CDCES Study Guide Questions with Complete Solutions, Exams of Advanced Education

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CDCES Study Guide Questions with

Complete Solutions

DSMES definition - Correct Answer-ongoing process of facilitating knowledge, skills, and ability necessary for prediabetes and diabetes self-care. Incorporates the needs, goals, and life experiences of PWD and is guided by evidence based standards. support informed decision-making, self-care behaviors, and problem solving 7 ADCES self-care behaviors - Correct Answer--healthy coping -taking medications -healthy eating -being active -monitoring -problem solving -reducing risks DSMES services - Correct Answer--develop 10 standards in order to apply for accreditation and recognition -needs to be accredited and recognized in order to receive reimbursement -need to have another Part B billing service with Medicare as part of requirements DSMES objectives - Correct Answer--Informed decision making -Self-care behaviors -Problem solving -Active collaboration with the healthcare team to improve clinical outcomes, health status, and quality of life 10 standards of DSMES - Correct Answer-1. Internal structure

2. Stakeholder Input
3. Evaluation of Population Served
4. Quality Coordinator Overseeing DSMES services
5. DSMES Team
6. Curriculum
7. Individualization
8. On-going support
9. Patient Progress
10. Quality Improvement topics in curriculum - Correct Answer--disease process -treatment options -physical activity -medications -monitoring

-preventing, detecting, and treating acute complications -preventing, detecting, and treating chronic complications -strategies for psychosocial issues and concerns -navigating healthcare system, learning self-advocacy, and e-health education patient generated health data standards of practice for diabetic educators - Correct Answer--Provide assessable, safe environment -Use pt specific, appropriate teaching materials -Structure DSME program from survival to advanced self-management -Address self-monitoring skills -Adjust to stress, age, psychological, etc changes with pt -Provide peer support opportunities -Integrates DMSE plan into overall plan of care -Establish follow-up and appropriate referrals teaching methods - Correct Answer--adult learning techniques -participatory, NOT didactic -storytelling and shared experiences -problem solving -role playing Medicare benefits - Correct Answer--10 hours of DSMES during initial year, 1 hour as 1- on-1 and the other 9 in group settings -3 hours of MNT during initial year with an RD -2 hours yearly after first year to follow up on goals and needs -2 hours of MNT with RD after first year 5 step process for DSMES - Correct Answer-1. assessment

2. goal setting
3. planning
4. implementation
5. evaluation and monitoring Diabetes Control and Complications Trial (DCCT) - Correct Answer--intense treatment for people with Type 1 -showed 60% reduction in micro-vascular complications if mean A1c was 7% compared to 9% in standard treatment group United Kingdom Prospective Diabetes Study (UKPDS) - Correct Answer--studied newly dx T2D for 10 years -A1c range kept at median of 7% -microvascular complications significantly reduced -can help reduce cardiac and stroke complications

Action to Control Cardiovascular Risk in Diabetes (ACCORD) - Correct Answer--study looked at how intensive glycemic management related to CVD complications -A1c <6% resulted in increased mortality -discontinued the strict glycemic management part of study goal setting - Correct Answer-Specific Measurable Achievable Realistic Time-bound measurable health outcomes - Correct Answer-clinical outcomes educational outcomes QOL behavioral outcomes cost-effective when to refer to DSMES - Correct Answer--at diagnosis -annual assessment of education, nutrition, and emotional needs -when new complicating factors influence self-management -when transitions in care occur Empowerment Approach - Correct Answer-promotes active participation in one's care, provided they have the information to make informed decisions instructional team for certified diabetes center - Correct Answer-primary educator must be an RD, RN, pharmacist, and/or a CDE diabetes diagnostic criteria - Correct Answer--fasting plasma glucose >= 126 mg/dL on 2 separate occasions OR -symptoms of hyperglycemia and casual plasma glucose of >= 200 mg/dL -2 hour plasma glucose >= 200 mg/dL when not to look at A1c - Correct Answer-sickle cell disease, pregnancy (second and third trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, or erythropoietin therapy normal triglyceride range - Correct Answer-below 150 mg/dL LDL range - Correct Answer-100 mg/dL or under HDL range - Correct Answer-above 40 mg/dL total cholesterol range - Correct Answer-under 200 mg/dL

