This chapter is the heart of the book and the heart of the examination. Domain II-C covers person-centered education across the full ADCES7 Self-Care Behaviors framework: healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem solving[1, 2]. Nearly four in ten scored questions live here, so study this chapter twice.
Healthy coping
Diabetes is a 24-hour self-management job with no vacations, and the psychological toll is measurable: diabetes distress — the emotional burden of living with and managing diabetes, distinct from depression[3] — is linked to elevated A1C and less optimal self-care[3]. Teach coping as a skill, not a pep talk: normalizing the burden, problem-solving around specific frustrations, setting boundaries with "diabetes police" family members, and recognizing when distress crosses into depression requiring referral. Diabetes distress and depression are distinct — distress is content-specific (about diabetes), depression is pervasive — but both deserve screening and both change the plan. Never psychologize away a skills gap: a patient who "doesn't care" may simply never have been taught.
Healthy eating
Nutrition education starts from the ADA's anchor: there is no ideal macronutrient distribution; it follows individualized assessment of eating patterns, preferences, and metabolic goals[4]. Teach what the evidence supports: emphasize minimally processed, nutrient-dense, high-fiber carbohydrate sources, at least 14 g of fiber per 1,000 kcal[5]; replace sugar-sweetened beverages with water or low- or no-calorie drinks[6], with water promoted as the healthiest option[7]. Multiple eating patterns can work — Mediterranean, DASH, low-fat, carbohydrate-restricted, vegetarian, vegan — selected by patient preference and metabolic goals, not by ideology[3].
Practical skills beat theory: reading nutrition labels, estimating portions, meal planning at the patient's level — the plate method is a simple visual tool[3], carbohydrate counting is a more advanced skill[8], and approaches should match numeracy and food literacy[3] — plus timing meals with medications and managing eating away from home. Alcohol counseling matters: alcohol can cause hypoglycemia and delayed hypoglycemia, particularly with insulin or secretagogues[3], so patients learn to monitor glucose after drinking[9].
Being active
Teach the targets from Chapter 2's assessment table: 150+ minutes/week of moderate-to-vigorous aerobic activity over at least 3 days with no more than 2 consecutive days off, plus 2–3 weekly resistance sessions on nonconsecutive days[10, 11]. Then teach the safety skills: glucose monitoring around exercise, carbohydrate or dose adjustment, and above all hypoglycemia prevention — with insulin or secretagogues, activity can cause hypoglycemia if medication or carbohydrate is not adjusted[12], and lows can occur and last for hours afterward[13]. Assess conditions that may contraindicate certain exercise, such as untreated proliferative retinopathy, peripheral or autonomic neuropathy, and a history of foot ulcers[3]. Start low, go slow, and build from the patient's current baseline — the sedentary patient walks 10 minutes, not 150.
Taking medication
Medication education covers what each drug does, when and how to take it, what to do when a dose is missed, storage, side effects, and interactions — including the complementary and alternative products assessed in Chapter 2. For insulin users, teach injection technique — subcutaneous, not intramuscular[14], with site rotation to avoid lipohypertrophy[15] — plus timing relative to meals, dose adjustment principles per the prescriber's plan, and sick-day rules. Teach the signature counseling points from Chapter 4: SGLT2 inhibitor sick-day holds, GLP-1 RA nausea expectations, sulfonylurea hypoglycemia risk with missed meals, metformin GI tolerance strategies.
Adherence is a design problem, not a character flaw. Treatment decisions must weigh regimen complexity, the person's capacity, and cost[15], and simplifying an insulin plan to match self-management abilities reduces hypoglycemia and distress without worsening glycemia[16]. Align dosing with daily routines, address cost barriers directly, and confirm understanding with teach-back[17]. Never shame nonadherence — assess its reasons.
Monitoring
Teach monitoring as decision-making, not data collection. For blood glucose monitoring: timing (fasting, pre/post-meal, bedtime, symptomatic), technique, meter quality (FDA-approved meters, unexpired strips from licensed sources[18]), and — critically — what each result means for action. For CGM: wearing the sensor consistently, interpreting trend arrows, setting alerts, and using the data for therapy adjustment with the care team[19]. Confirm every CGM user has backup blood glucose monitoring available at all times[20].
