Which fasting range defines impaired fasting glucose?
A. 90–99 mg/dL fasting
B. 126–139 mg/dL fasting
C. 80–89 mg/dL fasting
D. 100–125 mg/dL fasting

D. 100–125 mg/dL fasting

Which 2-hour OGTT range defines impaired glucose tolerance?
A. 120–139 mg/dL 2-hour
B. 200–239 mg/dL 2-hour
C. 140–199 mg/dL 2-hour
D. 100–119 mg/dL 2-hour

C. 140–199 mg/dL 2-hour

A 2-hour plasma glucose of which value diagnoses diabetes (75-g OGTT)?
A. 200 mg/dL
B. 199 mg/dL
C. 140 mg/dL
D. 125 mg/dL

A. 200 mg/dL

Which A1C range defines prediabetes?
A. 6.5–7.4%
B. 5.7–6.4%
C. 4.0–5.6%
D. 6.0–6.9%

B. 5.7–6.4%

Screening should be considered at any age when BMI ≥25 kg/m² plus:
A. Age >45 only
B. No symptoms present
C. At least one risk factor
D. Any normal fasting glucose

C. At least one risk factor

In adults without risk factors, testing should begin no later than:
A. Age 35
B. Age 40
C. Age 50
D. Age 45

D. Age 45

A teen presents with DKA and weight loss. The primary defect in type 1 diabetes is:
A. Autoimmune beta-cell destruction
B. Hepatic insulin overproduction
C. Muscle glucose transporter failure
D. Alpha-cell hyperplasia primary

A. Autoimmune beta-cell destruction

The hormonal state resulting from type 1 beta-cell loss is best described as:
A. Relative insulin excess
B. Absolute insulin deficiency
C. Isolated glucagon deficiency
D. Selective cortisol deficiency

B. Absolute insulin deficiency

Why can type 1 diabetes have months–years of silent progression?
A. Renal glucose threshold increases
B. Glucagon remains fully suppressed
C. Peripheral insulin sensitivity increases
D. Pancreas has large insulin reserve

D. Pancreas has large insulin reserve

Autoantibodies to GAD65 appear to provoke attack by:
A. Killer T lymphocytes
B. B lymphocytes
C. Neutrophils
D. Eosinophils

A. Killer T lymphocytes

Type 1 diabetes HLA association includes linkage to:
A. HLA-A and HLA-B
B. HLA-C and HLA-E
C. HLA-DGA and HLA-DQB
D. HLA-DP and HLA-DO

C. HLA-DGA and HLA-DQB

Which statement about HLA-DR/DQ alleles is correct?
A. DR/DQ alleles never protective
B. DR/DQ alleles can either be predisposing or protect
C. Only DRB is predisposing
D. Only DQB is protective

B. DR/DQ alleles can either be predisposing or protect

Insulin autoantibodies may be found in people who:
A. Always used insulin previously
B. Only have type 2 diabetes
C. Are only on metformin
D. Never received insulin therapy

D. Never received insulin therapy

In type 2 diabetes development, hyperglycemia requires:
A. Complete alpha-cell failure
B. Autoimmune islet destruction
C. Acute cortisol deficiency
D. Beta-cell secretory impairment

D. Beta-cell secretory impairment

By the time type 2 diabetes is diagnosed, beta-cell function loss can reach:
A. 50% loss
B. 10% loss
C. 90% loss
D. 25% loss

A. 50% loss

Early type 2 diabetes commonly features which insulin abnormality?
A. Excess first-phase insulin
B. Inadequate first-phase insulin
C. Absent basal insulin secretion
D. Increased insulin clearance

B. Inadequate first-phase insulin

Inadequate first-phase insulin fails to suppress which hormone?
A. Growth hormone
B. Cortisol
C. Epinephrine
D. Glucagon

D. Glucagon

The main consequence of glucagon hypersecretion is:
A. Increased hepatic glucose output
B. Increased muscle glucose uptake
C. Decreased gluconeogenesis
D. Increased peripheral insulin action

A. Increased hepatic glucose output

Increased free fatty acids causing metabolic injury is termed:
A. Glucotoxicity
B. Ketosis
C. Lipotoxicity
D. Glycogenesis

C. Lipotoxicity

Increased free fatty acids directly cause which change?
A. Increased insulin sensitivity
B. Decreased insulin sensitivity
C. Increased GLUT4 translocation
D. Increased insulin receptor density

B. Decreased insulin sensitivity

Free fatty acids also tend to:
A. Impair insulin secretion
B. Improve beta-cell recovery
C. Reduce hepatic glucose output
D. Abolish glucagon secretion

A. Impair insulin secretion

A prediabetic patient asks about risk reduction. Supported weight loss target is:
A. 1–2% body weight
B. 3–4% body weight
C. 10–12% body weight
D. 5–7% body weight

