Sugar Surfing(TM) Workshop Dallas Texas Slide Deck Sept 20 2014

Welcome!
Pre-order the book here: sugarsurfing.com
Like “The Power Within by Stephen Ponder MD, FAAP CDE”
stephenponderMD.com

Sugar Surfing
™
Stephen W. Ponder MD, FAAP, CDE (aka “doctor juicebox”)

Sugar Surfing
Deltec Insulin pump MDI: Lantus and Humalog

Different users: which one is the surfer?
A Type 1 surfer dude B Non-d adult woman

But this is Sugar Surfing too…

Sugar Surfing is a process, not a result

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.
Sugar Surfing emphasizes significance
YOUR
GETTING
LOW!

Sugar Surfing is Fuzzy Logic in motion

Almost as “tight”as it gets

This is about as tight as it gets

7 year old American Sugar Surfer

A 7 year old Sugar Surfing in Canada!

“Dr. Ponder lines” in Canada

Sugar Surfing™ is driven by
“The Power Within”
Like The Power Within by Stephen Ponder MD, FAAP CDE
facebook.com/stephenponderMD

©
Kicks Diabetes
Sugar Surfing

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-bolusing
• Knowing your DIA (IOB)
• Nudging, pushing and shoving sugar
• Pre-empting
• “Taking the drop”
• The trend is your friend
Gluca-bunga!

Appreciate the flux of sugar levels in non-d persons

Remember: Sugar Surfing is all about managing…

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

(Sugar in – Sugar out) = FLUX
Here is a picture of FLUX and DRIFT

“Life is not a matter of holding good cards, but of playing a poor hand well.”
R.L. Stevenson (1850-1894)

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…

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

Diabetes care is about choices

What do these numbers mean?
23%
221

Diabetes care must be individualized

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

223 mg/dl
114 mg/dl
95 mg/dl
76 mg/dl
52 mg/dl
Oops!
5%
95% of the
time
Oops!
5%

Glargine vs new long acting insulin

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

“Chance favors the prepared mind” Louis Pasteur
…dude

“I haven't failed. I've just found 10,000 ways that won't work.” Thomas Edison

Hang in there. Don’t give up!

Knowledge alone does not imply understanding

“You can delegate authority but you can’t
delegate responsibility”

Do 2 RN’s = 1 kid?
=
Ok? Ok to me!

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.

Genetic
Predisposition
Autoimmune
process begins
Trigger
Measureable
loss of insulin
Diagnosis
Residual insulin
ability
honeymoon
Time in YEARS
100%
50%
20%
How insulin ability fades in type 1 diabetes

You CAN influence how long beta cells last
diabetes treatment preserves INTERNALLY made insulin

Is the future already here?
80
75
70
65
60
55
50
Lifespan with type 1 diabetes vs. without
1964 1980
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. 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.

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)

Diabetes care is best approached 1 day at a time

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

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

present
Actions Actions
“CONTROL”
past future

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 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)

Setting your targets…
CAN’T
MISS!

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

How much total sugar is in the blood for a 100 mg/dl BG level?
Human circulatory system
110 pound (50 kg) boy
(3.45 grams)
55 pound (25 kg) girl
(1.75 grams)
165 pound (75 kg) man
(5.1 grams)
aka “glucose transit system” = 4 gram glucose tab

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

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

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

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 of 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

This is where it all happens
I’m a Dexcom
G4 sensor tip
I’m a pump
catheter tip

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

“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

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

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

In the BG range you want to be most accurate in…
Steady trend
Calibrate your CGM…
On a steady trend when you can…
2 hours
Steady trend

4 hours post start up calibration (extra)

Settling in at 6 hours: wobble

Sensors are not always right
Or is it the meter that’s off?

Meter-Sensor mismatch/confusion
Dropping over 75-90 minutes 1st BG check: Hmmmm

First recheck: re-cleaned hands 2nd recheck a few minutes later

Sugar Surfing Calibration tips
1) On a steady trend line
2) In your target range
3) Make sure initial cal samples match closely
1) 2)
3)

Settling in: Morning madness?
After 14 hours after new
CGM sensor insertion…
After calibrating with
112 mg/dl, the sensor
immediately reads this
But BG meter calibration
shows 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.