Teach the glucose targets that give numbers meaning (ADA Standards of Care 2026, Section 6): premeal 80–130 mg/dL[21] and peak postmeal <180 mg/dL, measured 1–2 hours after the start of the meal[22, 23], for many nonpregnant adults; for CGM users, time in range >70%[24] with time below 70 mg/dL <4%[25]. Teach ketone checking in the presence of symptoms and precipitating factors, especially when glucose exceeds 200 mg/dL[26]. And teach the hypoglycemia levels in Appendix C1, because a patient who can name level 2 can act on it.
Reducing risk
Risk-reduction education prevents the complications that bring patients to the emergency department and the dialysis unit. Foot care: daily inspection[27], not walking barefoot or in open-toed shoes[27], prompt reporting of blisters or calluses — with referral to a foot care specialist for those at moderate or high risk[27]. Eye and kidney screening: dilated eye exams on the schedules in Appendix C[28] and at least annual UACR/eGFR[29]. Vaccinations: annual influenza (not the live attenuated form)[30], plus other routinely recommended immunizations[31]. Smoking: ask at every visit — smoking raises macrovascular and microvascular risk and premature death[32].
Cardiovascular risk reduction deserves emphasis because ASCVD is the leading cause of morbidity and mortality in people with diabetes[33]. Teach blood pressure awareness (on-treatment goal <130/80 mmHg when safely attainable, ADA 2026 rec 10.4[34]), statin use (moderate intensity for ages 40–75 without ASCVD[35]), aspirin only per clinician recommendation[36], and the protective role of the SGLT2 inhibitors and GLP-1 receptor agonists covered in Chapter 4.
Problem solving
Problem solving is the meta-skill: what the patient does when the plan meets reality. Teach structured approaches to the predictable problems: sick days (continue insulin and pills as usual, test every 4 hours, drink fluids, call if ketones are present[37] — with the clinician deciding whether to hold metformin or an SGLT2 inhibitor when intake fails[38]), hypoglycemia (15 g of glucose, recheck in 15 minutes[39], glucagon use by family[40]), hyperglycemia patterns (looking for causes before changing doses), travel (supplies in a carry-on, time-zone plans[41]), and special situations (steroid courses[38], surgery, fasting). The examination tests problem solving with "what should the patient do first" scenarios — the answer is almost always the safety step, not the optimization step.
Key numbers & deadlines
| Figure | Value | Source |
|---|---|---|
| Premeal glucose goal (ADA 2026, §6) | 80–130 mg/dL (many nonpregnant adults) | [21] |
| Peak postmeal goal (ADA 2026, §6) | <180 mg/dL, 1–2 h after meal start | [22, 23] |
| CGM time in range / below range (ADA 2026, §6) | >70% at 70–180 mg/dL; <4% below 70 mg/dL | [24, 25] |
| Aerobic activity | ≥150 min/week, ≥3 days, no >2 consecutive days off | [10] |
| Resistance exercise | 2–3 sessions/week, nonconsecutive days | [11] |
| Ketone check | Symptoms/precipitants, especially glucose >200 mg/dL | [26] |
| CGM backup | Blood glucose monitoring available at all times | [20] |
| Sugar-sweetened beverages | Replace with water or low-/no-calorie drinks | [6] |
| Fiber | At least 14 g per 1,000 kcal | [5] |
| Hypoglycemia treatment | 15 g glucose; repeat after 15 min if still low | [38, 39] |
| Influenza vaccine | Annual; avoid live attenuated form | [30] |
Key takeaways
- The ADCES7 framework organizes everything: coping, eating, activity, medication, monitoring, risk reduction, problem solving[1].
- Nutrition is individualized — no ideal macro distribution; fiber-rich carbs, water over sugary drinks[4, 6].
- Exercise needs safety teaching: hypoglycemia prevention including delayed onset, foot and eye precautions.
- Monitoring education is about decisions, not data: ADA 2026 goals of 80–130 premeal and <180 postmeal[21, 22].
- Problem solving means safety first: sick days, the 15-15 rule, travel, steroids.
Chapter 6 quiz — 25 questions
Answer each question, then check the key that follows.
1. A patient says diabetes "never takes a day off" and feels overwhelmed by the constant demands. Which ADCES7 behavior does this concern belong to?
