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Rationale of the Week | Exercise & Heart Rate Mystery

For our April 13th Question of the Week, 62% of respondents chose the best answer. We wanted to “take a closer look” into this question.

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: LR loves going to the gym 3 times a week. LR is 78, with Latent Autoimmune Diabetes (LADA) and is on basal bolus insulin. LR also takes a statin and ACE Inhibitor. LR has a history of retinopathy and peripheral neuropathy. During your assessment, LR proudly shares that when on the treadmill, their heart rate never goes above 100 beats per minute.

What best explains this heart rate?

Answer Choices:

Excellent cardiovascular health from regular exercise
Cardiac autonomic neuropathy
Stiff heart syndrome
ACE Inhibitors can contribute to lower heart rates

As shown above, the most common choice was option 2, the second most common answer was option 4, then option 1, and finally option 3.

Getting to the Best Answer

Answers & Rationale

Answer 1 is incorrect, 10.55% chose this answer, “Excellent cardiovascular health from regular exercise .” On first blush, this answer is tempting, yet it doesn’t consider in all the factors described in the case study. If we look at his age and the presence of microvascular disease and neuropathy, we are correct to suspect that he may also have autonomic neuropathy. Therefore, his low heart rate isn’t an indication of robust health but a sign of autonomic dysfunction.

Answer 2 is correct, 62.38% of you chose this answer, “Cardiac autonomic neuropathy.” Good job! When we look at his age and the presence of microvascular disease and neuropathy, we are right to suspect he also has cardiac autonomic neuropathy. As a result of nerve disease, his heart rate isn’t able to respond to the cardiac demand of intense exercise and never exceeds 100. This “fixed heart rate” is a sign of autonomic dysfunction that warrants further investigation.

Answer 3 is incorrect, 2.98% of you chose this answer, “Stiff heart syndrome.” People with diabetes are more likely to have stiff fibrotic hearts and this can lead to increased risk of heart failure. However, there is no such condition as a “stiff heart syndrome”. This answer was a distractor.

Answer 4 is incorrect, 24.09% of you chose this answer, “ACE Inhibitors can contribute to lower heart rates.” This was our juicy answer. The blood pressure class of ACE Inhibitors does not lower heart rates but does lower blood pressure. The blood pressure class Beta Blockers, can lower heart rate, but it was not included in this question. See our Med Cheat Sheets 2021 | Hypertension, Lipids, and Neuropathy for more info.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Rationale of the Week | Type 1, Ramadan & Fasting

For our April 6th Question of the Week, 47% of respondents chose the best answer. We wanted to “take a closer look” into this question.

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: RS observes Ramadan and fasts from sunrise to sunset. RS is 13 years old, has type 1 diabetes, uses an insulin pump and CGM. RS’s insulin-to-carb ratio is 1:12 and correction is 1:45. Basal settings range from 0.5 -1.2 units an hour.

What would be the best recommendation for RS to keep blood sugars in the target range during Ramadan?

Answer Choices:

See if RS can get a note from their doctor to allow eating during the day.
Take bolus insulin when RS eats a meal or snack.
Decrease basal insulin rate by 50% during periods of fasting.
Monitor urine ketones at least twice a day.

As shown above, the most common choice was option 2, the second most common answer was option 3, then option 4, and finally option 1.

Getting to the Best Answer

Answers & Rationale

Answer 1 is incorrect, 5.79% chose this answer, “See if RS can get a note from their doctor to allow eating during the day.” As diabetes specialists, we are at our best when we tap into our cultural humility. We may not be familiar with the customs and celebrations of other cultures, but we can honor these traditions and express sincere interest in learning more about them. In this situation, we would respect their tradition, explore potential issues surrounding fasting and help with problem solving and creating a back up plan in case an issue arises.

Answer 2 is correct, 47.06% of you chose this answer, “Take bolus insulin when RS eats a meal or snack.” Good Job! When the basal rates of an insulin pump are set correctly, a person with type 1 diabetes can fast and still keep glucose on target. This background or basal insulin works to manage glucose levels in between meals and through the night. Actually, this period of fasting will provide an opportunity to evaluate if basal settings need adjustment or if they are set correctly. When RS breaks the fast at sunset, they will just need to dose for carbohydrates and cover for hyperglycemia if needed.

