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Sugar Surfing Master Slide Deck August 27 2014

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Sugar Surfing is a discipline I created to leverage the power of the continuous glucose monitor with and without use of the insulin pump. Here is a copy of the in person presentation I give at workshops around the country and world. These principles are my creation and intellectual property.

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Sugar Surfing Master Slide Deck August 27 2014

  1. 1. Welcome! Like “The Power Within by Stephen Ponder MD, FAAP CDE” stephenponderMD.com sugarsurfing.comPre-order the book here:
  2. 2. Sugar Surfing Stephen W. Ponder MD, FAAP, CDE (aka “doctor juicebox”) ©
  3. 3. Sugar Surfing* returns to Dallas! When: Saturday September 20, 2014 10AM-12:30PM Where: Tom Hunt Auditorium 10th floor Charles A. Sammons Cancer Center 3410 Worth Street Dallas, Texas 75246 Lite refreshments provided Cost: NONE RSVP: Kaye Harmon kharmon@sw.org 254-935-5048 * Dynamic Diabetes Self Management using a CGM Device Stephen Ponder MD, FAAP, CDE Endocrinologist Type 1 since March 1, 1966 I’m comin’ back, dudes!!!
  4. 4. This is Sugar Surfing…
  5. 5. And this is Sugar Surfing…
  6. 6. Sugar Surfing
  7. 7. Sugar Surfing Deltec Insulin pump MDI: Lantus and Humalog
  8. 8. Sugar Surfing
  9. 9. Sugar Surfing
  10. 10. Sugar Surfing
  11. 11. Sugar Surfing
  12. 12. Sugar Surfing
  13. 13. A “normal day”
  14. 14. But this is Sugar Surfing too…
  15. 15. Sugar Surfing is a process, not a result
  16. 16. Sugar Surfing is
  17. 17. Your blood glucose is 100 mg/dl dropping at a rate of 2-3 mg/dl/min and your insulin pump is delivering at 1.3 U/hr. YOUR GETTING LOW! Sugar Surfing emphasizes significance
  18. 18. Sugar Surfing is Fuzzy Logic in motion
  19. 19. Almost as “tight”as it gets
  20. 20. This is about as tight as it gets
  21. 21. 7 year old American Sugar Surfer
  22. 22. A 7 year old Sugar Surfing in Canada!
  23. 23. “Dr. Ponder lines” in Canada
  24. 24. Sugar Surfing is driven by “The Power Within” Like The Power Within by Stephen Ponder MD, FAAP CDE stephenponderMD.com
  25. 25. © Kicks Diabetes SugarSurfing
  26. 26. 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 (IOB) • Nudging, pushing and shoving sugar • Pre-empting • “Taking the drop” • The trend is your friend Gluca-bunga!
  27. 27. Principles
  28. 28. Appreciate the flux of sugar levels in non-d persons
  29. 29. Remember: SugarSurfingis all about managing…
  30. 30. Sugar Surfing requires the following skills… 1. Understanding some 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
  31. 31. (Sugar in – Sugar out) = FLUX Here is a picture of FLUX and DRIFT
  32. 32. “Life is not a matter of holding good cards, but of playing a poor hand well.” R.L. Stevenson (1850-1894)
  33. 33. 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…
  34. 34. Diabetes Police?
  35. 35. To unleash your Power Within… 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
  36. 36. Diabetes care is about choices
  37. 37. What do these numbers mean? 23% 221
  38. 38. Diabetes care must be individualized
  39. 39. ISO and FDA allowable errors • ± 20% for 95% of BG values ≥ 75 mg/dl • ≤ 15 mg/dl for 95% of BG values < 75 mg/dl • 5% “outliers” of ANY DEGREE of magnitude “Glycemic Roulette”? Diabetes Spectrum Volume 25, Number 3, 2012 ISO 15197 Standards for SMBG
  40. 40. 95 mg/dl 114 mg/dl 76 mg/dl 223 mg/dl 52 mg/dl 95% of the time Oops! Oops! 5% 5%
  41. 41. Glargine vs new long acting insulin
  42. 42. Pump basal rates “wobble” • It takes 2 hours for a basal rate change to reach a “steady” level • Notice the “wobble” in how rapid insulin works when delivered through a pump. • Chaos is a trait of any injected or infused insulin delivery system
  43. 43. “Chance favors the prepared mind” Louis Pasteur …dude
  44. 44. 3 virtues of the well managed
  45. 45. “I haven't failed. I've just found 10,000 ways that won't work.” Thomas Edison
  46. 46. Hang in there. Don’t give up!
