Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Secrets of Sugar Surfing with a Continuous Glucose Monitor: May 11, 2014

3,577 views

Published on

The current slide deck for the topic Sugar Surfing with a CGMS b

Published in: Healthcare, Health & Medicine

Secrets of Sugar Surfing with a Continuous Glucose Monitor: May 11, 2014

  1. 1. 5/11/2014 1 Welcome Like “The Power Within by Stephen Ponder MD, FAAP CDE” www.stephenpondermd.com Sugar Surfing Stephen W. Ponder MD, FAAP, CDE (aka “doctor juicebox”) ©
  2. 2. 5/11/2014 2 Unleashing the “Power Within” Like “The Power Within by Stephen Ponder MD, FAAP CDE” www.stephenpondermd.com © “Kickin’ D’s Butt”
  3. 3. 5/11/2014 3 By the end of this presentation, you will know the meaning of the following Sugar Surfing terms… • The Sugar Surfers credo (the 3 virtues) • Flux and drift • Static vs. dynamic diabetes self care • Proper calibration and basal checking • Timing is everything • Actionable thresholds • Micro-carbing and micro-blousing • Knowing your DIA • Nudging, pushing and shoving sugar • Pre-empting • “Taking the drop” • The trend is your friend Principles
  4. 4. 5/11/2014 4 Dynamic Diabetes Management (DDM) requires… 1. Comprehending a system with basic principles/concepts 2. Adjusting to changing or shifting conditions/situations 3. Frequent assessments and re- assessments LIKE…. • Driving a car • Flying an airplane • Walking a tightrope • Surfing Appreciate the flux of sugar levels in non-d persons
  5. 5. 5/11/2014 5 Remember: SugarSurfingis all about managing… (Glucose production – Glucose disposal) = FLUX Here is a picture of FLUX and DRIFT
  6. 6. 5/11/2014 6 “Life is not a matter of holding good cards, but of playing a poor hand well.” R.L. Stevenson (1850-1894)
  7. 7. 5/11/2014 7 These are classic illustrations by a famous graphic artist from the early 20th century. These specific images were taken from a handbook for new patients with diabetes. Some things NEVER change and never will. Here are 3 priceless pieces of diabetes wisdom… Diabetes Police?
  8. 8. 5/11/2014 8 To unleash your Power Within… Work to let go of… • Judging • Feeling defective/broken • Shame • Fearing the future • Isolation • Pity • Insecurity/denial Embrace/cultivate… • Acceptance • Normalcy • Openness • Enjoying the moment • Teamwork • Empowering/supporting • Self-confidence
  9. 9. 5/11/2014 9 Diabetes care is about choices
  10. 10. 5/11/2014 10 23% 221 Diabetes care must be individualized
  11. 11. 5/11/2014 11 “Chance favors the prepared mind” Louis Pasteur …dude
  12. 12. 5/11/2014 12 3 virtues of the well managed Hang in there. Don’t give up!
  13. 13. 5/11/2014 13 “I haven't failed. I've just found 10,000 ways that won't work.” Thomas Edison Knowledge alone does not imply understanding
  14. 14. 5/11/2014 14 “You can delegate authority but you can’t delegate responsibility” Do 2 RN’s = 1 kid? = Ok? Ok to me!
  15. 15. 5/11/2014 15 Concrete thinkers* can’t… 1. Consider a hypothesis 2. Consider multiple possibilities in a scenario 3. Systematically solve a problem 4. Use combinatorial logic *Lasts until 15-17 years of age *25% of adults are concrete thinkers.
