Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
ā¢Download as PPTX, PDFā¢
12 likesā¢10,441 views
1) Managing diabetes well requires comprehending changing glucose levels, adjusting to situations, and frequent assessments like surfing glucose levels with a CGM. 2) Effective CGM use involves wearing it often, checking trends, understanding sensor and insulin lag times, and being willing to experiment to improve skills over time. 3) "Sugar surfing" with a CGM means anticipating glucose level changes and giving small, frequent insulin doses or carbohydrate intake to keep levels in target range despite fluxes, rather than large reactive doses.
Recommended
Recommended
More Related Content
What's hot
What's hot (8)
Similar to Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
Similar to Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014 (20)
Recently uploaded
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
- 1. Sugar Surfing with a CGM Stephen W. Ponder MD, FAAP, CDE
- 2. Managing ādā well requiresā¦ ā¢ Comprehending a system with basic principles/concepts ā¢ Adjusting to changing or shifting conditions/situations ā¢ Frequent assessments and re- assessments LIKEā¦. ā¢ Driving a car ā¢ Flying an airplane ā¢ Walking a tightrope ā¢ Surfing
- 3. Appreciate the flux of sugar levels in non-d persons
- 4. Remember: Sugar Surfing is all about managingā¦
- 6. Diabetes is best approached 1 day at a time
- 7. 8 versus 1440 ādecision pointsā 7:03 115 9:33 129 12:15 95 3:34 131 6:12 168 9:49 107 11:53 114 3:05 132 * * * * * * * *
- 8. Donāt pass up an opportunity to assess a trending BG ā¢ Choose what you consider āactionableā ā¢ Set personal action thresholds ā¢ Use situational thinking: consider recent, current and impending actions ā¢ Check your BG results over time ā¢ ātreat to targetā (repeat as needed, but donāt āoverstackā your insulin)
- 9. (Glucose production ā Glucose disposal) = FLUX Here is a picture of FLUX and DRIFT
- 10. 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 āglucose transit systemā
- 11. static vs. dynamic diabetes care static ā¢ Actions predetermined ā¢ Minimal flexibility: RIGID ā¢ Outcomes donāt immediately affect subsequent actions ā¢ Easy to teach/learn ā¢ Less time-intensive ā¢ Favors concrete thinking ā¢ Less motivation needed dynamic ā¢ Actions are dependent on situation/circumstance ā¢ Flexible and adaptable ā¢ Outcomes constantly influence subsequent actions ā¢ Training needed, plus ongoing reinforcement ā¢ More time intensive ā¢ Favors problem-solving ā¢ Requires ongoing motivation
- 13. A pancreas canāt predict the future ā¢ It acts so fast it doesnāt need to. ā¢ Can shut off insulin immediately ā¢ Can release premade insulin ā¢ Insulin it releases can start working in minutes ā¢ Can rapidly respond to shifts in sugar levels
- 14. Set āactionableā thresholds ā¢ Upper/Lower limits ā¢ 80 mg/dl and 140 mg/dl ā¢ 90 mg/dl and 180 mg/dl ā¢ Rates of change ā¢ Up or down arrows ā¢ Factor in recent/current/future events as you are able ā¢ Test your skills, experiment a little within reason
- 15. Traits of effective CGM users ļ¼Wear it most of the time ļ¼Check trend line often ļ¼They āwork the lagā times ļ¼FOOD lag ļ¼INSULIN lag ļ¼SENSOR lag ļ¼Not afraid to experiment ļ¼Not expecting perfection
- 16. Principles of Sugar 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 happenā¦ 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.Donāt let āgood enoughā be the enemy 11.Calibrate carefully 12.Pre-empt when you can
- 17. āTHE TREND IS YOUR FRIENDā 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
- 18. Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate
- 19. Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert
- 20. Timing 101 ā 20 min. match Insulin Food
- 21. Timing 101 ā 45 min. mismatch Insulin Food
- 22. Be realistic ļ¼Accept that the first 6-12 months are on a ālearning curveā ļ¼Set higher and wider targets ļ¼Have low expectations to start ļ¼Itās still a finicky technology ļ¼PLEASE BE PATIENT
- 23. BG awareness vs. alarm fatigue ā¢ Set reasonable alarm thresholds ā¢ Depends on your goals ā¢ Avoid high spikes? ā¢ Avoid lows? ā¢ Toddler? Child? Teen? Adult? ā¢ Make sure you can hear/sense the alarm ā¢ Anticipatory action can minimize alarms
- 24. Cal-i-bra-tion (noun Ėka-lÉ-ĖbrÄ- shÉn) ā¢ Comparing the sensor to an accepted āstandardā value ā¢ The accepted āstandardā value is a fingerstick BG level ā¢ So the sensor itself can be no more accurate than the BG meter itās compared toā¦or how well the BG meter was used
- 25. Calibration tips ā¢ The first sensor day can be erratic as it āsettles inā ā¢ Donāt over calibrate! ā¢ Try to calibrate on a steady trend ā¢ Try to calibrate when in your target range
- 26. CGM calibration tipā¦ steady 2 hours Whenever possible: calibrate the CGM system when on a āsteadyā sugar trendline 2 hr āwaitā time between āturning onā sensor and providing 2 calibration BG readings to start session steady baseline
- 27. Daily calibrating on a steady baseline
- 28. Steady trend 2 hours Calibrate your CGMā¦ On a steady trend when you canā¦ In the BG range you want to be most accurate inā¦ Steady trend
- 29. 4 hours post start up calibration (extra)
- 30. Settling in at 6 hours: wobble
- 31. Sensors are not always right Or is it the meter thatās off?