Answer 3 is incorrect, 31.15% of you chose this answer, “Decrease basal insulin rate by 50% during periods of fasting.” When the basal rates of an insulin pump are set correctly, a person with type 1 diabetes can fast and still keep glucose on target. This background or basal insulin works to manage glucose levels in between meals and through the night. If RS is receiving too much basal insulin and experiences low blood sugars during periods of fasting, they will need to fine tune their basal rates. However, we would not suggest to automatically decrease basal rate by 50% in preparation for fasting.

Answer 4 is correct, 16.01% of you chose this answer, “Monitor urine ketones at least twice a day.” Since RS has an insulin pump that delivers basal insulin 24 hours a day, they are at low risk for ketosis. Ketosis is usually a result of insufficient insulin administration. Without adequate insulin, fats are utilized as an alternate energy source, leading to positive ketones. In this situation, RS is receiving adequate insulin through the pump and is not at increased risk of significant ketosis.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Rationale of the Week | Black Spots in Eyes

For our March 30th Question of the Week, 79% of respondents chose the best answer. We wanted to “take a closer look” into this question. What is the best action to take for some one who is experiencing eye issues?

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: JR was recently diagnosed with type two diabetes. JR‘s A1 C was 13.9%, but now blood sugars are running in the 100 to 180 range. JR mentions that they have been noticing “black spots” floating in their eyes.

What is the best response by the diabetes specialist?

Answer Choices:

This is an expected finding when blood sugars drop rapidly.
On a scale of 1 to 10, how much are these spots affecting your daily quality of life?
That must be really scary. Make sure to mention this at your next provider visit.
Let’s get you scheduled in to see ophthalmology.

As shown above, the most common choice was option 4, the second most common answer was option 1, then option 2, and finally option 3.

Getting to the Best Answer

Answers & Rationale

Answer 1 is incorrect, 7.67% chose this answer, “This is an expected finding when blood sugars drop rapidly.” Actually, this is not an expected finding and warrants immediate investigation.

When people with diabetes experience fluctuations in blood sugars, they may complain of blurry vision and their glasses not working due to fluid shifts. However, a rapid drop in glucose can intensify the risk of retinal bleeds. “Black dots” or floaters can indicate retinal bleeding and warrant an immediate evaluation by an eye professional (Ophthalmologist or Optometrist). Delayed treatment can lead to serious eye problems.

Answer 2 is incorrect, 7.51% of you chose this answer, “On a scale of 1 to 10, how much are these spots affecting your daily quality of life?” This assessment question would be appropriate if the person was receiving treatment for eye problems already and we are evaluating the impact on daily life. However, this is not the case.

This sudden appearance of black dots” or floaters can indicate retinal bleeding and warrant an immediate evaluation by an eye professional (Ophthalmologist or Optometrist). Delayed treatment can lead to serious eye problems.

Answer 3 is incorrect, 5.63% of you chose this answer, “That must be really scary. Make sure to mention this at your next provider visit.” Yes, it is important to notify the provider, IMMEDIATELY. What if the next provider visit is in 6 months or a year? What if JR misses that appointment and gets lost to follow-up?

Answer 4 is correct, 79.19% of you chose this answer, “Let’s get you scheduled in to see ophthalmology.” GREAT JOB. Most of you chose this answer. This sudden appearance of black dots” or floaters can indicate retinal bleeding and warrant an immediate evaluation by an eye professional (Ophthalmologist or Optometrist). Delayed treatment can lead to serious eye problems and many people with diabetes don’t receive regular eye care. Let’s help break down barriers and make sure people with diabetes get the eye care they deserve.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!

Rationale of the Week | How Many Insulin Pens?

Our March 23rd Question caused a lot of commotion. Less than half (43%) of respondents chose the best answer, so we wanted to dive deeper into this question of how many pens are needed.

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: JR is 24 years old and uses an insulin pen for their basal insulin injections each evening. JR takes 30 units a night and each insulin pen holds 300 units of insulin.

How many insulin pens would JR need for one month?

Answer Choices:

3 pens
4 pens
10 pens
1 box

As shown above, the most common choice was option 2, the second most common answer was option 1, then option 4, and finally option 3.

Getting to the Best Answer

We had over 1,500 attempts at getting to the best answer. If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. The exam will present questions that require test takers to make sure the answer matches the key intent of the question. This is also a word problem. Setting up the problem correctly before doing the math is very important.

In this situation, we are asked to answer, “How many insulin pens would JR need for one month?” The main goal of this question is to make sure that test-takers incorporate the 2 unit air shot into calculating how much insulin is needed for the month.