  16. 16. 5/11/2014 16 You CAN influence how long it lasts diabetes treatment preserves INTERNALLY made insulin Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625; data interpretation DX'd 1950-1964 DX'd 1965-1980
  17. 17. 5/11/2014 17 Is the future already here? 50 55 60 65 70 75 80 1964 1980 Lifespan with type 1 diabetes vs. without Average American Type 1 Diabetes Linear (Average American) Log. (Type 1 Diabetes) 1996 DX'd 1950-1964 DX'd 1965-1980 DX'd 1980--?? Five things to remember about T1D 1) Diabetes care isn’t a contest. It’s overrun with numbers. Don’t judge. 2) Let the remaining guilt (if any) go! NO one is perfect. 3) Diabetes care is not an action, it is a SKILL SET. Therefore, it can be practiced and improved upon. 4) Control is the end result of your decisions and choices. This applies to minute to minute control as well as long term control. 5) NO health care provider manages anyone’s diabetes. They never can and they never will. It’s a self managed condition.
  18. 18. 5/11/2014 18 Five practical advanced diabetes care tips 1) Better synchronize your insulin and your meals 2) Check blood sugars 2-3 hours after meals 3) Correct any out of range sugar you discover (“treat to target”) 4) Work to get morning blood sugars into target range (F-F-F) 5) Review/analyze your blood sugars at least weekly Diabetes care is best approached 1 day at a time
  19. 19. 5/11/2014 19 A pancreas can’t predict the future… • But it acts so fast it doesn’t need to. • Can shut off insulin immediately • Can release premade insulin • Insulin it releases start working in minutes (plus other things) • Can rapidly respond to shifts in sugar levels static vs. dynamic diabetes care static • Actions predetermined • Minimal flexibility: RIGID • Outcomes don’t immediately affect subsequent actions • Easy to teach/learn • Less time-intensive • Favors concrete thinking • Less motivation needed dynamic • Actions are dependent on situation/circumstance • Flexible and adaptable • Outcomes constantly influence subsequent actions • Training needed, plus ongoing reinforcement • More time intensive • Favors problem-solving • Requires ongoing motivation
  20. 20. 5/11/2014 20 present past future Actions Actions “CONTROL”
  21. 21. 5/11/2014 21 8 versus 1440 “decision points” 7:03 115 9:33 129 12:15 95 3:34 131 6:12 168 9:49 107 11:53 114 3:05 132 * * * * * * * * Don’t pass up an opportunity to assess a trending BG • Choose what you consider “actionable” • Set personal action thresholds • Use situational thinking: consider recent, current and impending actions • Check your BG results over time • “treat to target” (repeat as needed, but don’t “overstack” your insulin)
  22. 22. 5/11/2014 22 How much sugar is in the bloodstream for a 100 mg/dl BG level? Human circulatory system 165 pound (75 kg) man (5.1 grams) 55 pound (25 kg) girl (1.75 grams) 110 pound (50 kg) boy (3.45 grams) = 4 gram glucose tabaka “glucose transit system” Traits of effective CGM users Wear it most of the time Check trend line often They “work the lag” times FOOD lag INSULIN lag SENSOR lag Not afraid to experiment Not expecting perfection
  23. 23. 5/11/2014 23 To Sugar Surf, set action thresholds • Upper/Lower limits • e.g., 80 mg/dl and 140 mg/dl • e.g., 90 mg/dl and 180 mg/dl • What rates of change • Up or down arrows • Factor in recent/current/future events as you are able to • Test your skills, experiment a little within reason Be realistic Accept that the first 6-12 months are on a “learning curve” Set higher and wider targets Have low expectations to start It’s still a finicky technology PLEASE BE PATIENT