  47. 47. Knowledge alone does not imply understanding
  48. 48. “You can delegate authority but you can’t delegate responsibility”
  49. 49. Do 2 RN’s = 1 kid? = Ok? Ok to me!
  50. 50. 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.
  51. 51. Genetic Predisposition Autoimmune process begins Trigger Measureable loss of insulin Diagnosis Residual insulin ability honeymoon Time in YEARS 100% 20% 50% How insulin ability fades in type 1 diabetes
  52. 52. You CAN influence how long beta cells last diabetes treatment preserves INTERNALLY made insulin
  53. 53. 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--??
  54. 54. 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. Control exists “in the moment” 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.
  55. 55. Five practical advanced diabetes care tips 1) Better synchronize your insulin and your food 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 (if not continually)
  56. 56. Proactive versus Reactive
  57. 57. Diabetes care is best approached 1 day at a time
  58. 58. 4 day non-diabetic CGM plot
  59. 59. 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 changes in sugar levels
  60. 60. 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
  61. 61. present past future Actions Actions “CONTROL”
  62. 62. Proactive-Reactive
  63. 63. Proactive-Reactive
  64. 64. Proactive-Reactive
  65. 65. Largely reacting here
  66. 66. 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 * * * * * * * *
  67. 67. Don’t miss an opportunity to check out a trending BG • Choose what you consider “actionable” (worth doing something about) • Set personal action thresholds • Use situational thinking: consider recent, current and impending actions • Check your own BG results over time • “treat to target” (repeat as needed, but don’t “overstack” your insulin)
  68. 68. Setting your targets… CAN’T MISS!
  69. 69. Target setting tips (for actions to be considered) 1) Make them easy to hit 2) Aim high and wide at first 3) Develop confidence 4) Don’t rush it 5) Lower/tighten them gradually
  70. 70. How much total sugar is in the blood 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”
  71. 71. 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
  72. 72. 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 (really…dots) • Factor in recent/current/future events as you are able to • Test your skills, experiment a little within reason
  73. 73. 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
  74. 74. 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
  75. 75. Principlesof Sugar Surfing 1. A CGM is no better or worse than the person using 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 an enemy 11.Calibrate carefully 12.Pre-empt: stay ahead of the wave
  76. 76. This is where it all happens I’m a Dexcom G4 sensor tip I’m a pump catheter tip
  77. 77. Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate
  78. 78. Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert
  79. 79. “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
  80. 80. Calibration
  81. 81. 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
  82. 82. 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
  83. 83. 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
  84. 84. Daily calibrating on a steady baseline
  85. 85. 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
  86. 86. 4 hours post start up calibration (extra)
  87. 87. Settling in at 6 hours: wobble
  88. 88. Sensors are not always right Or is it the meter that’s off?
  89. 89. Meter-Sensor mismatch/confusion Dropping over 75-90 minutes 1st BG check: Hmmmm
  90. 90. First recheck: re-cleaned hands 2nd recheck a few minutes later
  91. 91. 1) On a steady trend line 2) In your target range 3) Make sure initial cal samples match closely Sugar Surfing Calibration tips 1) 2) 3)
  92. 92. Settling in: 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…
  93. 93. Failing Sensor after several weeks
  94. 94. Day 1 New Sensor Chaos
  95. 95. End of multi-week sensor session (dying sensor: erratic) NEW sensor session 2nd sensor session (stop-restart) New sensor chaos erratic
  96. 96. Sensors can take time to settle in Calibration day 1 (May 21) Next day (May 22)
  97. 97. Overnight basal: first sensor day “wobble” calibration Sensor session started Late dinner Breaking in your new surfboard Tips: 1) Give 2-3 additional BG checks in first 12 hours 2) Things begin to improve after 12-18 hours 3) Don’t give up, breaking in a sensor takes time
  98. 98. Pop Quiz: What is it a good time to do here? Sensor: 127 mg/dl; meter 122 mg/dl
  99. 99. Overlapping receivers...week 2 to 3 (you need to save your receivers) End of week 2 sensor session Start of week 3 sensor session
  100. 100. Dual receivers linked to same sensor 2 hours What have we learned: calibration 1) Best done on a steady trend 2) Best done in your target range 3) Do a couple extra on day 1 4) Re-calibrate after large swings 5) You can over-do it
  101. 101. Basal testing
  102. 102. Overnight basal testing
  103. 103. Overnight basal in range (glargine)
  104. 104. Overnight basal testing
  105. 105. Overnight in range!