assessment for DSMES - Correct Answer--lifestyle issues and factors -promote self-disclosure of concerns -identify special needs or barriers of ADLs -respect cultural differences -health disparity barriers -uncover priorities of medical need medical history - Correct Answer--personal and family health history -nutrition habits and practices -physical therapy -meds - OTC, herbal, and Rx -history of substance abuse -mobility and dexterity issues -food insecurity and basic needs psychosocial history - Correct Answer--previous education and knowledge of self- behavior skills -barriers to learning - vision, literacy, hearing, cognitive -behavioral health -family support -financial and occupational concerns components of education plan - Correct Answer--learning objective: what should be achieved by end of session -content: info to help make positive behavior change -teaching strategies: how to demonstrate the info -evaluation of education plan lifespan and behavior changes - Correct Answer--readiness to learn and make changes depend on person's age and maturity -make sure goals are age specific -involve support system learning objectives - Correct Answer-what the participant will achieve at the end of a specific educational session. point in time. knowledge measurement behavioral objectives - Correct Answer--measurable change in specific behavior that is achieved during a specific period in time -takes time cultural awareness - Correct Answer-ability to recognize personal prejudice and biases towards other cultures and understand own personal cultural/ethnic background cultural humility - Correct Answer--commit to on-going self evaluation and self discipline -be willing to address power imbalance in patient/provider relationship

-develop mutually beneficial relationships with communities and organizations on behalf of a defined population cultural knowledge - Correct Answer--develop educational foundation that incorporates various world views of different cultures -integrate knowledge regarding biological variations, disease, and health conditions and variations in drug metabolism cultural skill - Correct Answer--collect culturally relevant data regarding presenting problem and health history -culturally based physical assessment in culturally sensitive manner cultural desire - Correct Answer--commit to engage in process of cultural competency -demonstrate compassion, humility, openness -provide care regardless of conflict standards of practice for DSMES - Correct Answer-1. provide accessible and safe environment

2. facilitate DSMES to progress from basic and survival skills to more in-depth self- management skill development
3. address basics in DM management
4. provide increasingly advanced DSMES based on needs and goals
5. opportunities for peer support
6. integrate DSMES into overall plan of care
7. share DSMES educational plan and progress with referring provider
8. establish follow up
9. provide group format when possible formative evaluation - Correct Answer--make adjustments to program as needed -ongoing component of assessment, planning, implementation summative evaluation - Correct Answer--determines effects of teaching -what happened health belief model - Correct Answer--importance of individual's perception of risk factors, likelihood of making behavior changes -more serious or higher the risk, more likely person will make preventative behavior change -perceived susceptibility, severity, benefits, barriers -self efficacy -cues to action social cognitive theory - Correct Answer--people learn not only from their personal experience but also from observation of other's behaviors/consequences -uses psychosocial elements and behavioral change methods -help identify how they can make positive changes

theory of reasoned action/planned behavior - Correct Answer--individual behavior is based on attitudes and beliefs of targeted behavior -affected by how others in their community think about the targeted behavior -dependent on skills and knowledge person has to perform the targeted behavior change transtheoretical model - Correct Answer--6 stages of readiness to make behavioral change

1. pre-contemplation (not aware of problem and no intent to change)
2. contemplation (aware of problem, thinking about a change)
3. preparation (making plans)
4. action (engages in behavioral change)
5. maintenance (positive, long term change)
6. relapse (need to focus on previous success) empowerment model - Correct Answer--identify problem -identify concerns/feelings -identify long term goals -identify short term goals -implement and evaluate plan family concerns - Correct Answer--stress and coping -guilt -problem solving -medication issues -financial issues -nutrition (food deserts, shopping) -QOL -social interactoins -trust with caregivers and providers concerns with kids - Correct Answer--coping with stress and burden of care -establishing schedules and limits -depression, eating disorders, risky behaviors -family conflicts -growth and development concerns -emotional disturbances -needle anxiety -chaotic family environment parents and teens - Correct Answer-need to have good role models and get encouragement/praise. parent needs to help with transportation to events, promoting healthy lifestyles, advocating for proper health care adult support system concerns - Correct Answer--weaker system or no support