- A. Healthy eating patterns
- B. Taking prescribed medication
- C. Healthy coping strategies
- D. Being physically active
2. Which statement about diabetes distress is correct?
- A. It is the same condition as major depressive disorder exactly
- B. The emotional burden of self-management, linked to A1C
- C. It never affects glycemic control at all
- D. It occurs only in patients with type 1 diabetes
3. A patient asks what proportion of calories should come from carbohydrates. What is the evidence-based answer?
- A. Exactly 50% for every single patient seen
- B. Zero percent — eliminate all carbohydrates completely now
- C. A fixed 80% for all patients with diabetes always
- D. No ideal distribution exists; individualize the carbohydrate share
4. Which beverage guidance is correct for a patient with diabetes?
- A. Swap sugar-sweetened drinks for water, the healthiest choice
- B. Sugar-sweetened beverages are fine in moderation every day
- C. Fruit juice is equivalent to water
- D. Soda is the best treatment for hyperglycemia
5. A sedentary patient with type 2 diabetes asks how to start exercising safely. What is the best advice?
- A. Begin with 150 minutes of vigorous exercise in the very first week
- B. Build gradually from baseline toward 150 or more minutes weekly
- C. Avoid all exercise because it is always dangerous in diabetes
- D. Only exercise once a month to avoid any hypoglycemia
6. A patient on insulin plans a 2-hour hike. What is the most important safety teaching?
- A. No preparation is needed for any planned exercise session
- B. Skip all of the insulin entirely for that whole day
- C. Only exercise when glucose is above 300 mg/dL always
- D. Carry glucose and monitor, since lows can occur hours later
7. Which injection teaching point is correct for insulin users?
- A. Always inject into the same exact spot for consistency
- B. Rotate injection sites, and inject into fat rather than muscle
- C. Insulin can be injected through clothing without any concerns at all
- D. Expired insulin works better than fresh unexpired insulin vials
8. A patient on once-daily metformin misses a dose. What is the correct teaching?
- A. Take it if the next dose is not near
- B. Double the next dose to catch up
- C. Take it at bedtime together with the next scheduled dose
- D. Skip it and call the prescriber before resuming any doses
9. Which meter-quality teaching is correct?
- A. Any meter from any source is perfectly fine
- B. Expired strips are actually more accurate
- C. FDA-approved meters, with unexpired strips from licensed sources
- D. Meters never need any quality checks
10. A patient's fasting glucose is consistently 95–110 mg/dL and postmeal peaks are under 160 mg/dL. How do these compare with ADA targets for most nonpregnant adults?