  106. 106. Overnight control in range
  107. 107. Basal testing…
  108. 108. Overnight basal control - Lantus
  109. 109. Overnight basal testing
  110. 110. Overnight basal testing
  111. 111. Overnight basal testing
  112. 112. Overnight basal testing
  113. 113. Overnight basal testing
  114. 114. Basal Testing
  115. 115. Sugar Surfing tip: midday basal testing Omitted lunch steady
  116. 116. Afternoon basal testing
  117. 117. 0.8 Units/hr basal rate In the pipe Don’t forget the basal!
  118. 118. Basal…Basal…Basal
  119. 119. Why basal testing is important
  120. 120. Basal testing with a 3 year old
  121. 121. What have we learned: basal testing 1) You are always scanning over your basal control 2) Especially in the morning 3) A steady basal insulin effect is important to successful surfing 4) Keep basal insulin as simple as possible Basal checking…always
  122. 122. Timing is everything
  123. 123. 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
  124. 124. Timing 101 – 20 min. match Insulin Food
  125. 125. Timing 101 – 45 min. mismatch Insulin Food
  126. 126. Why timing is everything
  127. 127. 3 units @6:10 28 gm @ 6:50 Timing…waiting for the bend “window”
  128. 128. 6 units Novolog @ 5:27AM 28 gm CHO @ 6:11AM Basic Surfing: Timing 45 min
  129. 129. 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike
  130. 130. Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the “bend”!
  131. 131. Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM)
  132. 132. 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
  133. 133. 4U @ 5:302.1U @ 3:30 1.75 U per calc2.1 U per calc BG = 187BG = 180 IOB = 3 hours Correction factor = 30 “Direction affects Correction” Target= 110 mg/dl just leveled off
  134. 134. 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 ”
  135. 135. 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
  136. 136. Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl
  137. 137. What have we learned: timing 1) Watch your lag times 2) Inflection points matter 3) “Wait for the bend” 4) Know insulin peaks 60-90 minutes 5) Know the duration of insulin effect
  138. 138. Micro-dosing
  139. 139. 1 unit Novolog @ 3:37AM Leveling off Microbolusing calibration
  140. 140. 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”
  141. 141. 2:42AM 1 unit Novolog 5:37AM 1 unit Novolog microbolusing
  142. 142. BG 137 mg/dl and rising slowly 3 units lispro “Micro-bolusing”
  143. 143. 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)
  144. 144. BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time
  145. 145. 112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline 1.5 units ~ 2 hours
  146. 146. 2 units Humalog @ BG 130 mg/dl 3 scrambled eggs @ 9:20 AM Microdosing Humalog at Churchi Slow protein rise?
  147. 147. 8:39AM 1 unit Novolog nudge via pump Micro-dosing insulin Basal rate constant here
  148. 148. 2 units via pump 160 mg/dl Pump “nudge”
  149. 149. CGM 125 mg/dl 2 U Novolog 5:40 AM via pump Calibration CGM: 123 mg/dl Meter: 123 mg/dl Nudging
  150. 150. 3U lispro @ 3:40AM
  151. 151. 4 unit lispro “push” “Pre-empting” Well balanced basal insulin
  152. 152. 8 gm juice nudge 8 gm juice nudge 8 gm juice nudge Micro-carbing practice dinner Any other suggestions?