- 32. Morning madness? After 14 hours after new CGM sensor insertionā¦ 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 āsettle inā or āreadā properly. Take this under consideration and donāt give up on a session too soon. But BG meter calibration shows THISā¦
- 34. Overnight basal in range (glargine)
- 36. Overnight control in range
- 37. Basal testingā¦
- 38. Overnight basal control - Lantus
- 40. Learning from the Line Graph ā 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
- 41. Why timing is everything
- 42. 3 units @6:10 28 gm @ 6:50 Timingā¦waiting for the bend āwindowā
- 43. 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike
- 44. Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the ābendā!
- 45. Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM)
- 46. Point āAā Point āBā sugar trend Insulin ācorrectionā Carb ācorrectionā ~ 2 hours for insulin ~ 15-30 minutes for carbs Range of possible BG outcomes āthe trend is your friendā Blood glucose level
- 47. 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 āDirection affects correction ā
- 48. Although subtle, this can be āfeltā
- 49. 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
- 50. Micro-bolusing (dosing) Steady baseline BG trend BG 136 mg/dl 2 units lispro Wait 2 hours Target zone ā¢ Very advanced ā¢ CGM needed! ā¢ Note flat BG ābaselineā trend ā¢ Calibration good ā¢ Not ācorrectionā per se ā¢ More of an āadjustmentā
- 51. BG 137 mg/dl and rising slowly 3 units lispro āMicro-bolusingā
- 52. BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time
- 53. 112 mg/dl to 78 mg/dl after 1.5 units by injection on a āsteadyā BG baseline 1.5 units ~ 2 hours
- 55. 4 unit lispro āpushā āCourse correcting for smooth sailingā Well balanced basal insulin
- 56. 6 unit āshoveā at 133 mg/dl ļ¬
- 57. 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 pointsā¦ a. Know your insulin āumbrellaā 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
- 58. 6:53PM BG 108 inj 6 units 7:15-7:35 9:52PM BG 125ā inj 4 units āEffective durationā of insulin action: 3 hrs āActive insulinā ā¢ Example: Slow carb meal (fried food) ā¢ e.g., Chicken fried steak, cream gravy and 3 onion rings and 8 French fries ā¢ Estimated 60 grams: 6 units: inject 6 units lispro ā¢ NO rise in BG for 3 hours, then rapid ascent ā¢ Time until rise reflects āactive insulinā effect ā¢ Must do this many times and take the average
- 59. Duration of insulin effect can be determined here ~ 4 hours
- 60. IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal
- 61. Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours
- 62. 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus āInflectionsā calibration Tex-Mex Dinner calibration āRemember the Alamoā
- 63. Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl
- 64. 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes
- 65. Correction with 20 grams carbs 20 gm CHO
- 66. 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 ā¢ Experimented here: ā¢ Ate a pasta meal at the Olive Garden ā¢ Took a single insulin shot (70 gm = 7 units) ā¢ Sugar dropped at time of usual peak insulin action: ~60-90 minutes ā¢ BG recovered without treatment ā¢ Late rise in BG required second injection Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro
- 67. 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 ā¢ Ate a pasta meal at the Olive Garden ā¢ Took a single insulin shot (70 gm = 7 units) ā¢ Sugar dropped at time of usual peak insulin action: ~60-90 minutes ā¢ BG recovered without treatment ā¢ Late rise in BG required second injection ā¢ Notice the insulin-food ābalanceā and how it effects BG levels Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro Insulin effect Food effect
- 68. āFried-food revengeā and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours
- 69. āRevenge of the Ribeyeā and āThe Insulin Strikes Backā BG 167: 4 units LAG 2-3h
- 70. Slow BG rise from protein-fat laden meal