Answers & Rationale

Answer 1 is incorrect, 37.59% chose this answer, “3 pens.” JR takes 30 units of basal insulin a night. However, we know that JR needs to prime their insulin pen with a 2 unit air shot before each injection. To make sure the insulin pen and needle are working correctly, we instruct people to use a new pen needle and to prime the pen before injection. This means that JR will use 32 units of insulin each night (30 units for the injection, 2 units to prime the pen).

32 units x 30 days = 960 units. If each pen holds 300 units, 3 pens only hold 900 units. JR would run out of insulin at least 2 days ahead of time. For this reason, this answer is not correct.

Answer 2 is correct, 43.94% of you chose this answer, “4 pens.” Great job. You considered that JR needs to prime their pen before each injection.

JR takes 30 units of basal insulin a night. We know that JR needs to prime their insulin pen with a 2 unit air shot before each injection. To make sure the insulin pen and needle are working correctly, we instruct people to use a new pen needle and to prime it before injection. This means that JR will use 32 units of insulin each night (30 units for the injection, 2 units to prime the pen).

32 units x 30 days = 960 units. If each pen holds 300 units, JR will need 4 insulin pens for the month.

Answer 3 is incorrect, 9.20% of you chose this answer, “10 pens.” This was a juicy answer. Respondents who chose this probably looked quickly at the question and divided 300 by 30 to get 10 pens. In this question, paying attention to the details before diving into math is really important.

Each pen holds 300 units and JR takes 30 units of insulin a night. When you add in the 2 units to prime the pen, JR needs 4 insulin pens a month.

Answer 4 is incorrect, 9.27% of you chose this answer, “1 box.” This is another juicy answer. But, it doesn’t match the unit of measure of the question. The question asks, how many insulin pens and this response answers with a different unit, 1 box. The question also doesn’t ask how the prescription would be written. It only asks for how many pens. For this reason, this is not the best answer.

However, in the clinical setting, the prescription would be written for a box of 5 pens, since that is the usual dispensing unit.

Insulin Storage Cheat Sheet – Download for FREE. Provides all kinds of important details on the storage of different types of insulin pens, vials, and more!

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Rationale of the Week | Giving Up Tortillas?

For our March 16th Question of the Week, over 86% of respondents chose the best answer!

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: PZ arrives for their diabetes appointment with their food diary and glucose log book. PZ’s blood glucose levels have improved since last visit by about 20 points, with morning glucose levels in the 130 range and bedtime glucose in the 180 range. When you ask PZ about what changes they have made, PZ shrugs their shoulders and says, “I quit eating tortillas because my children said they are bad for me.”

What is the best response?

Answer Choices:

Good for you, giving up tortillas is really hard.
Your children sound like they are worried about your health?
Yes, we don’t recommend tortillas since they are high in starch.
How are you feeling about giving up tortillas?

As shown above, the most common choice was option 4, the second most common answer was option 2, then option 1, and finally option 3.

Getting to the Best Answer

Answers & Rationale

Answer 1 is incorrect, 2.31% chose this answer. “Good for you, giving up tortillas is really hard”. We notice that PZ shrugs their shoulders when they tell us they have given up tortillas. In addition, PZ states that they have stopped eating tortillas, not because they think it is best for them to stop, but because their children advised them that tortillas are bad. The word “bad” is loaded with judgment and perhaps PZ is feeling ashamed for eating this traditional food that has been part of their everyday life for decades. For this response, instead of affirming giving up tortillas, a better choice would be to explore this choice further.

Answer 2 is incorrect, 9.49% of you chose this answer. “Your children sound like they are worried about your health?” This seems like an accurate response, but is it the BEST response? The goal of DSME is to provide a person-centered approach. This question puts the emphasis on the children’s belief that tortillas are bad instead of exploring how the person with diabetes is responding to this drastic behavior change.

Answer 3 is incorrect, 1.28% of you chose this answer “Yes, we don’t recommend tortillas since they are high in starch.” One corn tortilla has 15gms of carbohydrate, plus fiber and other micronutrients. Tortillas can absolutely be included as part of a healthy meal plan. In addition, tortillas are more than a serving of starch, they are a central and traditional part of the meal for many cultures.

Answer 4 is correct, 86.92% of you chose this answer. ” How are you feeling about giving up tortillas?” GREAT JOB. Most of you chose this person-centered response which gives us an opportunity to see how giving up tortillas is impacting PZ from an emotional standpoint. As diabetes specialists, we know that eliminating tortillas completely may not be the best choice from an evidence-based and emotional perspective.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Rationale of the Week | Get Your Calculator Ready!