  24. 24. 5/11/2014 24 BG awareness vs. alarm fatigue • Set reasonable alarm thresholds • Depends on your goals • Avoid high spikes? • Avoid lows? • Toddler? Child? Teen? Adult? • Make sure you can hear/sense the alarm • Anticipatory action can minimize alarms Principles ofSugar Surfing 1. A CGM is no better or worse than the person responding to it. 2. If you can measure it, you can predict it. 3. Flux and drift happen… manipulate them! 4. Keep your eye on your line. 5. The trend is your friend 6. Learn lag limits; be patient 7. Zero in on your zone 8. Master micro-dosing 9. Factor in glycemic inertia and insulin momentum 10.Don’t let “good enough” be the enemy 11.Calibrate carefully 12.Pre-empt when you can
  25. 25. 5/11/2014 25 Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert
  26. 26. 5/11/2014 26 “THE TREND IS YOUR FRIEND” CHECKING INSULIN BOLUSES WITH CGM 6 pm 8 pm 10 pm 300 200 100 60 Carb bolus Correction bolus 6 pm 8 pm 10 pm Goal: green lines Calibration
  27. 27. 5/11/2014 27 Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən) • Comparing the sensor to an accepted “standard” value • The accepted “standard” value is a fingerstick BG level • So the sensor itself can be no more accurate than the BG meter it’s compared to…or how well the BG meter was used Calibration tips • The first sensor day can be erratic as it “settles in” • Don’t over calibrate! • Try to calibrate on a steady trend • Try to calibrate when in your target range
  28. 28. 5/11/2014 28 CGM calibration tip… steady 2 hours Whenever possible: calibrate the CGM system when on a “steady” sugar trendline 2 hr “wait” time between “turning on” sensor and providing 2 calibration BG readings to start session steady baseline Daily calibrating on a steady baseline
  29. 29. 5/11/2014 29 Steady trend 2 hours Calibrate your CGM… On a steady trend when you can… In the BG range you want to be most accurate in… Steady trend 4 hours post start up calibration (extra)
  30. 30. 5/11/2014 30 Settling in at 6 hours: wobble Sensors are not always right Or is it the meter that’s off?
  31. 31. 5/11/2014 31 Morning madness? After 14 hours after new CGM sensor insertion… After calibrating with 112 mg/dl, the sensor immediately reads this Take home message: a new CGM sensor site might take a day or so to properly “settle in” or “read” properly. Take this under consideration and don’t give up on a session too soon. But BG meter calibration shows THIS… Dual receivers linked to same sensor 2 hours 1. Steady trend 2. In target range Remember…
  32. 32. 5/11/2014 32 Basal testing Overnight basal testing
  33. 33. 5/11/2014 33 Overnight basal in range (glargine) Overnight basal testing
  34. 34. 5/11/2014 34 Overnight in range! Overnight control in range
  35. 35. 5/11/2014 35 Basal testing… Overnight basal control - Lantus
  36. 36. 5/11/2014 36 Basal testing… Sugar Surfing tip: midday basal testing Omitted lunch steady
  37. 37. 5/11/2014 37 Basal testing with a 3 year old Timing is everything
  38. 38. 5/11/2014 38 Learning from the Line Graph – Insulin Timing 8a 10a 70 140 210 350 280 8a 10a 70 140 210 350 280 TodayYesterday Insulin bolus: 7:30 AM Breakfast: 7:30 AM Insulin bolus: 7:10 AM Breakfast: 7:30 AM M I MI
  39. 39. 5/11/2014 39 Timing 101 – 20 min. match Insulin Food Timing 101 – 45 min. mismatch Insulin Food
  40. 40. 5/11/2014 40 Why timing is everything 3 units @6:10 28 gm @ 6:50 Timing…waiting for the bend “window”
  41. 41. 5/11/2014 41 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the “bend”!