- 71. Slow overnight rise and early AM correction
- 72. Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours
- 73. 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A ārandom riseā in BG during a routine day. 2-3 hours
- 74. Working itā¦(i.e., glucose control exists āin the momentā) ~ 2 hours Oops! I Ate an EXTRA breakfast taco! BG 142 ā : took 5 units hypothetical real
- 75. And thirdly, the correction and carb ratios is more what youād call āguidelinesā than actual rules āMost of our assumptions have outlived their usefulnessā Marshall McLuhan
- 76. 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
- 77. 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 ā¦flux?ā āWhat theā¦
- 79. 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization
- 80. Two gulps of juice (15-20g CHO)
- 81. 5 gram CHO ānudgeā @ 66 m/dl Dropping < 1 mg/dl/min āThe nudgeā (aka microcarbing)
- 82. 5 gram CHO ānudgeā @ 66 m/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone
- 83. Leisurely walk from 7:00 to 8:30: straight line
- 84. Exercise ābump upā Moderate intensity 75 minute duration Glycogen ļØ Glucose
- 85. 2 units 1 hr walk āWalking downā a trend
- 86. Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection 4 units ~ 2 hours
- 87. Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk 2 units ~ 2 hours
- 88. 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours āPushing sugarā
- 89. BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons
- 90. 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait Taking the dropā¦
- 91. āTaking the dropā BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth
- 92. 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) āLivinā la vida Glucoā
- 93. 182 mg/dl : 7 units lispro Insulin lag time 30-40 min Eat breakfast here Food lag time 124 mg/dl Timing is everythingā¦do you have the patience or the time? Slow BG rise overnight from fried meal BG drop time 20-30 min
- 94. Missed 9PM basal dose (glargine) Normal time Lantus taken (9PM) Detected rising sugar level @ 2AM Humalog dose (7U) AND usual Lantus taken (20U) Sensor āgapā!! dinner Fell asleep! All back in range by morning!
- 95. 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
- 96. Stress effect
- 97. Endocrinology Board Exam taken every 10 years Stress and Sugar ā¢ Strong emotional stress triggers release of a several hormones ā¢ These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body ā¢ Stress hormones also make the liver produce sugar from substances like protein and fat ā¢ This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood ā¢ CGM allows for more aggressive anti-stress treatment of rising sugars
- 98. Crossing 140 mg/dl @ 3AM and a 2.5 U lispro correction ~ 2 hours Lag time Why act? ā¢ Slow upward BG trend (red arrow) ā¢ Crossed personal āaction considerationā threshold: 140 mg/dl in my case (yellow line) ā¢ Knew the CGM would alert me to a rapidly dropping BG later if I over treated ā¢ Have done this many times before: practice, practice, practice
- 99. Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
- 100. Awakened by CGM alarm to a BG below 60 mg/dl Lag time 20gm Rationale ā¢ Slow downward BG trend (red arrow) ā¢ Crossed personal āaction considerationā threshold: 60 mg/dl in my case (yellow bottom line) ā¢ Drank 20 gm grape juice and went back to sleep ā¢ Knew the CGM would alert me to a rapidly rising BG later if I over treated ā¢ Have done this many times before: practice, practice, practice
- 101. This can be āsensed tooā CHO A steady trend The bodyās 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 ā¢ Blood sugar control is complex, it includes the brain and nervous system ā¢ Long term damage to the autonomic nervous system can result in loss of classic signs/symptoms of low blood sugar ā¢ 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) ā¢ A CGM device can serve as a ābiofeedbackā device of sorts in adults willing to develop the ability over time.