D. 5–7% body weight

The physical activity target linked to benefit is:
A. 10 minutes brisk daily
B. 30 minutes brisk most days
C. 60 minutes jogging weekly
D. Resistance training only

B. 30 minutes brisk most days

Lifestyle changes can reduce diabetes risk by:
A. 5–10%
B. 10–20%
C. 29–67%
D. 70–90%

C. 29–67%

Lifestyle changes may delay type 2 diabetes onset for at least:
A. 10 years
B. 2 years
C. 6 months
D. 5 years

A. 10 years

For pharmacologic prevention, ADA recommends (with lifestyle):
A. Acarbose only
B. GLP-1 agonist only
C. Pioglitazone only
D. Metformin only

D. Metformin only

Metformin prevention is especially emphasized for:
A. BMI 24, age 66
B. BMI 28, age 62
C. BMI 36, age 58
D. BMI 23, age 41

C. BMI 36, age 58

Counterregulatory hormones have what net effect relative to insulin?
A. Same glucose-lowering effect
B. Opposite effect of insulin
C. No effect on metabolism
D. Only increase insulin secretion

B. Opposite effect of insulin

After eating, two “anticipatory” hormones amplify insulin release. Which pair fits?
A. Amylin and insulin
B. Cortisol and glucagon
C. Epinephrine and norepinephrine
D. GLP-1 and GIP

D. GLP-1 and GIP

A patient asks where incretins come from. Best answer?
A. Gastrointestinal tract after ingestion
B. Pancreatic alpha cells post-meal
C. Adipose tissue during fasting
D. Liver sinusoids during stress

A. Gastrointestinal tract after ingestion

A resident explains why incretins matter clinically. Key effect?
A. Delay insulin until absorption
B. Increase renal glucose reuptake
C. Anticipatory insulin rise pre-absorption
D. Trigger ketogenesis after meals

C. Anticipatory insulin rise pre-absorption

A1C measures:
A. Serum fructosamine
B. Glycosylated hemoglobin
C. Glycated albumin fraction
D. Total plasma glucose burden

B. Glycosylated hemoglobin

A patient’s A1C is reviewed. It best reflects glycemia over:
A. Prior 6–8 weeks
B. Prior 48–72 hours
C. Prior 10–14 days
D. Prior 6–12 months

A. Prior 6–8 weeks

Why does A1C rise with hyperglycemia over time?
A. Enzymatic hemoglobin phosphorylation
B. Rapid protein acetylation process
C. Insulin-driven hemoglobin oxidation
D. Nonenzymatic, concentration-dependent glycation

D. Nonenzymatic, concentration-dependent glycation

For many non-pregnant adults, ADA’s reasonable A1C goal is:
A. <6.5%
B. <7%
C. <7.5%
D. <8%

B. <7%

A highly motivated patient wants tighter control. Lower A1C may be reasonable if:
A. Advanced complications already present
B. Limited life expectancy expected
C. No significant hypoglycemia/adverse effects
D. Persistent postmeal excursions continue

C. No significant hypoglycemia/adverse effects

A frail patient has severe hypoglycemia history. A less stringent goal is most appropriate when:
A. Severe hypoglycemia, limited life expectancy, complications
B. Newly diagnosed, no comorbidities
C. Pregnancy planning this year
D. Early disease, low hypoglycemia risk

A. Severe hypoglycemia, limited life expectancy, complications

A pump user asks what drives rapid-acting bolus needs most. Best determinant?
A. Meal protein grams
B. Meal sodium content
C. Meal fiber density
D. Total meal carbohydrate grams

D. Total meal carbohydrate grams

A patient notices worse control after fried foods. High-fat meals primarily:
A. Improve insulin sensitivity acutely
B. Interfere with insulin signaling
C. Suppress hepatic glycogenolysis
D. Increase incretin release persistently

B. Interfere with insulin signaling

In nutrition counseling, lower-fat patterns are expected to:
A. Worsen insulin sensitivity
B. Increase hepatic glucose output
C. Reduce incretin secretion
D. Improve insulin sensitivity

D. Improve insulin sensitivity

Trials comparing eating patterns show similar A1C and weight improvements with:
A. High- or low-carbohydrate eating patterns
B. Zero-carbohydrate ketogenic diet only
C. Protein-only dietary pattern
D. Sodium-restricted pattern alone

A. High- or low-carbohydrate eating patterns

When comparing carbohydrate type/amount versus energy intake, the more important driver is:
A. Glycemic index category
B. Total energy intake
C. Dietary cholesterol intake
D. Protein timing with meals

B. Total energy intake

A dietitian teaches “carb counting.” One average carbohydrate serving equals:
A. 10 g carbohydrate
B. 12 g carbohydrate
C. 15 g carbohydrate
D. 20 g carbohydrate

C. 15 g carbohydrate

A patient asks for a fiber target. Recommended intake is:
A. 14 g per 1000 kcal
B. 10 g per 1000 kcal
C. 25 g per day
D. 40 g per day