Failing Sensor after several weeks

End of multi-week sensor session
(dying sensor: erratic)
NEW sensor session
2nd sensor session
(stop-restart)
New sensor chaos
erratic

Sensors can take time to settle in
Calibration day 1 (May 21) Next day (May 22)

Breaking in your new surfboard
calibration
Overnight basal: first sensor day “wobble”
Tips: 1) Give 2-3 additional BG checks in first 12 hours
Sensor
session
started
2) Things begin to improve after 12-18 hours
3) Don’t give up, breaking in a sensor takes time
Late dinner

Pop Quiz: What is it a good time
to do here?
Sensor: 127 mg/dl; meter 122 mg/dl

Overlapping receivers...week 2 to 3
(you need to save your receivers)
End of week 2 sensor session Start of week 3 sensor session

2 hours
Dual receivers linked to same sensor
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

Overnight basal in range (glargine)

Overnight basal control - Lantus

Sugar Surfing tip: midday basal testing
Omitted lunch
steady

Don’t forget the basal!
0.8 Units/hr basal rate
In the pipe

Important basal insulin concept:
the point of the basal insulin is to keep you
steady, not to consistently raise or lower your BG
levels.

3U @ 8:03
4U @ 7:41
5U @ 9:23
3U @ 8:36
Duration of insulin effect(s) Basal takes over
0.6 Units/hour pump basal rate
meal
Birthday dinner
Remington’s

Why basal testing is important

Basal testing with a 3 year old

REMEMBER
Always keep your eyes on the basal trending

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

Learning from the Line Graph – Insulin Timing
M
I I M
8a 10a
350
280
210
140
70
8a 10a
350
280
210
140
70
Yesterday Today
Insulin bolus: 7:30 AM
Breakfast: 7:30 AM
Insulin bolus: 7:10 AM
Breakfast: 7:30 AM

Timing 101 – 20 min. match
Insulin
Food

Timing 101 – 45 min. mismatch
Insulin
Food

Timing…waiting for the bend
3 units @6:10 28 gm @ 6:50
“window”

Basic Surfing: Timing
6 units Novolog
@ 5:27AM
28 gm CHO
@ 6:11AM
45 min

Timing insulin and meals to prevent a spike
3 U lispro @ 6:22AM
28 GM CHO @ 6:52AM

Wait for the bend!!
6U @146
Wait for the “bend”!
mg/dl Eat here @132
mg/dl
45 minutes

Stopping sugar spikes
3 units
(5:32AM)
Meal
(5:48 AM)

“the trend is your friend”
Point “A” Point “B”
sugar trend
Insulin “correction”
Carb “correction”
~ 2 hours for insulin
~ 15-30 minutes for carbs
Range of possible
BG outcomes
Blood glucose level

“Direction affects Correction”
BG = 180 BG = 187
2.1 U per calc 1.75 U per calc
2.1U @ 3:30 4U @ 5:30
Target= 110 mg/dl
Correction factor = 30
IOB = 3 hours
just leveled off
Basal rate 0.650 U/hr

“Direction affects correction ”
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

BG = 157 mg/dl
Inj 4 U lispro @3:15
2-3 hours
A 20-30 min
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

Correction and meal
6 units (161
mg/dl)
Meal
(26 gm CHO)
~ 45m
126 mg/dl

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) BG direction and speed affects
correction and the timing of your
actions

1 unit Novolog
@ 3:37AM
Leveling off
Microbolusing
calibration

Micro-bolusing (dosing)
BG 136 mg/dl
Steady baseline BG trend
2 units lispro
Target zone
Wait 2 hours
• Very advanced
• CGM needed!
• Note flat BG
“baseline” trend
• Calibration good
• Not “correction”
per se
• More of an
“adjustment”

microbolusing
2:42AM
1 unit Novolog
5:37AM
1 unit Novolog

“Micro-bolusing”
BG 137 mg/dl
and rising slowly
3 units lispro

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)

Microbolus experimentation
BG 124 mg/dl injected
1.5 units lispro
@3:56AM
2 hours
Lag time

112 mg/dl to 78 mg/dl after 1.5 units by
injection on a “steady” BG baseline
1.5 units
~ 2 hours

Microdosing Humalog at Churchi
2 units Humalog
@ BG 130 mg/dl
3 scrambled eggs
@ 9:20 AM
Slow protein rise?