  42. 42. 5/11/2014 42 Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM) Point “A” Point “B” sugar trend Insulin “correction” Carb “correction” ~ 2 hours for insulin ~ 15-30 minutes for carbs Range of possible BG outcomes “the trend is your friend” Blood glucose level
  43. 43. 5/11/2014 43 Noticed rising trend at 1:43 PM: 165 mg/dl Took 5 units lispro @ 1:45 PM 4 hours Late BG rise after the morning: no lunch eaten 135 mg/dl @ 2 hours “Direction affects correction ” BG = 157 mg/dl Inj 4 U lispro @3:15 2-3 hours 20-30 minA B C Correction tips (on a steady trend) A. Remember the lag time before insulin starts to effectively lower BG B. Remember the length of time it takes to accomplish the desired task C. Patience and practice make these kinds of results possible
  44. 44. 5/11/2014 44 Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl Micro-dosing
  45. 45. 5/11/2014 45 Micro-bolusing (dosing) Steady baseline BG trend BG 136 mg/dl 2 units lispro Wait 2 hours Target zone • Very advanced • CGM needed! • Note flat BG “baseline” trend • Calibration good • Not “correction” per se • More of an “adjustment” BG 137 mg/dl and rising slowly 3 units lispro “Micro-bolusing”
  46. 46. 5/11/2014 46 Subtle correction • BG 125 and rising • Took 4 units lispro • 2 for the slow rise • 2 for the correction • Waited almost 2 hours (yellow arrow) • Notice lag time before BG “turns” (red arrow) BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time
  47. 47. 5/11/2014 47 112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline 1.5 units ~ 2 hours 3U lispro @ 3:40AM
  48. 48. 5/11/2014 48 4 unit lispro “push” “Course correcting for smooth sailing” Well balanced basal insulin Hello Kitty…goodbye low blood sugar 2 Pez @ 62 mg/dl
  49. 49. 5/11/2014 49 6 unit “shove” at 133 mg/dl  “Shoving Sugar” 3U @ 3:32 5U @ 4:50 6 @ 6:17 Gently turning a curve
  50. 50. 5/11/2014 50 Learn your own insulin duration To forge I-chains Mealtime insulin @ 8:30PM 7 units lispro Duration of insulin 3hr Insulin correction dose @ 2:53AM 6 units lispro lag 2 hours to correct Teaching points… a. Know your insulin “umbrella” b. Slow carbs cause unexpected highs c. Insulin onset of action = lag time d. Rise in BG levels has vector qualities e. It takes time to correct a high a b c d ea b
  51. 51. 5/11/2014 51 6:53PM BG 108 inj 6 units 7:15-7:35 9:52PM BG 125↑ inj 4 units “Effective duration” of insulin action: 3 hrs “Active insulin” • Example: Slow carb meal (fried food) • e.g., Chicken fried steak, cream gravy and 3 onion rings and 8 French fries • Estimated 60 grams: 6 units: inject 6 units lispro • NO rise in BG for 3 hours, then rapid ascent • Time until rise reflects “active insulin” effect • Must do this many times and take the average Duration of insulin effect can be determined here ~ 4 hours
  52. 52. 5/11/2014 52 IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal
  53. 53. 5/11/2014 53 Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus “Inflections” calibration Tex-Mex Dinner calibration “Remember the Alamo”
  54. 54. 5/11/2014 54 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Slow carbs • Experimented here: • Ate a pasta meal at the Olive Garden • Took a single insulin shot (70 gm = 7 units) • Sugar dropped at time of usual peak insulin action: ~60-90 minutes • BG recovered without treatment • Late rise in BG required second injection Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Fast insulin + slow carbs = low BG • Ate a pasta meal at the Olive Garden • Took a single insulin shot (70 gm = 7 units) • Sugar dropped at time of usual peak insulin action: ~60-90 minutes • BG recovered without treatment • Late rise in BG required second injection • Notice the insulin-food “balance” and how it effects BG levels Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro Insulin effect Food effect