A. 14 g per 1000 kcal

A patient without renal disease asks about protein restriction. Best guidance?
A. Increase protein to 30% energy
B. Avoid protein entirely at dinner
C. Reduce protein below usual intake
D. Remain 15–20% of energy

D. Remain 15–20% of energy

Long-term high-fat and high saturated fat intake is associated with:
A. Reduced insulin resistance
B. Improved insulin sensitivity
C. Increased insulin resistance
D. No change in insulin action

C. Increased insulin resistance

A supplement-focused patient asks about antioxidants. Routine supplementation is:
A. Recommended for all diabetics
B. Required with metformin use
C. Preferred in hypertensive patients
D. Not advised routinely

D. Not advised routinely

A patient asks if sodium advice differs in diabetes. Appropriate target is:
A. Under 2300 mg per day
B. Under 1500 mg per day
C. Under 3500 mg per day
D. No sodium restriction needed

A. Under 2300 mg per day

Sodium reduction lowers blood pressure in:
A. Only hypertensive individuals
B. Only normotensive individuals
C. Normotensive and hypertensive individuals
D. Only patients with complications

C. Normotensive and hypertensive individuals

A patient plans exercise; pre-exercise glucose is 92 mg/dL. Best immediate step?
A. Skip carbohydrates before exercise
B. Eat carbohydrates before exercise
C. Take bolus insulin immediately
D. Delay exercise until bedtime

B. Eat carbohydrates before exercise

A patient on Amylin mimetics (pramlintide) asks what it does. Primary postmeal effects?
A. Stimulates hepatic glucose production
B. Inhibits DPP-4 enzyme activity
C. Decreased glucagon, delayed gastric emptying
D. Increases glucagon, accelerates emptying

C. Decreased glucagon, delayed gastric emptying

A patient has postprandial hyperglycemia despite lifestyle changes. Alpha-glucosidase inhibitors (acarbose, miglitol) work by:
A. Inhibiting intestinal α-glucosidase that digests carbs
B. Stimulating beta-cell insulin release
C. Blocking hepatic gluconeogenesis enzymes
D. Activating amylin receptors

A. Inhibiting intestinal α-glucosidase that digests carbs

A patient asks why Biguanides (metformin) helps without “pushing insulin.” They:
A. Enhance insulin secretion directly
B. Delay gastric emptying markedly
C. Inhibit intestinal α-glucosidase
D. Suppressing hepatic glucose production

D. Suppressing hepatic glucose production

DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) normally degrades which peptides?
A. Amylin and insulin
B. GLP-1 and GIP
C. Cortisol and epinephrine
D. Glucagon and growth hormone

B. GLP-1 and GIP

Exenatide, Liragludite are:
A. GLP-1 receptor agonists
B. GLP-1 receptor antagonists
C. GLP-2 receptor agonists
D. GLP-2 receptor antagonists

A. GLP-1 receptor agonists

Sodium-glucose transporter 2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin) cause glucosuria by preventing filtered glucose from returning to blood. What is the key mechanism?
A. Inhibit intestinal carbohydrate enzymes
B. Activate GLP-1 receptors
C. Increase beta-cell insulin synthesis
D. Block renal glucose reabsorption

D. Block renal glucose reabsorption

A patient worries a GLP-1 receptor agonist will cause hypoglycemia when fasting. Why is insulin release limited at normal glucose?
A. Only with hyperglycemia present
B. Works only during exercise
C. Requires hepatic glycogen depletion
D. Depends on insulin receptor upregulation

A. Only with hyperglycemia present

After starting exenatide, a patient reports early satiety and smaller post-meal spikes. Which effect set best explains this?
A. Increase glucagon, faster emptying
B. Reduce insulin, faster emptying
C. Reduce glucagon, delay emptying
D. Increase insulin, faster emptying

C. Reduce glucagon, delay emptying

A patient takes an insulin secretagogue (Meglinitres) at the start of meals for postprandial control. Which drugs fit?
A. Glipizide and Repaglinide
B. Repaglinide and Nateglinide
C. Canagliflozin and Nateglinide
D. Liraglutide and Repaglinide

B. Repaglinide and Nateglinide

Which medication is a second-generation sulfonylurea?
A. Sitagliptin
B. Nateglinide
C. Glimepiride
D. Dapagliflozin

C. Glimepiride

A patient prefers long-term therapies that preserve beta-cell function. Which concern best matches sulfonylureas?
A. Primary hepatic glucose stimulation
B. Postmeal glucagon hypersecretion
C. Marked gastric emptying acceleration
D. Weight gain, beta-cell exhaustion

D. Weight gain, beta-cell exhaustion

A patient with insulin resistance is placed on pioglitazone and rosiglitazone (thiazolidinediones). Primary therapeutic effect?
A. Increase urinary glucose clearance
B. Increase insulin secretion acutely
C. Decrease peripheral insulin resistance
D. Inhibit intestinal carbohydrate digestion