Micro-dosing insulin
8:39AM 1 unit Novolog
nudge via pump
Basal rate constant here

2 units via pump
160 mg/dl
Pump “nudge”

CGM 125 mg/dl
2 U Novolog
5:40 AM via pump
Calibration
Nudging
CGM: 123 mg/dl
Meter: 123 mg/dl

“Pre-empting”
4 unit lispro “push”
Well balanced basal insulin

Micro-carbing practice
8 gm juice nudge 8 gm juice nudge 8 gm juice nudge
dinner
Any other suggestions?

Hello Kitty…goodbye low blood sugar
2 Pez @ 62 mg/dl

6 unit “shove” at 133 mg/dl 

3U @ 3:32
5U @ 4:50
6 @ 6:17
Gently turning a curve

Combo bolus experimenting
0.8 Units/hr basal rate
6
6
4
Manicotti and 2 Rolls
Combo bolus
Meal Carb nudges

6
Sugar Surfing on the Rio Grande
2 “nudge”
“50-50-5”
6 units “extended” (5 hours - 6:26-11:26PM)
Tacos al carbon, queso and chips: 80-100 gm CHO

Vinegar Challenge
+ + =
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
NOPE!

7U apidra
7:30AM
5U apidra
9:15AM
5U apidra
10:03AM
56 CHO
bend
Pre-empt
Breakfast cereal
challenge day 1
Take the drop
0.650 Units/hour basal rate

Breakfast cereal challenge
next attempt
12U apidra
7:30AM
5U apidra
3:37PM
56 CHO
Pre-empt
Take the drop
bend

Breakfast cereal challenge
third attempt
12U apidra
11:48AM
56 CHO
5 units over 3 hours

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

Learn your own insulin duration
To forge I-chains

Mealtime insulin @
8:30PM 7 units lispro
b
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
a e

7:15-7:35
6:53PM BG 108 inj 6 units
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

IOB after 6 units and fried meal
6 units
3.5-4 hours
2 units
Walk Fried
Meal

Rising BG trend (132
mg/dl) @ 2:06AM
5 units lispro @ 2:12
Fried Chicken
2.5 hours

“Remember the Alamo”
20 Lantus
“Inflections”
3 U Lispro 8 U 6 U 5 U 5 U
calibration
Tex-Mex Dinner
calibration

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

What have we learned? DIA and I-Chains
1) Slow carbs can expose your duration of
insulin action after a single rapid acting
insulin dose
2) Learn how to find/look for it
3) Overlap your DIA chains to mimic an
extended insulin bolus through a pump

“Fried-food revenge” and correction
Fried food earlier in evening
@ 8PM
BG = 194
6 unit correction @ 7AM
BG = 115 in 3
hours

“Revenge of the Ribeye” and “The Insulin Strikes Back”
BG 167: 4 units
LAG
2-3h

Slow BG rise from protein-fat laden meal

Correction at 2:45 AM after slow post dinner
rise with 5 units
5 units
~ 2 hours

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

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

A “random rise” in BG during a routine day.
3 units lispro
Breakfast
BG 173 mg/dl
5 units lispro
Meeting
2-3 hours

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

“Most of our assumptions have outlived their usefulness”
Marshall McLuhan
And thirdly, the correction and carb ratios is more
what you’d call ‘guidelines’ than actual rules

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”

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”

Insulin to carb ratios are only a start
7 U @ 10:54AM
8 U @ 9:30AM
6 U @ 12:29PM
60 grams carbs
Ultimately 21 U lispro

“What the…
7
5
4
5
…flux?”
Large bowl turkey soup and 2
small pieces cornbread @ 6:30

• 7:06PM 5.0
• 7:48PM 4.0
• 8:03PM 2.0
• 8:20PM 3.0
• 8:46PM 3.0
• 9:23PM 3.0
• 10:03PM 3.0
• 11:06PM 4.0 square
• 11:12PM 4.0

9 units lispro for 90 gm
Mexican food lunch @3:30
6 units lispro @ 6:30PM for
rising BG after 3 hr IOB
Stabilization

“Working down” a rising BG
4 units @
173 mg/dl
2 units @
167 mg/dl
7 units @ 2PM for
Whataburger and rings

Mexican food standoff
9 U
7 U
6 U
5 U
Basal rate good
Basket of chips and
Mexican Plate

Anatomy of a preemptive correction
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”!