- 103. Feel the drop and level off
- 104. Subtle correction ā¢ BG 125 and rising ā¢ Took 4 units lispro ā¢ 2 for the slow rise ā¢ 2 for the correction ā¢ Waited almost 2 hours (yellow arrow) ā¢ Notice lag time before BG āturnsā (red arrow)
- 105. This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min
- 106. āWorking downā a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings
- 107. 4 units Humalog @ 11:07PM BG rising after insulin effect isāwaningā. BG = 146 mg/dl Dinner (soft tacos, refried bean and chips/salsa); 7 units lispro taken 20 minutes premeal at 7PM My āDIAā = 3-4 hours Notice the obligatory ālag timeā! Anatomy of a preemptive correction
- 108. 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
- 109. 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
- 110. Day vs. Night: any thoughts about why?
- 111. Interpret these two images Hint: sensor is over two weeks old
- 112. What is it a good time for and why?
- 113. Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl
- 115. 6 U 4 U 4 U 4 U 5 U 6 U 28 GM 90+ GM 1. Stacked insulin + delayed eating 2. āHyper-treatedā severe low 3. Fought āreboundā high BG all night 4. Took the drop and timed meal
- 116. Dislodged insulin pump siteā¦ Picked up early by CGM Pump site changed, insulin dose given, carb correction takenā¦$13,000 saved
- 117. Penny stock day trading strategyCGM is āsugar surfingā board
Editor's Notes
- Music: Beach Boys
- Change āManaging ādā well with the words: Sugar Surfing requires the following skills and equipment
- Normal tides and swells in non-d humans
- Itās all about riding the waves, crests and troughs
- Based on the principle of FPM (frequent pattern management)
- BG (mg/dl) x 75 ml/kg blood volumes x weight in kg x 1dL/100 ml = mg of BG in TBV
- Timing 3 at 6:32 28 GM at 6:52 started at 127 and are at 108
- āThe Umbrella EffectāIāve packed a lot of useful teaching points into one image here.While long-acting or basal insulin delivery(insulin glargine, insulin detemir, or the basal delivery rate on a pump) is like having a long roof over your glycemic āheadā. Injections or boluses of rapid acting insulin have umbrella-likeproperties. Properties of any insulin include 1) time to onset of sugar lowering effect, 2) duration of peak sugar lowering activity, and 3) an effective duration of action. I always include a fourth dimension: day to day inconsistency, which can wobble or vary a bit. Itās not only helpful, but crucial that a person using insulin have a good working understanding of these properties of the insulin being taken. Without this understanding, manipulation of sugar levels as Iām about to describe are not possible. When properly applied, rapid-acting insulin protects the user (like an umbrella) from the āshowerā of after meal hyperglycemia that rains down for a certain period of time (a). It does so by disposing of glucose into cells. Extending the metaphor fully, basal insulin acts as a roof with gutters that continually and gradually shunts sugar into cells, but without a great capacity. So, in a sense insulin has umbrella-like qualities as I show here on my CGM sensor plot (a 12 hour display in this case). I ate late on this evening and chose one of my more challenging foods to manage: fried chicken (b). Itās a favorite and I donāt eat it regularly for this reason. Nevertheless it was my choice. Fried meals often take more time to digest into blood sugar. That time can extend well beyond the action of the meal time insulin used to cover the meal (i.e., the umbrella), as it did in this case. As you can see, my CGM device allows me to validate my duration of active insulin time, which for me is 3 hours (a). This is the actual span of my insulin umbrella in this case. After that time, the waning insulin effect is no longer able to contain the steady input of sugar coming into my blood stream from my fried meal and the basal insulin in my body canāt properly ācoverā this slow influx of sugar. The end result is a slow accumulation of sugar in my blood stream, registered as the rise on my CGM plot shown here (b).Well, I awoke and looked at my sensor and noted I was at 171 mg/dl (d) but the arrow was straight, meaning a gradual upward trend of under 1 mg/dl/minute. Looking at the trend line, recalling what I ate and knowing my prior responses to fried meals, I decided to correct this trend so I would not wake up in the morning with a BG well over 200 mg/dl. Therefore, I took 6 units of insulin to accomplish this. Normally this would take about 3 units since my correction factor is between 1:25 and 1:33 most of the time. But here is another teaching point: my BG was slowly rising and had a form of āmomentumā behind it. Had it been trending straight, or even downward, I would have taken very different actions. But since it was trending up, I knew from experience that I needed a greater insulin āforceā to neutralize the rise, turn the BG trend downward, and back to my desired target BG of 100 mg/dl. Soā¦I doubled it (6 units). As illustrated here, there was the customary 20 minute or longer ālagā time before any measureable effect of my correction insulin was seen (c). After the insulin lowering effect was underway, it took a full two hours to arrive and stabilize at my target (e). And by the way, I went back to sleep after I took those 6 units of lispro in the middle of the night. Crazy? I would agree with you 100% if I were not using a CGM device. I would be hesitant to take rapid-acting insulin so aggressively although I would have taken the standard 3 units. The result would have most likely been less than optimal, but it would have blunted the rise. My practice here is the end result of lots of practice and careful observation of my own unique responses. Anyone who attempts these maneuvers must find what best works for them. Itās also wise to discuss with your diabetes doctor. Although I must say that many docs might discourage such self-care independence. This is a look into how I manage the daily ebb and flow of my blood sugars. This is not childās play and requires the input of an experienced and motivated adult. Parents of children with diabetes can master these skills and many have, but it takes patience, consistency and resilience to achieve the confidence illustrated here. I hope this teaching slide is helpful to many of you. This further demonstrates how tight glycemic control truly exists āin the momentā, as I try to illustrate all the time.