- A. Both of these readings are dangerously low
- B. Both are within the ADA targets for most adults
- C. The targets are 200 mg/dL fasting and 300 mg/dL postmeal
- D. Glucose targets do not exist for diabetes care
11. A patient with diabetes asks about foot care. Which teaching is correct?
- A. Walk barefoot to toughen up the feet
- B. Foot care is unnecessary without any symptoms
- C. Soak the feet in hot water daily
- D. Inspect feet daily and wear protective shoes
12. A patient with proliferative diabetic retinopathy asks about exercise. What precaution applies?
- A. Individualized activity guidance with the eye care provider
- B. No precautions are ever needed with any eye disease
- C. All exercise is permanently forbidden for patients
- D. Only contact sports are a real concern
13. A patient feels shaky and sweaty with a glucose of 68 mg/dL. What is the correct first action?
- A. Wait a full hour to see if the symptoms pass
- B. Take 15 g of fast-acting glucose, then recheck
- C. Take extra insulin immediately right now
- D. Go for a brisk walk instead
14. Which sick-day teaching is correct for a patient taking an SGLT2 inhibitor?
- A. Continue every single medication unchanged during any illness episode
- B. Stop all diabetes medications permanently whenever feeling at all sick
- C. Hold the SGLT2 inhibitor if intake fails, and monitor closely
- D. Sick days require no special planning at all ever
15. A patient traveling across time zones with insulin asks what to pack. What is essential?
- A. No extra supplies are needed when traveling at all
- B. Extra supplies in carry-on, plus a time-zone plan
- C. Only a single day’s worth of supplies
- D. Leave all supplies in the checked luggage
16. Which statement about smoking and diabetes is correct?
- A. Smoking has no effect on diabetes complications
- B. Switching to e-cigarettes eliminates all risk
- C. Only heavy smoking matters
- D. It raises macrovascular and microvascular risk
17. A patient with neuropathy and foot deformity asks about footwear. What is the correct guidance?
- A. Wear the tightest shoes available for extra foot support
- B. Properly fitting protective footwear and specialist foot care
- C. Sandals are the safest footwear option
- D. Footwear does not matter with any neuropathy
18. A patient on a sulfonylurea drinks alcohol in the evening without eating. What is the risk and teaching?
- A. Hypoglycemia risk rises; eat when drinking and monitor glucose
- B. No risk; alcohol and sulfonylureas are a safe combination
- C. Alcohol only raises glucose and can never lower it
- D. The patient should drink more alcohol to prevent lows
19. A patient starting a CGM asks what the device training should cover. Which answer reflects the ADA standard?
- A. Only how to insert and remove each sensor
- B. Using and sharing the data to adjust therapy
- C. Nothing beyond the package insert
- D. How to stop using a blood glucose meter
20. Which carbohydrate-counting progression is correct for skill building?
- A. Begin with advanced insulin-to-carbohydrate ratios on the very first day
- B. Carbohydrate counting is never taught to any patients
- C. Plate method first; advanced ratios later, matched to skill
- D. Teach ratios only to patients with type 2 diabetes
21. A patient starting a GLP-1 receptor agonist asks what to expect. Which counseling is correct?
- A. Expect immediate weight gain and severe hypoglycemia together always
- B. Possible GI side effects, with no hypoglycemia when used alone
- C. The drug works by directly damaging the patient’s pancreas
- D. No counseling is needed for this drug class at all
22. A patient with diabetes and hypertension asks about aspirin for heart protection. What is the correct teaching?
- A. Take aspirin only if recommended for your cardiovascular risk
- B. Start daily aspirin on your own without telling anyone first
- C. Aspirin is contraindicated in all forms of diabetes
- D. Take triple the usual aspirin dose for extra protection
23. A patient on steroids for an asthma flare sees glucose rise sharply. What problem-solving teaching applies?
- A. Steroids never affect anyone’s glucose levels at all
- B. Monitor more often and follow the prescriber’s adjustment plan
- C. Stop the steroids immediately without any medical guidance whatsoever
- D. Ignore the high readings until the steroid course fully ends
24. Which statement about weight-management eating patterns in diabetes is correct?
- A. Only one specific diet plan works for every patient
- B. Weight management is impossible with any diabetes diagnosis
- C. Fad starvation diets are officially recommended for all
- D. Several evidence-based eating patterns can work, chosen by preference
25. A patient asks when to check ketones. What is the correct teaching?
- A. Never check ketones under any circumstances at all ever
- B. With symptoms or illness, especially above 200 mg/dL
- C. Check ketones only once per year
- D. Ketone checking is only for people without diabetes
Answer key & explanations
1. C. The ADCES7 behaviors include healthy coping alongside eating, activity, medication-taking, monitoring, risk reduction, and problem solving[1]. Feeling overwhelmed by diabetes' constant demands is the textbook presentation of a coping need.
2. B. Diabetes distress refers to the emotional burdens and worries of living with and managing a demanding chronic condition; it is distinct from depression and anxiety, with unique relationships to glycemia and other outcomes[3]. In adults it negatively affects medication-taking and is linked to elevated A1C, lower self-efficacy, and less optimal eating and exercise behaviors[3].
3. D. There is no ideal macronutrient distribution for people with diabetes; distribution follows individualized assessment of eating patterns, preferences, and metabolic goals[4]. Fixed percentages and carbohydrate elimination ignore the individual.
4. A. ADA advises people with diabetes to replace sugar-sweetened beverages — including any juices — with water or low-calorie or no-calorie beverages, and to minimize foods with added sugar[6]. Water is promoted as the healthiest beverage option[7]. Soda raises glucose and treats hypoglycemia, never hyperglycemia.
5. B. The ADA target is 150+ minutes weekly of moderate-to-vigorous activity over at least 3 days[10], but the sedentary patient builds from baseline — start low, go slow. Prescribing 150 vigorous minutes in week one invites injury and dropout.
6. D. In people taking insulin or insulin secretagogues, physical activity may cause hypoglycemia if the medication dose or carbohydrate consumption is not adjusted for the exercise session, and post-exercise hypoglycemia may last for several hours due to increased insulin sensitivity[12, 13]. Glucose should be checked prior to, during, and after exercise[42], and hypoglycemia treatment kits should include oral glucose[38].