Chicken Fried Steak
Large roll
Fried okra
Green beans
French fries
Fried cod
5.3 U
3.0 U
3.0 U
2.0 U
2.7U
Bending the trend

One goal to aim for: pre-empt meal spikes

Advanced Sugar Surfing: Engine Braking with a pump
11:49 PM
BG 102 mg/dl
1:49 AM
20% ↓ to 0.64 U/hour for 2 hr Back to normal 0.8 U/hr

Engine brake
0.0 basal rate 1hr

Engine braking
0.0 rate 1hr
2nd bolus

What have we learned? Pre-empting
1) Watch the trend line more often after meals
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

Shoving, pushing, nudging…
…and “Taking the Drop”

Too generous a snack? (pump user)
102 mg/dl
30 gm CHO

“Nudging a Drift”
(aka microcarbing)
Two gulps of juice (15-20g CHO)

5 gram CHO “nudge”
@ 66 m/dl
(aka microcarbing)
Dropping < 1 mg/dl/min

@ 66 mg/dl
@ 70 mg/dl
(aka microcarbing)

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

Managing “in the moment”
Proper basal
8 GM = 2 gulps
60 mg/dl

Carb “nudge”
BG 60 mg/dl: 6-8 grams fruit juice = 1 swallow (40-50 cc)

“nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice

Straight line trend
= 10 grams carbs
Straight line trend
60 mg/dl
90 mg/dl

Late day “nudge” after no lunch
with one “gulp” of fruit juice
84 mg/dl to 96 mg/dl

Leisurely walk from 7:00 to 8:30: straight line

Exercise “bump up”
Moderate intensity
75 minute duration
Glycogen  Glucose

2 units
1 hr walk
“Walking down” a trend

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

127 mg/dl @4:47AM
Injected 3 units lispro
1.5 hours
“Pushing sugar”
aka “Nudging a drift”

Timing insulin and food is like shooting clay pigeons
BG 137 mg/dl : dose 5 U lispro
Lag time
“launch window”
Eat breakfast here

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

6 units 6:23AM at 171 mg/dl
Lag
2 hours
Wedding Reception and
dinner (Mexican food and cake/ice
cream: slow carbs, slow rise)

6U bolus
Result of basal testing
2-3 hours

“Livin’ la vida Gluco”
Woke up at 3:55AM at
184 mg/dl
Wait (slept) about 3 hours
Took 4 units lispro
Bingo!
Tamale Soup at dinner
(slow carbs, slow rise)

Timing is everything…do you have
the patience or the time?
182 mg/dl : 7 units lispro
Insulin lag time
30-40 min
Eat breakfast here
124 mg/dl
Food lag time
Slow BG rise
overnight from
fried meal
BG drop time
20-30 min

85 mg/dl
164 mg/dl
3.5 U Novolog
@ 5:43AM
2 hours
Slept on sensor
Quality basal rate
lag
calibration

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

Stuff happens…
deal with it

“Smooth seas do not make skillful surfers”

4U @ 5:35AM
3U @ 7:06AM
28 carbs @
7:33AM (120 mg/dl)
Unexpected
morning BG rise
Waiting, waiting,
waiting…
Working the situation
on one day
0.650 units/hour insulin pump rate

Managing in the situation the next day:
notice the difference a day makes
3U Apidra
@ 6:52AM
28 grams carbs
@ 7:09AM
Steady baseline
lag
Minimal BG rise
0.650 units/hour insulin pump rate

28 grams carbs
@ 8:00AM
4U Apidra
@ 6:06 AM
5U Apidra
@ 7:05 AM
Yet another day…
Cal: 148 mg/dl