- āPlaying Chickenā with a CGM, blood sugar and insulinI have a weakness for fried chicken. I try not to indulge myself with it often since it requires some extra work to manage the after effects on my blood sugar. The other night I had two pieces of chicken, a roll, cole slaw and green beans (not shown) around 7PM. By midnight, the slowly digesting meal (lots of fat and carbs) combined with the waning effect of my suppertime insulin, could no longer contain the rising tide of glucose entering my bloodstream and hence the levels began to rise after midnight. I woke up and noticed this rise at 2:06 AM. I of course knew what I had eaten the night before, my typical BG pattern with foods like this (a slow steady rise after my meal insulin wears off), plus I realized that some chicken remained in my stomach and was waiting to get into the gut (fatty foods linger in the stomach longer, not a lot of glucose absorption happens there). Knowing this, plus my response to prior doses of insulin to offset these sorts of rises, I took 5 units of rapid-acting mealtime insulin (lispro), then went back to sleep. If I was still on my insulin pump, I would have taken a combination (dual-wave) bolus, but that is another discussion.Let me say that I would NEVER have taken 5 units of insulin at 132 mg/dl and then gone back to sleep. At least not before I had my Dexcom G4. My graphic shows what would most likely have happened if I had just slept through the night and done nothing. Waking up the next morning my BG would be over 200 mg/dl even though at bedtime I was in range. In fact, it is possible I would have taken a snack at bedtime on top of all this, further driving the reading up overnight. The training and understanding of health care providers has some catching up to do in regards to using dynamic versus static data sets created by CGM technologies. The preference is to have a machine make the call (the artificial pancreas or AP). That makes the most sense for the most people I agree. But cruise control is rarely used in rough terrain. I find that a well practiced working knowledge of oneās own body and responses, combined with experience and judgment, can allow some of us now to benefit from a āmanualā version of the AP of our own creation. But I agree this isnāt anything kids are able to do quite yet. But IMO the principles used to do this can help everyone in their daily problem-solving and trouble-shooting situations. Anyway, notice that over the next 2-3 hours, I was able to ābendā the glucose curve back the way I wanted it to go. The waviness in the line might have been the sensor on itās final day since I changed it the next day, but when I calibrated at 5:30, the sensor said 97 mg/dl and my meter said 102 mg/dl. Thank you, Dexcom G4!The power to safely experiment with otherwise forbidden or dangerous practices like taking a dose of 5 units rapid-acting insulin and then going back to sleep is something that is not discussed enough about CGMās. This is like practicing a high wire trapeze act with a big safety net underneath me: itās hard to get hurt too badly. Of course I have ample sources of fast sugar (juice) by my bedside (or car or at work) when I do this. My CGM gives me the ability to see highs or lows coming from a distance, not when they are right upon me. This is a tremendous benefit of these devices. When patients ask me, I tell them that a CGM can serve two functions. One the one hand it can serve as a āburglar alarmā that will buzz or beep at alert me when hypo or hyperglycemia is entering my body. On the other hand, it can also be a surveillance system that scans the horizon for possible intruders, allowing you to pick them off before they get too close. As you can see, I use it very proactively, but I am also still reacting to what is happening to me (the fried chicken on this occasion). But a CGM is also a biodfeedback device. I teaches me what different BG levels FEEL LIKE. I can now reliably predict when my BG is shiftingā¦up or down. What an added benefit indeed. I hope this post teaches a few things about knowing yourself, safely experimenting new approaches, and always looking at diabetes self care as a practicable skill, which in my opinion is exactly what it is. As always, feel free to share this post with others who might benefit. I hope you all turned your clocks BACK last night before going to bed. That includes all your diabetes devices too: pumps, sensors and meters.