C. Decrease peripheral insulin resistance

A patient needs background insulin to cover the post-absorptive state. Which insulins fit this role?
A. Lispro, Glargine, NPH
B. Glargine, Determir, NPH
C. Aspart, Determir, NPH
D. Regular, Determir, NPH

B. Glargine, Determir, NPH

A hospitalized patient is NPO overnight. Why is basal insulin still required?
A. Restrain hepatic glucose output
B. Prevent intestinal glucose absorption
C. Increase pancreatic insulin stores
D. Enhance renal glucose filtration

A. Restrain hepatic glucose output

Basal insulin also helps prevent excess substrate delivery to liver by:
A. Increasing glucagon secretion
B. Increasing hepatic ketone clearance
C. Accelerating adipose triglyceride breakdown
D. Limiting lipolysis and FFA flux

D. Limiting lipolysis and FFA flux

A patient asks when to inject detemir. Best guidance?
A. Only before breakfast
B. Only at bedtime
C. Any time, same daily
D. Only with largest meal

C. Any time, same daily

A patient wants to mix glargine with rapid-acting insulin in one syringe. Best advice?
A. Do not mix with others
B. Mix if dose is small
C. Mix only with NPH
D. Mix only at bedtime

A. Do not mix with others

A patient reports high glucose around waking despite stable daytime control. What phenomenon best fits?
A. Postprandial excursion
B. Dawn phenomenon
C. Reactive hypoglycemia
D. Exercise-induced hyperglycemia

B. Dawn phenomenon

A patient’s plasma glucose is 205 mg/dL and urinalysis shows glucose. The renal threshold is approximately:
A. 90–110 mg/dL
B. 120–140 mg/dL
C. 150–170 mg/dL
D. 180–220 mg/dL

D. 180–220 mg/dL

New-onset type 1 diabetes usually becomes clinically apparent after approximately what beta-cell loss?
A. 30–40% destruction
B. 50–60% destruction
C. 80–90% destruction
D. 95–99% destruction

C. 80–90% destruction

A conscious diabetic patient has tremor and diaphoresis with glucose 52 mg/dL. Preferred treatment?
A. Oral sucrose candy
B. Oral glucose
C. IV lipid emulsion
D. IM epinephrine

B. Oral glucose

Initial hypoglycemia treatment dose should be:
A. 15–20 g glucose
B. 5–10 g glucose
C. 25–30 g glucose
D. 40–50 g glucose

A. 15–20 g glucose

After giving oral glucose for hypoglycemia, expected initial response time is:
A. 1–3 minutes
B. 5–8 minutes
C. 10–20 minutes
D. 45–60 minutes

C. 10–20 minutes

An unconscious patient with hypoglycemia cannot take oral carbohydrates. Best immediate therapy?
A. Oral glucose tablets
B. Oral complex carbohydrates
C. IV fiber solution
D. Glucagon administration

D. Glucagon administration

In absolute insulin deficiency, adipose lipolysis increases partly due to:
A. Decreased adenylate cyclase activity
B. Increased adenylate cyclase activity
C. Increased insulin receptor signaling
D. Increased GLUT4 translocation

B. Increased adenylate cyclase activity

In insulin absence, fatty acid release also reflects reduced inhibition of:
A. Pyruvate dehydrogenase
B. HMG-CoA reductase
C. Glycogen phosphorylase
D. Hormone-sensitive lipase

D. Hormone-sensitive lipase

The liver generates ketone bodies in DKA primarily from increased:
A. Acetyl-CoA from FFA oxidation
B. Oxaloacetate from glycolysis
C. Lactate from anaerobic muscle
D. Citrate from TCA overflow

A. Acetyl-CoA from FFA oxidation

Which molecule is a major ketone body in DKA?
A. Oxaloacetate
B. Succinate
C. Beta-hydroxybutyrate
D. Malate

C. Beta-hydroxybutyrate

In DKA, the primary source of circulating glucose is:
A. Hepatic gluconeogenesis
B. Muscle glycogenolysis
C. Intestinal glucose absorption
D. Renal glucose reuptake

A. Hepatic gluconeogenesis

Insulin’s major hepatic effect on this pathway is to:
A. Activate hepatic gluconeogenesis
B. Inhibit hepatic gluconeogenesis
C. Replace hepatic glycogen stores
D. Increase hepatic ketone synthesis

B. Inhibit hepatic gluconeogenesis

Which complication category is most tightly linked to chronic hyperglycemia?
A. Macrovascular aneurysm rupture
B. Primary valve calcification
C. Microvascular complications
D. Primary arrhythmia syndromes

C. Microvascular complications

Chronic microvascular complications prominently involve:
A. Lungs, skin, marrow
B. Eyes, kidneys, nerves
C. Liver, pancreas, spleen
D. Heart, aorta, carotids