  55. 55. 5/11/2014 55 Dealingwith risingtides “Fried-food revenge” and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours
  56. 56. 5/11/2014 56 “Revenge of the Ribeye” and “The Insulin Strikes Back” BG 167: 4 units LAG 2-3h Slow BG rise from protein-fat laden meal
  57. 57. 5/11/2014 57 Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours Slow overnight rise and early AM correction
  58. 58. 5/11/2014 58 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes Correction with 20 grams carbs 20 gm CHO
  59. 59. 5/11/2014 59 Pre-empting 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A “random rise” in BG during a routine day. 2-3 hours
  60. 60. 5/11/2014 60 Working it…(i.e., glucose control exists “in the moment”) ~ 2 hours Oops! I Ate an EXTRA breakfast taco! BG 142 ↑ : took 5 units hypothetical real And thirdly, the correction and carb ratios is more what you’d call ‘guidelines’ than actual rules “Most of our assumptions have outlived their usefulness” Marshall McLuhan
  61. 61. 5/11/2014 61 8 U @ 9:30AM 7 U @ 10:54AM 6 U @ 12:29PM 60 grams carbs Ultimately 21 U lispro Insulin to carb ratios are only a start 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 …flux?” “What the…
  62. 62. 5/11/2014 62 Duration of insulin 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization
  63. 63. 5/11/2014 63 Shoving, pushing, nudging… …and “Taking the Drop” Two gulps of juice (15-20g CHO) “Nudging a Drift” (aka microcarbing)
  64. 64. 5/11/2014 64 5 gram CHO “nudge” @ 66 m/dl Dropping < 1 mg/dl/min “Nudging a Drift” (aka microcarbing) 4 gram CHO “nudge” @ 66 mg/dl 4 gram CHO “nudge” @ 70 mg/dl “Nudging a Drift” (aka microcarbing)
  65. 65. 5/11/2014 65 5 gram CHO “nudge” @ 66 mg/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone Late day “nudge” after no lunch with one “gulp” of fruit juice 84 mg/dl to 96 mg/dl
  66. 66. 5/11/2014 66 “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice Leisurely walk from 7:00 to 8:30: straight line
  67. 67. 5/11/2014 67 Exercise “bump up” Moderate intensity 75 minute duration Glycogen  Glucose 2 units 1 hr walk “Walking down” a trend
  68. 68. 5/11/2014 68 Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE) 4 units ~ 2 hours Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk (EXERCISE) 2 units ~ 2 hours
  69. 69. 5/11/2014 69 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours “Pushing sugar” aka “Nudging a drift” BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons “launch window”
  70. 70. 5/11/2014 70 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait “Taking the drop”… “Taking the drop” BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth
  71. 71. 5/11/2014 71 6 units 6:23AM at 171 mg/dl Lag 2 hours “Taking the drop” Wedding Reception and dinner (Mexican food and cake/ice cream: slow carbs, slow rise) Woke up at 3:55AM at 184 mg/dl Took 4 units lispro Wait (slept) about 3 hours Bingo! Tamale Soup at dinner (slow carbs, slow rise) “Livin’ la vida Gluco”
  72. 72. 5/11/2014 72 182 mg/dl : 7 units lispro Insulin lag time 30-40 min Eat breakfast here Food lag time 124 mg/dl Timing is everything…do you have the patience or the time? Slow BG rise overnight from fried meal BG drop time 20-30 min Stuff happens… deal with it
  73. 73. 5/11/2014 73 “Smooth seas do not make skillful surfers” I slipped on a banana… Large banana 7 units Humalog meal Identify the: drift lag(s) drop
  74. 74. 5/11/2014 74 Following the drop and meal… Calibration Missed 9PM basal dose (glargine) Normal time Lantus taken (9PM) Detected rising sugar level @ 2AM Humalog dose (7U) AND usual Lantus taken (20U) Sensor “gap”!! dinner Fell asleep! All back in range by morning!