- FFA Field trip home at 10PM. BG shot up at 2PM. Ate pizza for dinner at 8PM. Unknown insulin dose taken relative to meal Meter says 420 at 379 on sensor. Went to 56 by 10:45AM next AM
- At sensor calibration time, sensor read 103 mg/dl and meter read 101 mg/dl. After calibration it reset to 99 mg/dl
- Straight line trends need more subtle corrections
- Bad pump siteā¦
- Requirements of Penny Stock InvestorsYou should not get involved with day trading unless you are able to effectively monitor your holdings and can commit with the proper mind set and outlook. This strategy takes time, research, and a good deal of money (I suggest at least $4,000). Otherwise, you may not be able to benefit from such a trading methodology.You need to be able to check the prices of stocks on a moment's notice, and get an accurate and up-to-the-minute quote. Having internet access or a computer connection to your broker from work or home is generally best. When day trading, you may need to check stock prices frequently, possibly watching their prices all day. Using a computer it takes only a few minutes each time, you can get current prices, and can alter or submit new orders on-line after checking the penny stock's activity.Most of all, you need patience. Although day trading in penny stocks is probably the quickest profit and loss method in the financial world, patience still comes into play. The best day trading strategies involve often going a week or so without a trade, because you must wait to get the best prices. Impatience immediately negates the effectiveness of the day trading strategy.Finally, you need a strong stomach. You should understand that day trading in penny stocks can result in one week gains that are monumental, or can set you up for a loss. Whether making a big profit or taking an ugly loss, you should be able to handle both the good and bad stress that will come with this method of trading. Otherwise, you may make moves for the wrong reasons and compromise your objectives.What Day Trading IsDay trading is simply an attempt to capitalize on short term fluctuations in stocks. For example, with penny stocks it is possible to buy an issue at $0.12 and sell it the next week, day, or even a few hours later at $0.15, giving you a 25% short-term profit on your investment.If a profit of more than 20% to 25% presents itself, you often take it. Do this a few times and you are looking at a highly successful investment strategy.The downside of day trading comes into play when you buy an issue and it drops in value. At that point you either take a quick loss to keep your money available, or you sit and wait for a profit opportunity that may arise later, in which case your money is tied up until that time. This becomes less of a concern for traders who have more assets at their disposal, because while only a portion of their money is temporarily tied up in a stock that has fallen in value, the rest of their portfolio could be actively used.Now, let me tell you how to take advantage of day trading without significant risk, and with maximum profit potential. If you are going to begin day trading, read this section a few times through and adjust your own investment style accordingly.Goals of Day TradingThis is very important if you intend to be successful at day trading. Your overall goal is to make several hundred of percent on your investments on a year by year basis. However, this is to be done 40% and 30%, even sometimes 10% at a time. That is where most day trading strategies fall apart - investors donāt understand that taking the smaller gains more frequently will actually be more effective than the larger gains less frequently!Your goals for an effective day trading strategy should be as follows:ā¢Keep on top of your open buy and sell orders, and the trading activity of the underlying stocks so that you are rarely surprised by a penny stockās action.ā¢To take small profits when they present themselves. You will find that you have the opportunity for small 15-25% profits very frequently.You wonāt often be in a position to be taking the larger 30%-50% profits, because you already would have sold when your shares first began to rise. Therefore, as backwards as it sounds, if you find that you are taking 50% profits more often than 25% gains, you are probably doing something wrong. In the long run, you would likely make more money by grabbing the 25% gains again and again, instead of holding out for the larger returns.Effective Strategies and ConsiderationsThe first consideration of this trading method compared to others is that you will be taking commissions more frequently. If you are not already with a discount broker, or are paying more than $20 per trade, you probably should switch to a cheaper broker. You can read all about penny stock brokers, and get my list of the top ones earlier in this site.With penny stocks, you may often find that a buy or sell order goes partially filled. For example, you may only get $200 worth of shares and be stuck with a $20 commission. To avoid this, keep track of your orders during the trading day - you may pick up a portion of your order at the price you want, then have to adjust the purchase or sell price to make sure you get the rest of the order filled. Changing an