Most of you, 69%, chose the best answer for our May 11th Question of the Week. Great job! 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: RT is 33 years old and has had diabetes for the past 20 years.  RT uses an insulin pump and CGM and works hard to keep A1cs less than 7%.  Their most recent A1c increased to 7.9% and RT sets up an appointment with the diabetes specialist for help.  After downloading the report, the specialist thinks they have discovered the reason behind the increasing A1c. 

Which of the following would most likely explain the A1c increase?

Answer Choices:

1. Carbohydrate bolus insulin omissions
2. Basal insulin rate set too high
3. Bolus insulin given 15 minutes before meal
4. CGM sensor malfunction

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As shown above, the most common choice was option 1, the second most common answer was option 4, then option 2, 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 will present questions that require test takers to be familiar with diabetes technology and helping people with problem solving and getting glucose to target.

Answers & Rationale

Answer 1 is correct, 69.21% chose this answer, “Carbohydrate bolus insulin omissions.” GREAT JOB! Skipping coverage for carbs, even once a day, can lead to a 1% increase in A1c. When discussing the data download with RT, the diabetes specialist will recognize all the actions that RT is doing correctly. Then, the specialist will share their observations that it seems RT sometimes skips bolusing for carb intake. The specialist can pause and see what RT says or the specialist could say something like, “can you tell me more about what is happening around these meals?”

Answer 2 is incorrect, 5.43% of you chose this answer, “Basal insulin rate set too high.” Getting to the correct basal rate is important to maintain glucose levels on target. If the basal rate is set too high, this means that RT would be getting too much insulin. This would result in hypoglycemia and a drop in A1c.

Answer 3 is incorrect, 4.55% of you chose this answer, “Bolus insulin given 15 minutes before meal.” The timing of bolus insulin before meals can make a big difference in getting glucose to target. Giving bolus insulin 15 minutes before meals can actually improve glucose levels since it allows the insulin peak to more closely match the post meal glucose elevation.

Answer 4 is incorrect, 20.82% of you chose this answer, “CGM sensor malfunction.” This is a juicy answer, but it doesn’t match the intent of the question. If the question said, “according to the CGM download the estimated A1c is 7.0% and the lab A1c is 7.9%” then we might consider this answer. However, we have no indication that the CGM sensor wasn’t working, nor do we have any data from the CGM to consider. That’s why this juicy answer is not the best one.

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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Want to learn more about this question and more?

Enroll in our Level 4 | Insulin Calculation Workshop – From Injections to Pumps Course | 1.5 CEs

Determining basal and bolus rates for multiple daily injections or insulin pumps can seem overwhelming.  This 90-minute course provides participants with a step-by-step approach to determine basal rates, bolus ratios and how to problem solve when blood glucose levels aren’t on target. During this 90-minute course,  Coach Beverly will provide abundant case studies to give participants hands-on practice and build confidence when calculating insulin doses for a variety of situations.

Objectives:

1. Describe using formulas to determine appropriate insulin dosing.
2. Discuss strategies to determine and fine-tune basal insulin dose
3. Describe how to determine and fine-tune bolus rates including coverage for carbs and hyperglycemia.
4. Using a case study approach, utilize calculations to determine the best insulin dosing strategy.

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