For our March 9th Question of the Week, over 67% of respondents chose the best answer!

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: JR wants to lose weight in the next 30 days by drinking less juice. There are 100 calories per glass of juice and JR usually drinks 3 glasses a day.

How much weight would JR lose by only drinking 1 glass a day?

Answer Choices:

0.85 pounds
It depends on the type of juice
1.7 pounds
3000 calories

As shown above, the most common choice was option 3, the second most common answer was option 1, then option 2, and finally option 4.

Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. The exam will present questions that require test takers to apply their math skills to a word problem and choose the BEST answer. If you see a question that requires math, just take a deep breath, read the question carefully and call upon your abundant common sense. For this particular question, we also need to know that 1 pound equals 3,500 kcals.

Answers & Rationale

Answer 1 is incorrect, 19.89% chose this answer. “0.85 pounds”. This was the juicy answer designed to distract test takers from the best answer. JR was drinking 3 glasses of juice and is reducing their intake by 2 glasses of juice. Their net calorie reduction, therefore, is not one glass a day, but 2 glasses a day. Each glass contains 100 calories, leading to a 30-day calorie deficit of 6,000 calories a month (not 3,000 calories).

Answer 2 is incorrect, 7.73% of you chose this answer. “It depends on the type of juice”. Since we are given the caloric content of the juice, we don’t need to know what kind of juice to get the best answer.

Answer 3 is correct, 67.96% of you chose this answer “1.7 pounds”. Good job. JR was drinking 3 glasses of juice and is reducing their intake by 2 glasses of juice. Each glass contains 100 calories. This leads to a 200 calorie a day deficit, and a 30-day calorie deficit of 6,000 calories. 6,000 calories divided by 3,500 calories (1 pound) equals 1.7 pounds.

Answer 4 is incorrect, 4.42% of you chose this answer. “3,000 calories”. If you go back to the root of the question, it asks the test taker, “How much weight” would JR lose. Weight is expressed in kg or pounds, not calories. By making sure the answers’ unit of measure matches the questions’ unit of measure, test takers can eliminate wrong answers.

Special note: I want to acknowledge that weight and weight loss are complicated. It is so much more than a function of calories consumed or deprived. There are hormones, genetics, set-points, co-conditions, and a whole range of other influencing factors that contribute to weight at any given time. This sample test question does not address these factors since its main focus was providing a word problem with math calculations.

I would encourage you to check out this blog on Diabetes and Diet Culture, which interviews Megrette Fletcher, M.Ed., RD, CDCES, co-founder of The Center for Mindful Eating, co-founder of WN4DC Symposium, and author of five mindful eating books. Megrette is a trailblazer in the field and offers a new approach that values the individual first and encourages us to address our own weight biases.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!

Rationale of the Week | Steroids, Sugar Spikes and Management Strategies

For our March 2nd Question of the Week, over 58% of respondents chose the best answer!

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: JR is 53 yrs old with type 2 diabetes, BMI of 24.3 and is recovering from a COVID infection. In addition to metformin, a SGLT-2i and a weekly GLP-1 RA, JR is on daily prednisone. Morning blood glucose levels are in the low 100’s, lunch and dinner blood glucose levels are in the 250-300 range.

Which of the following is the best treatment intervention to get lunch and dinner blood glucose levels to goal?

Answer Choices:

Initiate a low carb meal plan
Add NPH or 70/30 insulin in morning
Start evening basal insulin and gradually increase
Ask provider to stop or reduce prednisone dose

As shown above, the most common choice was option 2, the second most common answer was option 1, then option 4, and finally option 3.

Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. The exam often presents vignettes that compel test takers to determine which option offers the BEST answer based on the action times of different insulins.

Answers & Rationale

Answer 1 is incorrect, 16.77% chose this answer. “Initiate a low carb meal plan “. JR has a BMI that is less than 25, which indicates a healthy weight. In addition, JR is recovering from COVID, so making sure they are eating adequate calories and healthy carbs during this recovery phase is very important. Lastly, the spike in blood glucose between lunch and dinner is an expected response since JR is taking morning prednisone.

AM steroids cause hyperglycemia through lunch and dinner.

Answer 2 is correct, 58.87% of you chose this answer. “Add NPH or 70/30 insulin in morning”. YES! Since morning steroids increase insulin resistance throughout the day, especially around lunch and dinner time, morning NPH insulin works remarkably well. This is because NPH action time peaks within 4-10 hours of injection. Another option is to use 70/30 insulin, which is a combination of 70% NPH (or basal) insulin plus 30% bolus. This insulin used before the first meal of the day, can help prevent lunch and dinner blood sugars from going above target later in the day.