  75. 75. 5/11/2014 75 What happens when a basal insulin dose is missed Usual time Lantus dose is taken: 9PM Rising BG discovered here Insulin correction given If not treated: high BG and ketones Treated: In range BG and NO ketones Stress effect
  76. 76. 5/11/2014 76 Endocrinology Board Exam taken every 10 years Stress and Sugar • Strong emotional stress triggers release of a several hormones • These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body • Stress hormones also make the liver produce sugar from substances like protein and fat • This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood • CGM allows for more aggressive anti-stress treatment of rising sugars Crossing 140 mg/dl @ 3AM and a 2.5 U lispro correction ~ 2 hours Lag time Why act? • Slow upward BG trend (red arrow) • Crossed personal “action consideration” threshold: 140 mg/dl in my case (yellow line) • Knew the CGM would alert me to a rapidly dropping BG later if I over treated • Have done this many times before: practice, practice, practice
  77. 77. 5/11/2014 77 Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery) Awakened by CGM alarm to a BG below 60 mg/dl Lag time 20gm Rationale • Slow downward BG trend (red arrow) • Crossed personal “action consideration” threshold: 60 mg/dl in my case (yellow bottom line) • Drank 20 gm grape juice and went back to sleep • Knew the CGM would alert me to a rapidly rising BG later if I over treated • Have done this many times before: practice, practice, practice
  78. 78. 5/11/2014 78  Fell asleep early evening after long day…woke up at 10:45PM  Late dosing of Lantus (20 units @ 10:45PM ) normally taken at 9PM  Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon)  CAUTION: These series of dosing actions are only possible with a CGM! 5U 6U 7U 6U9U 15 grams CHO MEAL Anatomy of a nighttime low A) 4 hour window B) 24 hour window C) 6 hour window D) Resolution 34 mg/dl 36 grams CHO 2.5 hours
  79. 79. 5/11/2014 79 6 U 4 U 4 U 4 U 5 U 6 U 28 GM 90+ GM 1. Stacked insulin + delayed eating 2. “Hyper-treated” severe low 3. Fought “rebound” high BG all night 4. Took the drop and timed meal
  80. 80. 5/11/2014 80 Dislodged insulin pump site… Picked up early by CGM Pump site changed, insulin dose given, carb correction taken…$13,000 saved How does this feel?
  81. 81. 5/11/2014 81 This can be “sensed too” CHO A steady trend The body’s defenses against low blood sugar include the brain Downward shifts, even small, can be sensed by the conscious brain Once sugar levels off, the brain senses stability Rationale • Blood sugar control is complex, it includes the brain and nervous system • Long term damage to the autonomic nervous system can result in loss of classic signs/symptoms of low blood sugar • But, the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (e.g., < 50 mg/dl) • A CGM device can serve as a “biofeedback” device of sorts in adults willing to develop the ability over time. Although subtle, this can be “felt”
  82. 82. 5/11/2014 82 Feel the drop and level off This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min
  83. 83. 5/11/2014 83 Pre-empting “Working down” a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings
  84. 84. 5/11/2014 84 4 units Humalog @ 11:07PM BG rising after insulin effect is“waning”. BG = 146 mg/dl Dinner (soft tacos, refried bean and chips/salsa); 7 units lispro taken 20 minutes premeal at 7PM My “DIA” = 3-4 hours Notice the obligatory “lag time”! Anatomy of a preemptive correction One goal to aim for: pre-empt meal spikes
  85. 85. 5/11/2014 85 Closing thoughts 6 month CGM data summary Average BG = 103 mg/dl Standard deviation = 34 mg/dl Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value
  86. 86. 5/11/2014 86 Day vs. Night: any thoughts about why? “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice
  87. 87. 5/11/2014 87 What is this called? Answer: “taking the drop” What is this called?
  88. 88. 5/11/2014 88 When to pull the trigger? Interpret these two images Hint: sensor is over two weeks old
  89. 89. 5/11/2014 89 What is it a good time for and why? Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl
  90. 90. 5/11/2014 90 This is about as tight as it gets Proactive-Reactive
  91. 91. 5/11/2014 91 Proactive-Reactive Proactive-Reactive
  92. 92. 5/11/2014 92 Largely reacting here Penny stock day trading strategySugarSurfing
  93. 93. 5/11/2014 93 © “Kicks D’sButt” Sugar Surfing

×