B. Eyes, kidneys, nerves

Microalbuminuria signals increased risk for:
A. Hyperthyroidism and stroke
B. DKA and pancreatitis
C. Nephrolithiasis and anemia
D. Atherosclerosis and nephropathy

D. Atherosclerosis and nephropathy

A pump user snacks between meals. If the snack contains >15 g carbs, what is often needed?
A. Additional basal insulin only
B. No insulin adjustment needed
C. Rapid-acting insulin before snack
D. Glucagon before snack

C. Rapid-acting insulin before snack

A 19-year-old with type 1 diabetes starts HIIT training. To prevent exercise-related hypoglycemia, advise checking glucose:
A. Before and after exercise
B. Only during exercise
C. Only after exercise
D. Only if symptomatic

A. Before and after exercise

For general lifestyle counseling, patients should strive for how much moderate exercise weekly?
A. 60 minutes weekly
B. 150 minutes weekly
C. 300 minutes weekly
D. 30 minutes monthly

B. 150 minutes weekly

A 26-year-old with oligomenorrhea and hirsutism has labs “consistent with PCOS.” The key lab features are:
A. Insulin resistance, hyperandrogenism
B. Hyperthyroidism, hypogonadism
C. Hyperprolactinemia, low cortisol
D. Hypoandrogenism, low insulin

A. Insulin resistance, hyperandrogenism

In PCOS, hyperandrogenism is mainly driven by which source, with another contributing?
A. Adrenals primary, ovary minor
B. Pituitary primary, ovary minor
C. Ovary primary, adrenals contribute
D. Liver primary, adrenals contribute

C. Ovary primary, adrenals contribute

A patient’s fasting plasma glucose is 128 mg/dL on screening. This is:
A. Normal fasting glucose
B. Impaired fasting glucose
C. Diabetes by fasting criteria
D. Reactive hypoglycemia

C. Diabetes by fasting criteria

A 75-g OGTT shows 2-hour plasma glucose 206 mg/dL. Best interpretation?
A. Diabetes by 2-hour value
B. Impaired glucose tolerance
C. Normal glucose tolerance
D. Indeterminate, repeat in a week

A. Diabetes by 2-hour value

A patient has polyuria and polydipsia. Random plasma glucose is 201 mg/dL. This indicates:
A. Prediabetes by random glucose
B. Normal random glucose
C. Requires fasting confirmation
D. Diabetes with classic symptoms

D. Diabetes with classic symptoms

A fasting plasma glucose of 110 mg/dL is best classified as:
A. Diabetes mellitus
B. Prediabetes (IFG)
C. Normal fasting glucose
D. Postprandial hyperglycemia

B. Prediabetes (IFG)

A 2-hour OGTT glucose of 180 mg/dL is best classified as:
A. Normal glucose tolerance
B. Diabetes mellitus
C. Prediabetes (IGT)
D. Laboratory artifact

C. Prediabetes (IGT)

An A1C of 6.1% is best classified as:
A. Prediabetes by A1C
B. Diabetes by A1C
C. Normal A1C
D. Hypoglycemia risk state

A. Prediabetes by A1C

A patient’s diabetes screen is normal. When should routine re-testing occur?
A. Every 6 months
B. Every 3 years
C. Every 10 years
D. Only if symptomatic

B. Every 3 years

Overweight youth should be screened if they have how many additional diabetes risk factors?
A. Two or more
B. One only
C. Three or more
D. None required

A. Two or more

For at-risk overweight youth, start screening at:
A. Age 5 regardless puberty
B. Age 18 only
C. Age 13 regardless puberty
D. Age 10 or puberty onset

D. Age 10 or puberty onset

Which set meets “overweight” criteria used for youth screening?
A. BMI ≥95th percentile only
B. BMI <50th percentile only
C. BMI≥85th, wt/ht≥85th, wt≥120%
D. Height <5th percentile only

C. BMI≥85th, wt/ht≥85th, wt≥120%

Which type 1 diabetes autoantibody targets tyrosine phosphatases?
A. GAD65 antibody
B. IA-2 / IA-2B
C. Insulin autoantibody
D. Islet cell antibody

B. IA-2 / IA-2B

Which list best matches circulating autoantibodies linked to beta-cell destruction in type 1 diabetes?
A. ANA, dsDNA, Smith
B. TPO, TRAb, Tg
C. RF, CCP, ANCA
D. ICA, IAA, GAD65, IA-2

D. ICA, IAA, GAD65, IA-2

Type 1 diabetes can be diagnosed at any age, but it occurs mostly:
A. Over age 65
B. Under age 30
C. Only in toddlers
D. Only after menopause

B. Under age 30

Peak type 1 incidence occurs between which ages in girls?
A. 5–7 years
B. 15–17 years
C. 10–12 years
D. 20–22 years