  153. 153. Hello Kitty…goodbye low blood sugar 2 Pez @ 62 mg/dl
  154. 154. 6 unit “shove” at 133 mg/dl 
  155. 155. 3U @ 3:32 5U @ 4:50 6 @ 6:17 Gently turning a curve
  156. 156. 0.8 Units/hr basal rate 6 6 4 Combo bolus experimenting Manicotti and 2 Rolls Combo bolus Carb nudgesMeal
  157. 157. 6 6 units “extended” (5 hours - 6:26-11:26PM) 2 “nudge” Sugar Surfing on the Rio Grande Tacos al carbon, queso and chips: 80-100 gm CHO “50-50-5”
  158. 158. ++ = 45 minutes 60 minutes 75 minutes 90 minutes 105 minutes 120 minutes 25 cc water 25 cc vinegar 2 bowls Rice Krispies + meal insulin dose before eating Vinegar Challenge NOPE!
  159. 159. What we have learned: microdosing 1) Experiment with insulin and carbs safely. Keep them both handy 2) “Aim small…miss small” 3) Develop skills at higher targets first 4) Practice, practice, practice 5) Prior skills must be mastered first 6) This is at the heart of Sugar Surfing
  160. 160. Learn your own insulin duration To forge I-chains
  161. 161. 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
  162. 162. 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
  163. 163. Duration of insulin effect can be determined here ~ 4 hours
  164. 164. IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal
  165. 165. Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours
  166. 166. 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus “Inflections” calibration Tex-Mex Dinner calibration “Remember the Alamo”
  167. 167. 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
  168. 168. 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
  169. 169. What have we learned? DIA and I-Chains 1) Slow carbs can expose your duration of insulin action 2) Learn how to find it 3) Overlap your DIA like chains to mimic an extended insulin bolus
  170. 170. Dealing with shifting tides
  171. 171. “Fried-food revenge” and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours
  172. 172. “Revenge of the Ribeye” and “The Insulin Strikes Back” BG 167: 4 units LAG 2-3h
  173. 173. Slow BG rise from protein-fat laden meal
  174. 174. Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours
  175. 175. 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes
  176. 176. Correction with 20 grams carbs 20 gm CHO
  177. 177. What have we learned? Slow Trends 1) Slow up and down trends happen 2) Some can be explained, others can’t 3) Bend the trend with insulin or carbs and be patient
  178. 178. Pre-empting
  179. 179. 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A “random rise” in BG during a routine day. 2-3 hours
  180. 180. 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
  181. 181. 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
  182. 182. TIGER: I’m down by 1, how should I play the next shot? CADDY: Just hit the ball at 44 meters per second with a 30 degree elevation into the wind, but only if it’s blowing from the south at less than 10 miles an hour Tiger and his caddy talk golf “Huh?, What an idiot”
  183. 183. ENDO: You just need new pump settings: Carb ratio 1:5 Correction 1:45 Basal rate 1.2 U/hr Target 110 mg/dl IOB: 3.5 hours. See you in 3 months! TEEN: Why am I having trouble with my diabetes? Endo and the teen “Huh?, What an idiot”
  184. 184. 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
  185. 185. 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 …flux?” “What the…
  186. 186. Duration of insulin
  187. 187. 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization
  188. 188. “Working down” a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings
  189. 189. Mexican food standoff 9 U 7 U 6 U 5 U Basal rate good Basket of chips and Mexican Plate
  190. 190. 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
  191. 191. One goal to aim for: pre-empt meal spikes
  192. 192. Advanced Sugar Surfing: Engine Braking with a pump Back to normal 0.8 U/hr20% ↓ to 0.64 U/hour for 2 hr BG 102 mg/dl 11:49 PM 1:49 AM
  193. 193. What have we learned? Pre-empting 1) Watch the trend line more often after a meal 2) Wait for a clear trend (up or down) 3) Use your action thresholds 4) Preempt on the rise or fall 5) Rapid rises or falls often require greater force to neutralize or turn
  194. 194. Shoving, pushing, nudging… …and“Taking the Drop”
  195. 195. Two gulps of juice (15-20g CHO) “Nudging a Drift” (aka microcarbing)
  196. 196. 5 gram CHO “nudge” @ 66 m/dl Dropping < 1 mg/dl/min “Nudging a Drift” (aka microcarbing)
  197. 197. 4 gram CHO “nudge” @ 66 mg/dl 4 gram CHO “nudge” @ 70 mg/dl “Nudging a Drift” (aka microcarbing)