existing order to get all the shares you want on one day, instead of over two or three days, means that you will only be subject to one commission.The beauty of day trading is that company fundamentals and overall market action become less significant. You are playing the day by day fluctuations instead of hoping the market will rise or the company will increase its earnings. Buying at the low end of volatility and selling at the high end equals success, despite monthly trends, company fundamentals, or the market outlook.Therefore, it doesnāt matter if the companies you invest in have a positive future or are bad long-term purchases. Whatās important is that you keep an eye on the trading activity of the issue in question, try to pick its higher and lower trading ranges, then execute buy and sell orders accordingly.With day trading you need to realize that most of your buy orders should go unfilled, because your bid price needs to be lower than the going trading price of the stock. Buy on the dips and you will have success - put in orders to acquire shares at or below the current bid price. If you put in ten buy orders over the course of a month, you may wind up only getting one of the buys you had wanted, but those shares will be yours at a great price, making it easier to unload them for a quick profit.When tigers hunt, they only catch a meal one out of ten attempts.Deciding on appropriate buy and sell prices at which to submit your orders is relatively simple. Look at a stock that has both high volume of bid lots, and high volume of ask lots. Many people are trying to buy at one price and many people are attempting to sell at another. Look at the spread between the bid and ask prices. If it is about 15% or more, you may want to put in a buy order at the bid price, and if it gets filled immediately put in a sell order at the ask price.Of great importance is the number of bid lots compared to the number of ask lots. There is a very different stock price outlook if the number of bid shares vastly outnumber the ask shares, or vice-versa. The more bid lots, the greater the buying pressure and price strength at that level. In other words, if there is a large level of demand, the price will likely solidify at that level and begin to climb, unless there are enough shares for sale to meet the demand.When getting a stock price quote, look at the number of bid lots and ask lots to get an idea of the demand and supply. This will give you a relatively accurate indicator of the direction the penny stock price will travel in the day, and perhaps throughout the following few days. Use the bid lot and ask lot volumes to help you come up with a price range that the penny stock will trade within.Day trading will prove most effective when you trade in penny stocks that you have been watching for a long time. You will be able to produce better results since you have developed a feel for the upper and lower price ranges. This is not a requirement for success, but rather an advantage.Hedging and Averaging DownAs a more advanced strategy, you may want to incorporate hedging into your day trading practices. When buying, this involves putting in buy orders for the same stock at different prices.Let's use an example: You put in an order to buy 4000 shares of OCN @ $0.23 and a separate order to buy 4000 shares of OCN @ $0.17. Now consult the chart below to see the possible outcomes of your strategy.Possible Hedging Outcomesā¢Outcome #1: If the price falls to or below $0.23, your first order gets filled. Now if the price drops further, you may get your second order filled at a lower price, averaging the price of your 8000 shares to $0.20. Profits could be realized now by selling at $0.22 or greater. If the price climbs, you will make a profit. If it continues to fall you will take a paper loss. This becomes an actual loss if you sell the shares, or if the shares never return to their $0.22 levels. However, in all likelihood the price will bounce around and will present an opportunity to profit or at least break even at some point in the future.ā¢Outcome #2: The price falls to or below $0.23 and your first order gets filled. The price then rises, leaving your second order unfilled, but providing you with the ability to profit on the 4000 shares you did buy.ā¢Outcome #3: The price does not fall low enough to fill your buy order. You donāt get the shares, but you are no worse off. You can extend your order, adjust your prices, or move on to a different penny stock. Again we must stress that an unfilled buy order means that you probably have the right idea. It is better to have an unfilled buy order than to get shares at too high of a price.These hedging strategies can also apply in the same manner when selling penny stocks.Of course, you are also getting exposed to extra commissions with this strategy.Day Trading SummaryDay trading penny stocks is as straight forward as it sounds. However, you will need a little luck, a lot of patience, and the ability to take the profits that present themselves. By keeping a close eye on the markets and following a simple strategy such as the one outlined above, day trading becomes a straight-forward technical process that requires little thought, yet can provide impressive penny stock returns.