Dosing for NPH or 70/30 depends on several factors, including steroid dose, diabetes type and history, body weight and health status. See our article on Steroids and Sugar Spikes – Management Strategies

Answer 3 is incorrect, 11.94% of you chose this answer “Start evening basal insulin and gradually increase”. When people are on morning steroids, their overnight blood sugars generally trend down. Basal insulin isn’t the best choice for addressing mid day to evening glucose elevations.

Answer 4 is incorrect, 12.42% of you chose this answer. “Ask provider to stop or reduce prednisone dose”. While it is true that stopping the prednisone will improve blood glucose levels, it could also contribute to a worsening health status. One of the most effective treatments for people with a serious COVID infection is steroid therapy to decrease inflammation, especially in the lungs. We approach this situation understanding that the steroid is essential and we can help with glucose management to promote recovery.

Want to learn more about this topic? Join Coach Beverly during the Virtual Conference, where she will be discussing treatment strategies for hyperglycemia secondary to steroids.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Includes an answer key with rationales for all questions included in the guide!

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Rationale of the Week | How to work in Birthday Cake?

For our February 23rd Question of the Week, over 94% of respondents chose the best answer!

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: A 59 year old with type 2 diabetes, A1c of 7.2%, takes bolus insulin before meals, plus basal insulin at night and metformin. They ask you how to best work in a piece of birthday cake for their grandchild’s upcoming birthday celebration.

What is the best advice?

Answer Choices:

Take additional bolus insulin to cover the extra carbs
Accept the cake but don’t actually eat it
Increase their nighttime basal insulin to prevent hyperglycemia
Skip the previous meal to allow for the extra cake carbs

As shown above, the most common choice was option 1, the second most common answer was option 3, then option 2, and finally option 4.

Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. The exam often presents vignettes that compel test takers to determine which option incorporates a person centered approach. Person centered choices are usually the BEST answer.

Answers & Rationale

Answer 1 is correct, 94.79% chose this answer. ” Take additional bolus insulin to cover the extra carbs”. Yes, this is the BEST person-centered answer. People with diabetes can choose to increase their bolus insulin to cover for special occasions, like birthday cake.

Answer 2 is incorrect, 1.29% of you chose this answer. “Accept the cake but don’t actually eat it”. Based on this vignette, the person with diabetes wants to “work” the cake into their meal plan. A person centered approach honors their choice and helps them determine how to enjoy the cake while managing blood sugars.

A person centered approach honors their choice and helps them determine how to enjoy the cake while managing blood sugars.

Answer 3 is incorrect, 3.56% of you chose this answer “Increase their nighttime basal insulin to prevent hyperglycemia”. Since basal insulin does not cover carbohydrates or protect against post prandial hyperglycemia, increasing nighttime basal is not the best answer. As a matter of fact, increasing nighttime basal could cause morning hypoglycemia.

Answer 4 is incorrect, 0.36% of you chose this answer. “Skip the previous meal to allow for the extra cake carbs”. This action could lead to hypoglycemia since this person is on basal bolus insulin. For this reason, it is not the best answer.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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Rationale of the Week | Exercise & Heart Rate Mystery

Getting to the Best Answer

Answers & Rationale

Want to learn more?

Join us for our Level 2 – Critical Assessment – Fine-Tuning your Diabetes Detective Skills – 2.0 CEs.

Rationale of the Week | Type 1, Ramadan & Fasting

Getting to the Best Answer

Answers & Rationale

On Sale | Now just $24.95 ADA 2021 Standards of Medical Care in Diabetes Book

Rationale of the Week | Black Spots in Eyes

Getting to the Best Answer

Answers & Rationale

Rationale of the Week | How Many Insulin Pens?

Getting to the Best Answer

Answers & Rationale

Rationale of the Week | Giving Up Tortillas?

Getting to the Best Answer

Answers & Rationale

Rationale of the Week | Get Your Calculator Ready!

Getting to the Best Answer

Answers & Rationale

Rationale of the Week | Steroids, Sugar Spikes and Management Strategies

Getting to the Best Answer

Answers & Rationale

ADCES Desk Reference + 5th Ed Review Guide Book Bundle

Rationale of the Week | How to work in Birthday Cake?

Getting to the Best Answer

Answers & Rationale

A person centered approach honors their choice and helps them determine how to enjoy the cake while managing blood sugars.

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