  198. 198. Advanced Sugar Surfing calibration tip 2 units Novolog @ 5:06AM A. Slight upward drift B. “Nudge” bolus C. Calibrate at “the bend” A B C C before after
  199. 199. Managing “in the moment” Proper basal 8 GM = 2 gulps 60 mg/dl
  200. 200. Carb “nudge” BG 60 mg/dl: 6-8 grams fruit juice = 1 swallow (40-50 cc)
  201. 201. “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice
  202. 202. Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl
  203. 203. 5 gram CHO “nudge” @ 66 mg/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone
  204. 204. Late day “nudge” after no lunch with one “gulp” of fruit juice 84 mg/dl to 96 mg/dl
  205. 205. “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice
  206. 206. Leisurely walk from 7:00 to 8:30: straight line
  207. 207. Exercise “bump up” Moderate intensity 75 minute duration Glycogen  Glucose
  208. 208. 2 units 1 hr walk “Walking down” a trend
  209. 209. 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
  210. 210. Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk (EXERCISE) 2 units ~ 2 hours
  211. 211. 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours “Pushing sugar” aka “Nudging a drift”
  212. 212. BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons “launch window”
  213. 213. 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait “Taking the drop”…
  214. 214. “Taking the drop” BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth
  215. 215. 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)
  216. 216. 6U bolus Result of basal testing “Taking the drop” 2-3 hours
  217. 217. 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”
  218. 218. 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
  219. 219. 164 mg/dl 3.5 U Novolog @ 5:43AM 2 hours 85 mg/dl Slept on sensor Quality basal rate lag calibration
  220. 220. 1.00 U Novolog 2.00 U Novolog 28 CHO 4 CHO 4 CHO “Bend a trend” 12 hour view Surfing Skills needed: morning basal review trend recognition microbolusing microcarbing meal timing carb counting 1.00 U Novolog
  221. 221. Stuff happens… deal with it
  222. 222. “Smooth seas do not make skillful surfers”
  223. 223. Nudge @2:34 Basal confidence Engine brake 40%↓ 11:44PM-1:44AM Basal rate 0.48 U/hr Basal rate 0.8 U/hr Basal rate 0.8 U/hr Micro-experimentation* 6U 5U 4U 6U Tomato/Caprese 1 16oz Blonde beer Large Cobb Salad Half-slice bread “Unexpected” late BG rise Pre-emptive insulin stacking (alt: Superbolus) Sugar Surfing Full throttle lag
  224. 224. BG 186 mg/dl @3:38AM: 5U aspart Lag 2-3 hours “Battle of the O-rings” hoorah
  225. 225. Unexplained high… explained Culprit: bad pump site First discovered… Corrected all by injection
  226. 226. Tunneling and CGM “pickup” 154 mg/dl 5 units Novolog “tunneling” 30 degree angled site is 2 days old
  227. 227. Long low and late high in 7 yo
  228. 228. Long low and late high in 57 yo
  229. 229. Overnight high in 9 y.o. pumper
  230. 230. 102 mg/dl Midnight BG checks at camp 30 gm CHO
  231. 231. I slipped on a banana… Large banana 7 units Humalog meal Identify the: drift lag(s) drop
  232. 232. Following the drop and meal… Calibration
  233. 233. 4 units @ 167 mg/dl 2-3 hours
  234. 234. 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!
  235. 235. 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
  236. 236. Stress effect
  237. 237. 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
  238. 238. 3 units Staff Meeting Stress “Hollow Highs” are more common from stress adrenaline
  239. 239. 3 units Tx Overtreatment of a stress high Stress EPI
  240. 240. Recovery from overtreatment of a “stress” high 3 units Tx Stress EPI
  241. 241. Rest of the day after a stress high overcorrection B A S A L
  242. 242. Steroid pulse
  243. 243. 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
  244. 244. Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
  245. 245. 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
  246. 246.  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
  247. 247. 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
  248. 248. Dislodged insulin pump site… Picked up early by CGM Pump site changed, insulin dose given, carb correction taken…$13,000 saved
  249. 249. Slept on transmitter
  250. 250. Barely out of range
  251. 251. Overlapping receivers to maintain continuity • Once you have a second Dexcom receiver (after replacing the first one), you have a spare receiver. • Program the receiver to the frequency of the new transmitter and overlap their use. • At least 2 hours before the current session ends, start up the other receiver and start the countdown process. No data gaps in weeks 2 and 3 (maybe 4?)