C. 10–12 years

Peak type 1 incidence occurs between which ages in boys?
A. 12–14 years
B. 6–8 years
C. 16–18 years
D. 22–24 years

A. 12–14 years

At type 1 diabetes diagnosis, approximately what fraction have ≥1 circulating autoantibody?
A. 10–20%
B. 30–40%
C. 50–60%
D. 85–90%

D. 85–90%

The HLA association in type 1 diabetes is most classically tied to:
A. HLA-A/B alleles
B. HLA-DR/DQ alleles
C. HLA-C alleles
D. HLA-E alleles

B. HLA-DR/DQ alleles

Within this HLA association, linkage is described to which genes?
A. HLA-A and HLA-B
B. HLA-C and HLA-E
C. DGA and DQB genes
D. DPB and DPC genes

C. DGA and DQB genes

This HLA association is also influenced by which gene?
A. DRB gene
B. HBB gene
C. INS gene
D. VHL gene

A. DRB gene

The type 1 “honeymoon phase” can last up to:
A. 6 months max
B. 2 years max
C. 4 years max
D. 8–10 years max

D. 8–10 years max

In type 2 diabetes, hyperglycemia does not manifest until what has occurred?
A. Alpha-cell hyperplasia predominates
B. Impaired beta-cell function present
C. Autoimmune beta-cell destruction occurs
D. Complete insulin absence develops

B. Impaired beta-cell function present

Insulin resistance in adipocytes increases circulating free fatty acids. Which change is expected?
A. Increased insulin secretion
B. Decreased hepatic glucose output
C. Increased insulin sensitivity
D. Decreased insulin secretion

D. Decreased insulin secretion

Elevated circulating free fatty acids contribute to fasting hyperglycemia primarily by:
A. Increasing hepatic glucose production
B. Increasing renal glucose reabsorption
C. Decreasing gastric emptying
D. Suppressing glucagon secretion

A. Increasing hepatic glucose production

Which combined triad best matches effects of elevated free fatty acids on insulin?
A. ↑ secretion, ↑ sensitivity, ↓ production
B. ↓ secretion, ↓ sensitivity, ↑ production
C. ↓ secretion, ↑ sensitivity, ↓ production
D. ↑ secretion, ↓ sensitivity, ↑ production

B. ↓ secretion, ↓ sensitivity, ↑ production

Multiple drugs reduced diabetes incidence in prevention trials. Which set matches those tested?
A. Metformin, acarbose, orlistat, rosiglitazone
B. Metformin, liraglutide, glipizide, insulin
C. Acarbose, sitagliptin, dapagliflozin, NPH
D. Orlistat, pramlintide, glargine, metoprolol

A. Metformin, acarbose, orlistat, rosiglitazone

ADA prevention pharmacotherapy is recommended for IGT/IFG or A1C:
A. 6.5–7.4%
B. 5.7–6.4%
C. 4.8–5.6%
D. 6.0–6.9%

B. 5.7–6.4%

Metformin prevention is also especially emphasized for:
A. Prior gestational diabetes
B. Prior nephrolithiasis
C. Prior asthma exacerbations
D. Prior hyperthyroidism

A. Prior gestational diabetes

Grain recommendation within prevention lifestyle guidance:
A. Avoid grains entirely
B. Whole grains ≥ half intake
C. Whole grains only at dinner
D. Whole grains < quarter intake

B. Whole grains ≥ half intake

Replacing saturated fats with which improves insulin resistance?
A. Trans fatty acids
B. Monounsaturated fats
C. Short-chain saturated fats
D. Dietary cholesterol

B. Monounsaturated fats

Another acceptable replacement for saturated fats is:
A. Polyunsaturated fats
B. Medium-chain triglycerides
C. Animal-based saturated fats
D. Hydrogenated oils

A. Polyunsaturated fats

Alcohol guidance in diabetes prevention is to limit to:
A. 3–4 drinks per day
B. 0 drinks always
C. 1–2 drinks per day
D. 1 drink per week

C. 1–2 drinks per day

A dietary pattern encouraged for prevention is:
A. Ketogenic pattern
B. Mediterranean-style pattern
C. Carnivore pattern
D. Very-low fiber pattern

B. Mediterranean-style pattern

Dietary cholesterol should be limited to:
A. <100 mg per day
B. <150 mg per day
C. <200 mg per day
D. <300 mg per day

C. <200 mg per day

Continuous glucose monitors primarily measure glucose in:
A. Interstitial fluid
B. Capillary blood
C. Venous plasma
D. Intracellular cytosol

A. Interstitial fluid

A stable patient meeting goals asks about A1C testing frequency. Minimum is:
A. Once yearly
B. Twice yearly
C. Quarterly
D. Monthly

B. Twice yearly

A patient with therapy changes is not meeting goals. A1C testing should be:
A. Every 6 months
B. Every 12 months
C. Four times per year
D. Every 2 years