7. B. Insulin should be injected or infused into subcutaneous tissue, not intramuscularly[14], and site rotation is necessary to avoid lipohypertrophy, which causes erratic absorption, glycemic variability, and unexplained hypoglycemia[15]. Using the same spot "for consistency" is the tempting error — it is precisely what builds lipohypertrophy and makes absorption inconsistent.
Sources cited in this excerpt
- National Standards for DSMES (2022) — ADCES7 Self-Care Behaviors framework. https://diabetesed.net/wp-content/uploads/2023/06/DSME-2022.pdf
- CBDCE 2026 Handbook — ECO I. Assessment (Effective July 1, 2024). https://www.cbdce.org/documents/20123/66178/CBDCE-exam-handbook_Current.pdf/8e2fda09-9289-947c-7587-712a4e74f10a?t=1588269156519
- ADA Standards of Care 2026 — Section 5 supplement (Facilitating Positive Health Behaviors). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care 2026, Section 5 — no ideal macronutrient distribution; individualize. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: fiber recommendation. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: replace sugar-sweetened beverages. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: water as healthiest beverage. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care 2026 §5 — carbohydrate counting. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: alcohol and delayed hypoglycemia counseling. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care 2026, Section 5 — 150 min/week aerobic activity (5.36). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care 2026, Section 5 — resistance exercise 2-3 sessions/week (5.37). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: exercise-related hypoglycemia (medication/carbohydrate adjustment). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 5 — Supplemental: delayed hypoglycemia after exercise. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care in Diabetes—2026, Section 9 — Supplemental: Injection sites, lipohypertrophy, U-500, honeymoon phase. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690185/
- ADA Standards of Care 2026 — Section 9 (Pharmacologic Approaches to Glycemic Treatment). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690185/
- ADA Standards of Care 2026 §13 — simplifying insulin plans. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690186/
- AHRQ PSNet — confirm comprehension with teach-back, not 'Do you understand?'. https://psnet.ahrq.gov/primer/personal-health-literacy
- ADA Standards of Care 2026, Section 7 — use only FDA-approved meters with unexpired strips (7.12). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690173/
- ADA Standards of Care 2026, Section 7 — initial and ongoing CGM education (7.3a). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690173/
- ADA Standards of Care 2026, Section 7 — CGM users must also have BGM access (7.10). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690173/
- ADA Standards of Care 2026, Section 6 — preprandial glucose target 80-130 mg/dL (Table 6.3). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026, Section 6 — peak postprandial target <180 mg/dL (Table 6.3). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026 §6 — postprandial timing. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026, Section 6 — time in range >70% goal (6.3b). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026 §6 — rec 6.3c. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026, Section 6 — measure ketones when glucose exceeds 200 mg/dL with symptoms. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026 — Section 12 (Retinopathy, Neuropathy, and Foot Care). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690177/
- ADA Standards of Care 2026, Section 12 — eye exam intervals (12.5). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690177/
- ADA Standards of Care 2026, Section 11 — annual UACR and eGFR screening (11.1a). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690176/
- ADA Standards of Care 2026, Section 4 — annual influenza vaccine; avoid live attenuated. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690184/
- ADA Standards of Care 2026, Section 4 — routine vaccinations for people with diabetes (4.5). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690184/
- ADA Standards of Care 2026 §5 — smoking risk. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690188/
- ADA Standards of Care 2026 §10 — ASCVD burden. https://pmc.ncbi.nlm.nih.gov/articles/PMC12690187/
- ADA Standards of Care 2026, Section 10 — on-treatment BP goal <130/80 (10.4). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690187/
- ADA Standards of Care 2026, Section 10 — moderate-intensity statin age 40-75 without ASCVD (10.18). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690187/
- ADA Standards of Care 2026, Section 10 — primary-prevention aspirin may be considered (10.36). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690187/
- CDC — Managing Sick Days (page last reviewed May 15, 2024). https://www.cdc.gov/diabetes/living-with/managing-sick-days.html
- ADA Standards of Care 2026 — Section 6 (Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026, Section 6 — glucose preferred treatment for hypoglycemia (6.15). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- ADA Standards of Care 2026, Section 6 — prescribe glucagon for insulin users (6.16). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/
- CDC — Tips for Traveling With Diabetes (packing). https://www.cdc.gov/diabetes/about/tips-for-traveling-with-diabetes.html
- ADA Standards of Care 2026 — Section 7 (Diabetes Technology). https://pmc.ncbi.nlm.nih.gov/articles/PMC12690173/