in pumps, boluses
NPH
- Onset 1 to 2 hours
- Pronounced 4-12 hr peak
- Cloudy, roll before dosing
Mealtime bolus vs peaking basal
Pre-Exercise Safety Check
- Glucose under 90 mg/dL→Eat 15-30g carb first(Recheck in 15 minutes)
- Glucose 90 to 250 mg/dL→Proceed with exercise(Normal range)
- Glucose over 250, ketones negative→Proceed with caution(Monitor closely)
- Glucose 250-349 with ketones→Do not exercise(Correct ketosis first)
- Glucose 350+ mg/dL→Do not exercise(Regardless of ketone result)
Insulin Onset, Peak, Duration
- Rapid-acting onset
- 10 to 15 minutes
- Rapid-acting duration
- 3 to 5 hours
- Regular insulin onset
- About 30 minutes
- Regular insulin use
- Only IV form, DKA/HHS
- NPH onset/peak
- 1-2 hr onset, 4-12 hr peak
- NPH handling
- Roll gently, never shake
- Glargine/detemir profile
- No pronounced peak, 24 hr
- Degludec duration
- Over 42 hours, flattest
- U-500 use
- Severe resistance, over 200u/day
Insulin Dose Rules
500 for carb ratio, 1800 for correction factor
500 / TDD = ICR1800 / TDD = correction, rapid1500 / TDD = correction, regular
GLP-1 RA vs SGLT2 Inhibitor
GLP-1 RA
- Glucose-dependent insulin release
- MTC boxed warning
- Avoid with pancreatitis history
SGLT2 inhibitor
- Blocks renal glucose reabsorption
- Euglycemic DKA risk
- Genital mycotic infection risk
Incretin effect vs renal glucosuria
Non-Insulin Agent Risks
- Metformin mechanism
- Reduces hepatic glucose output
- Metformin eGFR cutoff
- Contraindicated under 30
- Metformin B12 risk
- Deficiency in 5-10% long-term
- GLP-1 boxed warning
- Medullary thyroid carcinoma risk
- GLP-1/tirzepatide effect
- Weight loss, slowed emptying
- SGLT2 mechanism
- Blocks renal glucose reabsorption
- SGLT2 key risk
- Euglycemic DKA, glucose under 200
- Sulfonylurea risk
- Highest hypoglycemia of orals
- Glyburide risk
- Highest in class, elderly
rtCGM vs isCGM
rtCGM
- Streams data continuously
- Customizable high/low alarms
isCGM
- User scans to retrieve data
- No continuous background alarm
Continuous stream vs scan to view
MNT and Insulin Dose Math
- Carb serving
- 15 grams carbohydrate
- Rule of 500 (ICR)
- 500 divided by TDD
- Rule of 1800
- 1800 divided by TDD, rapid
- Rule of 1500
- 1500 divided by TDD, regular
- Sugar alcohols
- About 2 kcal per gram
- Nonnutritive sweeteners
- Little to no calories
Glycemic Targets
- General A1C goal
- Under 7%
- Preprandial glucose
- 80 to 130 mg/dL
- Peak postprandial glucose
- Under 180 mg/dL
- Time in Range goal
- Over 70%
- Time Below Range 1
- Under 4%, glucose under 70
- Time Below Range 2
- Under 1%, glucose under 54
- GMI formula
- 3.31 + 0.02392 x mean glucose
Glucose and Ketone Monitoring
- SMBG technique
- Wash hands, side of finger
- rtCGM
- Streams data, custom alarms
- isCGM
- Flash, scan to retrieve
- Sensor wear
- 10 to 15 days
- BHB testing trigger
- Glucose over 240, illness
- BHB high-risk level
- 1.6 to 3.0 mmol/L
- BHB DKA-likely level
- Over 3.0 mmol/L
Acute Complications
- Hypo Level 1
- 54 to 69 mg/dL
- Hypo Level 2
- Under 54 mg/dL
- Hypo Level 3