-less motivated to make self-care changes -if support downgrades the importance of self management, person is less motivated to make changes -need to look at positive and negative supports depression screenings - Correct Answer--symptoms are very similar to poor glycemic management -depression risk 2x higher than general population -can impair personal, social, and occupational functioning -affects self care!!! -symptoms: sadness, lack of pleasure, guilt, worthlessness, hopelessness, low energy, poor nutrition, difficult decision making, labile glucose patterns, change in weight diabetes distress - Correct Answer--ability to adapt to diabetes and daily social demands -how often the struggle is interfering with your daily needs, routine, mood DAWN 1 & 2 - Correct Answer--assessed how common diabetes distress is -most often diabetes distress is not addressed in plan of care -discovery: need to assess diabetes related family conflicts and support systems Medicare - Correct Answer--Part A: inpatient hospital services -Part B: outpatient and home health services -Part C: managed care -Part D: pharmacy/drug insurance each state regulates its own program, so can have different benefits and qualifications for children, pregnant women, uninsured with significant medical issues, disabled Medicare Managed Care - Correct Answer--referred to Medicare C -parts A and B, but when a carrier takes over management -should offer same benefits as A and B do fee for service - Correct Answer--provider bills insurance after services have been provided -insured person pays monthly premium and deductible medical necessity - Correct Answer-if person needs coverage, supplies, meds and they aren't covered under current policy criteria, provider can fill out documentation to justify the additional coverage is needed type 1 diabetes - Correct Answer--autoimmune destruction of beta cells in pancreas -absolute deficiency of endogenous insulin -lower in adults, rapid in children -low C peptide levels -prone to other autoimmune issues

-GAD antibody is best immunologic predictor of this honeymoon period - Correct Answer-glucose control appears normal but beta cell destruction continues type 2 diabetes - Correct Answer--insulin resistance and relative insulin deficiency -exogenous insulin not needed for immediate survival -abdominal body fat increases risk -develops gradually, often asymptomatic -significant genetic predisposition testing for GDM - Correct Answer-screen for this between 24-28 weeks gestation pre diabetes - Correct Answer--glucose levels are above normal but not yet in range to be classified as full diabetes -risk factors: increased abdominal fat, dyslipidemia, HTN -make lifestyle changes to delay onset fuel metabolism - Correct Answer--insulin and amylin help regulate glucose levels -insulin transports insulin in the blood, inhibits production of glucose from liver, inhibits glucagon release from alpha cells -amylin inhibits glucose secretion, inhibits glucose in blood by slowing gastric emptying fasting state - Correct Answer--blood sugars maintained by liver -body not provided energy = liver releases glucgon fed state - Correct Answer--carbs are eaten -fuel metabolism is started -insulin takes action, glucagon is low post-absorptive state - Correct Answer--4-16 hours after carbs eaten -insulin levels decrease -glucagon increases -blood sugar maintained by hepatic resources pre diabetes diagnosis criteria - Correct Answer--fasting blood sugar between 100- -blood glucose between 140-199 2 hours OGTT -A1c 5.7-6.4% weight loss goals - Correct Answer--5-7% decrease in weight can positively affect BP, glucose control, A1c, lipids, energy, improve attitude -approach goals in achievable baby steps and then focus on maintenance -small and stable is better than large and fast -consistent CHO intake and increase activity -bariatric surgery if BMI >= 35

CGM time in range goals - Correct Answer--in range >= 70% in 14 days -below range <4% and severe low <1% in 14 days -above range <25% for 181-250 and <5% for over 250 in 14 days diet issues to address - Correct Answer--portion control -food labels -meal planning -shopping -cooking -food insecurity -modifying recipes -eating out -sick day management general goals for diabetes - Correct Answer--A1c 7-8% (individualized) -BP <140/ -LDL <100 mg/dL -HDL >40-50 mg/dL (men-women) -achieve/maintain body weight goals -prevent or delay complications medical nutrition therapy - Correct Answer--specific nutrition diagnosis therapy and counseling for purposes of disease management -only RD or RDN can bill for this!!! MNT goals - Correct Answer--achieve and maintain glycemic control -reduce CVD risk by improving lipid panel -maintain BP goals -prevent long term complications -individualize needs based on personal, cultural, and willingness to make changes -integrate meal plan with insulin regimen -maintain eating as pleasure activity -meet lifestyle needs -address food insecurity type 1 nutrition goals - Correct Answer--integrate insulin therapy into eating and physical activity routine -those with fixed insulin regime should focus on consistency in eating routine and carb intake -carb counting and meal planning -sick day guidance -rescue for lows type 2 nutrition needs - Correct Answer--moderate 5-7% weight loss -150 minutes of moderate activity each week -reduce fat and calories in diet