(alt: Superbolus) Sugar Surfing
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
Pre-emptive insulin stacking
6U
Tomato/Caprese
1 16oz Blonde beer
Large Cobb Salad
Half-slice bread
“Unexpected” late BG rise
Full throttle
lag

BG 186 mg/dl
@3:38AM: 5U aspart
Lag
2-3 hours
“Battle of the O-rings”
hoorah

Unexplained high…
explained
Culprit: bad pump site
First discovered…
Corrected all by injection

Tunneling and CGM “pickup”
154 mg/dl
5 units Novolog
“tunneling”
30 degree angled site is 2 days old

Long low and late high in 7 yo

Long low and late high in 57 yo

Overnight high in 9 y.o. pumper

Midnight BG checks at camp
102 mg/dl
30 gm CHO

I slipped on a banana…
Large banana
7 units Humalog
meal
Identify the:
drift
lag(s)
drop

Following the drop and meal…
Calibration

4 units @ 167 mg/dl
2-3 hours

Missed 9PM basal dose (glargine)
Detected rising sugar
Normal time
level @ 2AM
Lantus taken (9PM)
Humalog dose (7U) AND
usual Lantus taken (20U)
Sensor “gap”!!
Fell asleep!
dinner
All back in range by morning!

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

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

“Hollow Highs” are more common from stress
3 units
Staff Meeting Stress
adrenaline

3 units
Tx
Overtreatment of a stress high
Stress
EPI

Recovery from overtreatment of a “stress” high
3 units
Tx
Stress
EPI

Rest of the day after a stress high overcorrection
B A S A L

Crossing 140 mg/dl @ 3AM
and a 2.5 U lispro correction
Lag time
~ 2 hours
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

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

 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
9U 6U
15 grams CHO
MEAL

1. Stacked insulin + delayed eating
2. “Hyper-treated” severe low
3. Fought “rebound” high BG all night
4. Took the drop and timed meal
6 U
4 U
4 U 4 U
5 U
6 U
28 GM
90+ GM

Dislodged insulin pump site…
Picked up early by CGM
Pump site changed, insulin dose given,
carb correction taken…$13,000 saved

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?)

BG bump up (10 mg/dl rise) after waking
at 4:45AM (real or not?)

This can be “sensed too”
CHO
The body’s defenses
against low blood sugar
include the brain
A steady trend
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”

> 1-2 mg/dl/min This feels stable
~ 1 mg/dl/min

Watch the dots, not just the arrow

Watch the dots…not just the arrows
Just 22 minutes later…

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!

A small micro-bolus nudge
1 unit Novolog
@ 5:07 AM @120 mg/dl

3 units Novolog
@ 6:29 AM @106 mg/dl
28 gm CHO
@ 6:52 AM (92)
Timing a dose and meal
The “bend”

“Overnudging” and micro-carbing
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

Timing a dose and meal
2 unit Novolog
@ 12:19 PM @ 71 mg/dl
28 gm CHO
@ 12:25PM (70)

81 mg/dl
4 gm
3:05PM
82 mg/dl
4 gm
4:11
micro-carbing
28 gm CHO
@ 12:25PM (70)

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

2U @ 5:54
1U @ 4:44
Combo bolus
7.5U @ 7:52
3U @ 11:28
3U @ 6:52 2.5 U over 5 hr
Fajitas, chips
& queso dip
?
0.650 U/hour pump basal rate (Apidra)
28 g 28 g
8 4
8 4
 Calibrations (in range)
 Basal (in range)
 Micro-dosing (carbs/insulin)
 Mystery BG surges (?)
 Combo bolus used
Sugar Surfing™
“In cruise mode”

CGM Frequently Asked Questions
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
Can children use these devices?
• Yes. FDA has approved them for as young as age 2
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

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

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

Day vs. Night: any thoughts about why?

What is this called?
Answer: “taking the drop”

What’s the message of this image?

What’s this image saying?
(hint: look at the time)

Interpret these two images
Hint: sensor is over two weeks old

What is it a good time for and why?

Penny stock dayS utrgaadri nSgu srtfrinatgegy

Sugar Surfing(TM) Workshop Dallas Texas Slide Deck Sept 20 2014

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