- Severe, needs assistance
- 15-15 Rule
- 15g carb, recheck 15 min
- AID-user hypo dose
- 5 to 10 grams carb
- Severe hypo treatment
- Glucagon, not oral carb
- DKA glucose
- Usually over 250 mg/dL
- DKA pH/bicarb
- pH under 7.3, bicarb under 18
- HHS glucose
- Usually over 600 mg/dL
- HHS ketones
- Minimal or absent
Chronic Complications Screening
- T1D retinopathy start
- Within 5 years diagnosis
- T2D retinopathy start
- At diagnosis
- UACR normal
- Under 30 mg/g
- UACR severely increased
- 300 mg/g or higher
- Neuropathy tool
- 10-gram monofilament
- Neuropathy tool 2
- 128-Hz tuning fork
- Charcot foot sign
- Warm, red, pulse present
- Charcot treatment
- Immediate offloading, casting
Physical Activity Guidance
- Aerobic target
- 150+ min/week moderate
- Resistance target
- 2 to 3 sessions/week
- Sitting break rule
- Interrupt every 30 minutes
- Pre-exercise glucose low
- Under 90, eat 15-30g carb
- Delayed hypoglycemia
- Hours later, even overnight
Pregnancy and GDM Targets
- Pregnancy fasting glucose
- Under 95 mg/dL
- Pregnancy 1-hr postprandial
- Under 140 mg/dL
- Pregnancy 2-hr postprandial
- Under 120 mg/dL
- Pregnancy A1C goal
- Under 6%
- GDM screening window
- 24 to 28 weeks
- Postpartum GDM retest
- 75-g OGTT, 4-12 weeks
NSDSMES 6 Standards
- Standard 1
- Support for DSMES services
- Standard 2
- Population and service assessment
- Standard 3
- DSMES team
- Standard 4
- Delivery and design
- Standard 5
- Person-centered DSMES
- Standard 6
- Measuring, demonstrating outcomes
Critical Times and DSMT Benefit
- Critical Time 1
- At diagnosis
- Critical Time 2
- Annually, not meeting targets
- Critical Time 3
- New complicating factors
- Critical Time 4
- Life or care transitions
- Medicare DSMT year one
- Up to 10 hours
- Medicare DSMT after year one
- 2 hours per year
Common Traps
Dawn Phenomenon vs Somogyi
Dawn: rising overnight glucose ≠ Somogyi: overnight low, rebound
DKA vs HHS Onset
DKA: rapid, hours, type 1 ≠ HHS: gradual, days, type 2
SGLT2 Euglycemic DKA
Glucose often looks normal ≠ Check ketones on symptoms alone
NPH Handling Error
Must roll gently before use ≠ Never shake the suspension
Milking the Fingerstick
Dilutes sample with tissue fluid ≠ Use adequate first drop instead
Level 3 Hypoglycemia Definition
Not a specific glucose number ≠ Defined by needing assistance
Rule of 1800 vs 1500
1800 divided by TDD, rapid ≠ 1500 divided by TDD, regular
Last Minute
- 1.Assessment 25%, Care 70%, Standards 5%
- 2.175 items, 150 scored, 4 hours
- 3.Passing score: scaled 70 of 99
- 4.A1C diagnosis cutoff is 6.5%
- 5.General A1C target under 7%
- 6.Preprandial target 80-130 mg/dL
- 7.Time in Range goal over 70%
- 8.Rapid-acting onset 10-15 minutes
- 9.SGLT2i risk: euglycemic DKA
- 10.GLP-1 boxed warning: MTC/MEN2
- 11.Metformin contraindicated eGFR under 30
- 12.15-15 Rule for non-severe hypoglycemia
- 13.Severe hypo treated with glucagon
- 14.DKA acidotic, HHS hyperosmolar
- 15.ADCES7 centers on Healthy Coping
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