-14gm/1000 calories of dietary fiber daily, half from whole grains kids/teens nutrition needs - Correct Answer--involve them with food planning and shopping -involve with food prep -need to involve entire family -adjust to meet nutritional needs for growth and activity -focus on nutrient dense foods type 2 in kids and teens goals/interventions - Correct Answer--promote 60 minutes per day of physical activity -limit non-academic screen time to less than 2 hours daily -cessation of excessive weight gain -get to near normal fasting glucose levels and A1c macronutrients - Correct Answer--carbohydrates, proteins, and fats -carbs affect blood glucose levels -protein and fat support body but do not raise glucose -no specific percentages to aim for -individualize needs micronutrients - Correct Answer--vitamins, minerals, water -no research for specific supplements identified -multi vitamin and healthy diet usually meets nutritional needs -elderly, strict vegetarians, calorie restricted diets, post bariatric surgery, pregnant women may need supplementation glycemic index - Correct Answer--estimates the post meal impact for cabs -ranks foods on scale of 1-100 over a 2 hour period -high GI = more rapidly digest and absorb into blood stream -low GI = slower to digest and gradually absorb into blood stream -balance high and low index glycemic load - Correct Answer--looks at quantity of food and GI value of food GL = GI x grams CHO where are carbs found? - Correct Answer-fruit, veggies, grains, starches, milk, milk substitutes dietary fats - Correct Answer--<7% should come from saturated fats (animal fats, coconut, palm oil, vegetable oils) -<10% polyunsaturated fats (corn oil, sunflower oils, walnuts) -monounsaturated fats are most beneficial (nuts, canola, olive, peanut oils) -daily cholesterol <300 mg/day (egg yolks, organs, dairy fat)

look AHEAD study - Correct Answer--looked at effectiveness of intentional weight loss interventions in reducing rates of heart disease, stroke, CVD in overweight and obese T2D -stopped early due to significant improvements with intensive intervention meds that cause weight gain - Correct Answer--sulfonylureas -TZDs -meglitinides -insulin meds that are weight neutral - Correct Answer--metformin -DPP- -alpha glucosidase -canagliflozin meds that cause weight loss - Correct Answer--GLP- -pramlintide diabetes & pregnancy goals - Correct Answer--achieve normal glycemic levels -prevent ketosis -tight glycemic control reduces risk for complications -weight loss not recommended -find good ratio of food intake to glycemic control weight gain recommendations during pregnancy - Correct Answer-Under weight (BMI <18): 28-40lbs Normal Weight (BMI 18.6-24.9): 25-35lbs Overweight (BMI 25-29.9): 15-25lbs Obese (BMI > 30): 11-20lbs preconception counseling for diabetics - Correct Answer--achieve euglycemia before and during pregnancy -delay conception until A1c <7% -refer for retinal, renal, neuro, PVD checks -thyroid studies important insulin and pregnancy - Correct Answer--rapid acting insulins have better results than short acting -goal is to get to normal levels -long acting insulin used for basal coverage -want 3-4 injections per day -total dose based on glucose readings, gestational age, calorie intake gastroparesis - Correct Answer--autonomic neuropathy that delays gastric emptying -risk for erratic glucose patterns -difficulty with absorption of nutrients

-more liquids than solids are helpful -basal bolus regimen recommended -small frequent meals are better than large meals -decrease fiber in diet -sit upright for 1-2 hours post meal food insecurity - Correct Answer--unreliable availability of nutritious foods and the inability to consistently obtain food without resorting to socially unacceptable practices -risk for hypoglycemia higher -avoid meds with hypoglycemic risk overall goals of MNT - Correct Answer--decrease risk of diabetes and CVD by intensive lifstyle modification -healthy food choices, increase physical activity, moderate and maintained weight loss -achieve and maintain ideal body weight -emphasize variety of nutrient dense foods and appropriate portions nutrition in T1D - Correct Answer--primary goal is to integrate insulin therapy into eating routines and physical activity pattern -if on fixed regimen: consistency in timing and amount of carbs -if on MDI or pump: focus on carb counting and meal planning -avoid excessive hypoglycemia nutrition in T2D - Correct Answer--emphasize healthy eating behaviors that result in reduction of energy, saturated and trans fats, cholesterol and sodium -increase physical activity -weight loss through focusing on behaviors that can be changed nutrition in pregnancy and lactation - Correct Answer--minimize blood sugar excursions -provide calorie intake that isn't excessive but will achieve appropriate weight gain without ketosis -safe nutrients for fetal health -focus on stability before conception -hypoglycemia common in first trimester -insulin needs increase in 2nd and 3rd trimester nutrition in kids/teens - Correct Answer--involve whole family and meet developmental needs of child -need enough caloric intake for normal growth and development -focus on intake of nutrient dense food -avoid the word diet, stick to meal plan -encourage kid to help with grocery shopping and meal prep nutrition in older adults - Correct Answer--incorporate cultural foods -meet calorie and nutrient needs -emphasis on protein