C. Four times per year

Medical nutrition therapy (MNT) improves which metabolic outcomes?
A. Glucose, A1C, lipids, BP, weight
B. Only A1C and weight
C. Only triglycerides and HDL
D. Only blood pressure

A. Glucose, A1C, lipids, BP, weight

In diabetes, MNT is associated with A1C reductions of:
A. 0.1–0.3%
B. 0.3–0.7%
C. 1–2% average
D. 3–5% average

C. 1–2% average

Cardioprotective MNT implemented by RDs reduced which lipid marker 7–21%?
A. HDL-cholesterol
B. Total cholesterol
C. Lipoprotein(a)
D. Apolipoprotein B

B. Total cholesterol

At what timepoint should medication changes be assessed to meet targets?
A. At 1 week
B. At 1 month
C. At 3 months
D. At 12 months

C. At 3 months

Effective nutrition interventions include which set?
A. Reduced energy/fat, MNT, portion control
B. High sodium, low fiber, skipping meals
C. High saturated fat, low activity, fasting
D. Low fluid, high alcohol, low protein

A. Reduced energy/fat, MNT, portion control

A complementary effective set includes:
A. High glycemic meals, random snacks
B. Healthy choices and carb counting
C. Low sodium only, no carbs
D. Cholesterol loading, high fat

B. Healthy choices and carb counting

Metabolic improvements often require what weight loss range with activity and RD meetings?
A. 1–3% weight loss
B. 3–5% weight loss
C. 5–7% weight loss
D. 7–8.5% weight loss

D. 7–8.5% weight loss

Which group often consumes ~65–75% energy from carbohydrate with reported benefits?
A. Competitive powerlifters
B. Vegans or vegetarians
C. Carnivore dieters
D. Ketogenic dieters

B. Vegans or vegetarians

Observational studies in diabetes report A1C benefits from which pattern?
A. Lower carb, higher fat
B. Higher carb, lower fat
C. Higher protein, lower carb
D. Higher fat, higher carb

B. Higher carb, lower fat

As weight loss progresses in type 2 diabetes, patients may become more:
A. Insulin resistant than deficient
B. Insulin deficient than resistant
C. Glucagon deficient than resistant
D. Amylin resistant than deficient

B. Insulin deficient than resistant

This shift helps explain why some type 2 patients eventually need:
A. ACE inhibitors
B. Insulin injections
C. Antioxidant supplements
D. Glucagon injections

B. Insulin injections

A patient notices better control when meal carbs are consistent. This implies:
A. Carb-consistent diet improves sugars
B. Protein variability improves sugars
C. Fat cycling improves sugars
D. Sodium loading improves sugars

A. Carb-consistent diet improves sugars

After a protein-only meal, plasma glucose barely changes. Which immediate hormonal pattern is expected?
A. Insulin rises, glucagon falls
B. Glucagon rises, insulin falls
C. Neither insulin nor glucagon rises
D. Insulin and glucagon both rise

D. Insulin and glucagon both rise

Which amino acid category is a substrate for gluconeogenesis?
A. Nonessential amino acids
B. Essential amino acids
C. Branched-chain amino acids
D. Aromatic amino acids

A. Nonessential amino acids

In type 2 diabetes, which dietary component lowers total and LDL cholesterol?
A. Omega-3 fish oil capsules
B. Plant sterol/stanol esters
C. Dietary cholesterol supplements
D. Medium-chain triglyceride oil

B. Plant sterol/stanol esters

ADA-recommended bariatric surgery for type 2 diabetes is best captured by:
A. BMI 32, good medical control
B. BMI 35, no comorbidities
C. BMI 38, comorbidities hard to control
D. BMI 40, comorbidities easily controlled

C. BMI 38, comorbidities hard to control

A patient on glyburide plans to drink alcohol tonight. Best advice?
A. Avoid all alcohol permanently
B. Drink fasting to prevent spikes
C. Omit dinner to offset calories
D. Consume with food to reduce hypoglycemia

D. Consume with food to reduce hypoglycemia

Which statement about moderate alcohol intake is supported in these notes?
A. Increases CVD mortality substantially
B. Associated with lower CVD mortality
C. Eliminates hypoglycemia risk on insulin
D. Requires skipping meals to compensate

B. Associated with lower CVD mortality

A patient asks how to “count” alcohol in their meal plan. Best guidance?
A. Replace dinner carbs with alcohol
B. Skip meals to balance calories
C. Add to meal plan; omit none
D. Use alcohol as bedtime snack

C. Add to meal plan; omit none

Which basal insulin is typically dosed twice daily?
A. Glargine
B. Detemir
C. Degludec
D. NPH

D. NPH

For a simplified insulin regimen, which premixed insulin is usually prescribed for type 2 diabetes?
A. Humulin/Novolin 70/30
B. Lispro only regimen
C. Aspart correction
D. Glargine plus pramlintide