  252. 252. BG bump up (10 mg/dl rise) after waking at 4:45AM (real or not?)
  253. 253. How does this feel?
  254. 254. 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.
  255. 255. Although subtle, this can be “felt”
  256. 256. Feel the drop and level off
  257. 257. This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min
  258. 258. Watch the dots, not just the arrow
  259. 259. Watch the dots…not just the arrows Just 22 minutes later…
  260. 260. What have we learned? Sensing changes 1) You can learn to sense drops and rises. Practice guessing 2) Use your inner sensations to complement your sensor and meter, they will always be ahead of the screen readout 3) The arrows are least helpful: watch the dots!
  261. 261. A day of Sugar Surfing
  262. 262. A day of surfing
  263. 263. Basal checking…always
  264. 264. 1 unit Novolog @ 5:07 AM @120 mg/dl A small micro-bolus nudge
  265. 265. 3 units Novolog @ 6:29 AM @106 mg/dl 28 gm CHO @ 6:52 AM (92) Timing a dose and meal The “bend”
  266. 266. 2 unit Novolog @ 8:02 AM @126 mg/dl 76 mg/dl 4 gm 9:19 65 mg/dl 4 gm 10:45 69 mg/dl 4 gm 10:30 “Overnudging” and micro-carbing
  267. 267. 2 unit Novolog @ 12:19 PM @ 71 mg/dl 28 gm CHO @ 12:25PM (70) Timing a dose and meal
  268. 268. 81 mg/dl 4 gm 3:05PM 82 mg/dl 4 gm 4:11 micro-carbing 28 gm CHO @ 12:25PM (70)
  269. 269. 6.0 units Novolog @ 8:08 PM @ 113 mg/dl 3.0 units Novolog @ 8:54 PM @ 89 mg/dl Dinner: Soft Shell Crab/Roll 82 mg/dl 4 gm 4:11 1.5 units Novolog @ 7:51 PM @ 113 mg/dl
  270. 270. A day of surfing
  271. 271. Do I need to be on an insulin pump before using a CGM? • No, you can be on injections (MDI) too Must my diabetes be present for a period of time first? • No Do I have to wear it all the time? Can I take a break? • Yes, certainly Can I reuse a sensor? • Yes. I will explain later CGM Frequently Asked Questions
  272. 272. Can children use these devices? • Yes. FDA has approved them for as young as age 2 CGM Frequently Asked Questions Do insurance companies cover these? • Yes. Usually Does Medicaid/Medicare cover these devices? • Not generally but there have been some successes reported Do I need special training to start using a CGM? • Ideally yes. There are tutorials for how to get started. But a live trainer is best
  273. 273. 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
  274. 274. Closing thoughts
  275. 275. Sugar Surfing principles to live by… • Get out in front of the sugar wave or drop (be aware) • Practice micro-dosing at higher baselines to start • Remember your successes, memorize your failures • If the wave (or a drop) gets in front of you, be patient, attack it and take the drop or the rebound • Rearrange your food order based on the glucose situation • Master nudges and shoves: they are at the heart of surfing • Set and refine your personal “action thresholds” • Calibrate and basal test daily
  276. 276. Quiz
  277. 277. Day vs. Night: any thoughts about why?
  278. 278. What is this called? Answer: “taking the drop”
  279. 279. What is this called?
  280. 280. What’s the message of this image?
  281. 281. What’s this image saying? (hint: look at the time)
  282. 282. What’s this image tell you?
  283. 283. What is this called?
  284. 284. When to pull the trigger?
  285. 285. Interpret these two images Hint: sensor is over two weeks old
  286. 286. What is it a good time for and why?
  287. 287. A good time to calibrate
  288. 288. Penny stock day trading strategySugarSurfing
  289. 289. © “Kicks Diabetes” SugarSurfing

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