-take into account taste preferences, lifelong eating habits, financial constraints, food prep abilities problem solving - Correct Answer--learned behavior that includes generating a set of potential strategies for problem resolution, selecting the most appropriate strategy and evaluating the effectiveness of the strategy -most difficult to teach; they're also the most difficult to learn -One of the AADE 7, but can be applied to all of the other 6 behaviors -3 Components: pt is goal directed., reaching a solution or goal requires a sequence of mental processes, mental processes involved are cognitive rather than automatic -complex mental process evolve through education, training and/or experiential learning rather than occurring spontaneously theoretical model of problem solving - Correct Answer--identifying the problem -generating alternative solutions -selecting, implementing, and evaluating a solution problem solving skills - Correct Answer--approach to dealing with problems and includes effective and ineffective approaches -effective: rational, logic -ineffective: impulsive, careless, avoidant problem solving orientation - Correct Answer--reflects emotional and attitudinal cognitive sets towards dealing with DM related problems or barriers -positive: effective for self management -negative: ineffective for self management transfer of past learning experiences (problem solving) - Correct Answer--problem solving leads to new learning because working through a problem creates potential for acquiring new knowledge or experience -effective: learns from experience and applies knowledge to new problem -ineffective: does not learn from the past or does not transfer knowledge direct instruction - Correct Answer--specific directions for patients to follow -Used when there is a specific course of action to follow and to consider alternatives would be too great of a risk for the pt recommended for: -Problem is well defined and straightforward -Problem has a single best strategy for resolution -Problem has known specific course of action that pt with diabetes should take for the problem resolution use of trial and error could be detrimental or life threatening levels of problems - Correct Answer-Level 1: clinical markers and emergencies (suboptimal BG control, acute complications, ER visits)

Level 2: problematic self-management behaviors (unhealthy diet, sedentary lifestyle, med non-compliance) Level 3: problems impacting self-management (lack of skills/knowledge, personal issues, intrapersonal issues) types of barriers to self management - Correct Answer--Emotional well-being and depression -Social pressures for children and adolescents -Financial barriers for middle and older adults -Socioeconomic, language, and knowledge barriers for minorities barrier categories - Correct Answer--Personal- includes depression, physical disabilities, poor coping skills, and inaccurate health beliefs -Interpersonal- includes family conflict and lack of rapport with diabetes educators -Environment- includes financial constraints, job- related issues and other competing priorities measurement tools for identifying problems - Correct Answer--some require a fee and may not be available to all educators -PAID questionnaire -used to facilitate discussion -can be limiting clinical problem solving by educator - Correct Answer-problem solving used as a clinical skill to assist in identifying/ diagnosing a problem, planning a course of action or treatment for the individual, and evaluating effectiveness (ie medications adjustments, managing pt during illness) patient as observer or partial contributor to problem solving by educator - Correct Answer--pt may provide input but educator carries the active role of the main problem solver Steps:

1. Identify problem 2.educator generates solutions which pt is encouraged to try -Used when pt is not able/does not assume autonomous role in decision making. patient and professional as collaborative team (problem solving) - Correct Answer- preferred approach after initial education preferred in helping pts to feel engaged in their treatment; equalizing power and joining in a common direction patient as problem solver facilitated by diabetes educator - Correct Answer-pt is the problem solver. Educator guides pt through pt centered questions and responses using a problem solving process to allow pt to come up with their own solution

planning for problem solving training/intervention - Correct Answer--assess pt's needs and assets (knowledge, skills, beliefs) -understand pt's problem solving skills to design problem solving training and to select intervention techniques problem solving assessment strategies/measures - Correct Answer--interviewing assesses pt's intervention needs as well as formal measures, which have the advantage of standardizing the problem solving assessment and quantifying pt's problem solving ability 2 measures can be used in evaluating educator's program: -Diabetes Specific Measures- can be administered in interviews, questionnaires, multiple choice or open ended questions, and address different diabetes specific knowledge based problem solving, specific problem solving style or ability -Broader Measures: generic measures have been used in diabetes research and show that generic problem solving measures may be somewhat less sensitive to diabetes outcomes than diabetes specific measures diabetes specific problem solving training - Correct Answer-visual media, computer based education, discussion groups, DSME classes, diabetes summer camps, PCP offices; some focus on problem solving intervention approach, others focus on problem solving skills training or problem resolution as the core intervention problem solving in group setting - Correct Answer--conduct basic needs assessment of all participants (assessment tool, etc.) -educator may have opportunity to model the problem solving approach and teach the group in the process -establish rapport with group to assist w/ effectively facilitating discussion -can help with empowerment factors influencing problem solving - Correct Answer--cognitive impairment - dementia, psych disorders, autism, etc. -age: childhood, older adults -education level -ethnicity -urgent situations healthy literacy and education - Correct Answer--Pts must learn DSM via a method that allows them to retain the content and apply it in practice. -Patient- focused methodology allows pts to interpret the content and information in their own way -Allows pts to internalize info and come up with their own strategies to implement solutions or self- care -education is about retention and application of info

educator vs facilitator - Correct Answer--educator: teaches patients info that they need to know in order to manage diabetes -facilitator: assists in making learning process easier, navigates teaching process and focuses on patients agendas what can patients teach us? - Correct Answer--"non-compliant" - pt is aware they were unable to implement or do what they should be doing -counterproductive for educator to keep teaching same materials/info that is not working for pt -ask questions to see what patient and family is willing to do to succeed with task/challenge A1c testing guidelines (ADA) - Correct Answer--test twice yearly in patients meeting glycemic targets -test quarterly on patients on insulin with recent therapy changes and patients not meeting glycemic targets DASH diet emphasis - Correct Answer--emphasis on fruits, veggies, low-fat dairy, whole grains, poultry, fish, nuts -reduce saturated fats, sweets, and sugary drinks -following this diet and decreasing sodium intake is more effective in lowering BP than sodium reduction alone ways to improve LDL - Correct Answer-weight loss, sub mono and polyunsaturated fats for saturated fats, consume omega-3 fatty acids vegans at risk for what deficiency? - Correct Answer-Vitamin B -B12 found in meat, poultry, fish, diary products, fortified cereals, nondairy milks, soy protein, and some margarines fiber recommendation (ADA) - Correct Answer-14g per 1,000 kcal daily for men and women fiber intake level for improving glycemic stability - Correct Answer->50g daily metabolic syndrome diagnosis - Correct Answer-3 of the 5:

1. large waist circumference (>35in females, >40in males)
2. fasting triglycerides >150mg/dL
3. Low HDL (<50mg/dL women, <40mg/dL men)
4. fasting glucose >
5. BP >135/85 or on treatment increasing omega-3 intake - Correct Answer-2 or more servings of fatty fish per week (salmon, mackerel, herring)

Mediterranean Diet focus - Correct Answer--moderate alcohol consumption -increase consumption of legumes, fruits, veggies, non-refined cereal -low consumption of meat and meat products -moderate consumption of milk and dairy epidemic - Correct Answer-disease that affects a defined group of people in a specific geographical location simultaneously pandemic - Correct Answer-Extremely widespread or globally occurring disease that affects many populations simultaneously chronic care model - Correct Answer-provides ideal framework to support DSME because it provides a cogent basis on which to promote self-management based on AADE 7 essential elements of healthcare system that encourage high quality chronic disease care - Correct Answer--Community -The health system -Self-management support -Delivery system design -Decision support and clinical information systems DSME training/provider levels - Correct Answer--Level 1: Non-healthcare workers, do not have clinical background -Level 2: Health care professionals, non-diabetes educators -Level 3: Non-credentialed DM Educator -Level 4: CDE -Level 5: Board certified- advanced diabetes management