A. Humulin/Novolin 70/30

In insulin-treated patients, glucose 30–60 minutes after a meal is typically:
A. Near fasting nadir
B. Near postprandial peak
C. Unchanged from baseline
D. Below baseline typically

B. Near postprandial peak

In many patients, glucose about 2 hours after a meal is ideally:
A. Still rising sharply
B. At absolute minimum
C. Doubles above baseline
D. Returning toward baseline

D. Returning toward baseline

First-line pharmacotherapy for most type 2 diabetes is:
A. Exenatide monotherapy
B. Glyburide monotherapy
C. Metformin monotherapy
D. Canagliflozin monotherapy

C. Metformin monotherapy

Why do many type 2 diabetics benefit from combination therapy?
A. Avoid all lifestyle changes
B. Address different pathophysiologic defects
C. Eliminate need for monitoring
D. Guarantee insulin independence lifelong

B. Address different pathophysiologic defects

Over time, many type 2 diabetics require:
A. Insulin therapy, alone or combined
B. Lifelong diet alone
C. Only alpha-glucosidase inhibitors
D. Only GLP-1 agonists

A. Insulin therapy, alone or combined

A patient starts pramlintide for postmeal spikes. What is the key effect pair?
A. Increase glucagon; speed emptying
B. Increase insulin; speed emptying
C. Decrease glucagon; delay emptying
D. Block renal glucose reabsorption

C. Decrease glucagon; delay emptying

Acarbose lowers postprandial glycemia primarily by:
A. Enhance GLP-1 receptor signaling
B. Inhibit intestinal α-glucosidase enzyme
C. Increase renal glucose excretion
D. Activate PPAR-gamma in adipose

B. Inhibit intestinal α-glucosidase enzyme

Metformin lowers glucose mainly by:
A. Suppress hepatic glucose production
B. Stimulate pancreatic insulin secretion
C. Increase gastric emptying speed
D. Block intestinal fat absorption

A. Suppress hepatic glucose production

Which statement about metformin is true?
A. Promotes insulin secretion acutely
B. Acts as GLP-1 agonist
C. Blocks DPP-4 degradation
D. Does not stimulate insulin secretion

D. Does not stimulate insulin secretion

Sitagliptin works primarily by:
A. Block SGLT2 in proximal tubule
B. Inhibit DPP-4 degrading incretins
C. Directly open beta-cell KATP
D. Bind PPAR-gamma receptors

B. Inhibit DPP-4 degrading incretins

DPP-4 inhibition most directly causes:
A. Increase glucagon and insulin
B. Decrease insulin; increase glucagon
C. Glucose-dependent insulin rise; glucagon falls
D. Insulin rise independent of glucose

C. Glucose-dependent insulin rise; glucagon falls

GLP-1 receptor agonists typically:
A. Increase glucagon; speed emptying
B. Decrease insulin; increase appetite
C. Increase insulin always; hypoglycemia
D. Delay emptying; lower glucagon; raise insulin

D. Delay emptying; lower glucagon; raise insulin

Which hormone set directly stimulates gluconeogenesis?
A. Insulin, leptin, GLP-1
B. Thyroxine, calcitonin, PTH
C. Amylin, GIP, somatostatin
D. Cortisol, adrenaline, glucagon

D. Cortisol, adrenaline, glucagon

Which set correctly lists ketone bodies?
A. Lactate, pyruvate, alanine
B. Acetoacetate, acetone, beta-hydroxybutyrate
C. Citrate, succinate, fumarate
D. Glucose, glycogen, galactose

B. Acetoacetate, acetone, beta-hydroxybutyrate

Ketone bodies in insulin absence derive primarily from:
A. Oxaloacetate from glycolysis
B. Glucose-6-phosphate from glycogen
C. Malonyl-CoA from lipogenesis
D. Acetyl-CoA from FFA oxidation

D. Acetyl-CoA from FFA oxidation

At type 1 diabetes diagnosis, an initial total daily insulin dose is about:
A. 0.1–0.2 units/kg/day
B. 1.0–1.2 units/kg/day
C. 0.5–0.6 units/kg/day
D. 2.0–3.0 units/kg/day

C. 0.5–0.6 units/kg/day

Initial total daily insulin is typically divided as:
A. All basal, no bolus
B. Mostly bolus, minimal basal
C. One-third basal, two-thirds bolus
D. Half basal, half bolus

C. One-third basal, two-thirds bolus

Alcohol should be consumed with food to reduce hypoglycemia risk in:
A. Patients on metformin only
B. Patients on ACE inhibitors
C. Insulin or secretagogue users
D. Patients on SGLT2 inhibitors

C. Insulin or secretagogue users

During physiologic stress, which hormone directly stimulates gluconeogenesis?
A. Insulin
B. Leptin
C. Amylin
D. Glucagon

D. Glucagon