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This is Sugar Surfing…

And this is Sugar Surfing…

Sugar Surfing

Sugar Surfing

Deltec Insulin pump MDI: Lantus and Humalog

Different users: which one is the surfer?

A BType 1 surfer dude Non-d adult woman

Sugar Surfing

Sugar Surfing

Sugar Surfing

Sugar Surfing

Sugar Surfing

A “normal day”

But this is Sugar Surfing too…

Sugar Surfing is a process, not a result

Sugar Surfing is

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

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

“KDA not DKA”

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

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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!

Principles

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…

Diabetes Police?

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, 2012ISO 15197 Standards for SMBG

95 mg/dl

114 mg/dl

76 mg/dl

223 mg/dl

52 mg/dl

95% of the time

Oops!

Oops!

5%

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

3 virtues of the well managed

“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.

GeneticPredisposition

Autoimmuneprocess 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

You CAN influence how long beta cells last

diabetes treatment preserves INTERNALLY made insulin

Is the future already here?

50

55

60

65

70

75

80

1964 1980

Lifespan with type 1 diabetes vs. without

Average American

Type 1 Diabetes

Linear (Average American)

Log. (Type 1 Diabetes)

1996

DX'd 1950-1964

DX'd 1965-1980

DX'd 1980--??

Five things to remember about T1D

1) Diabetes care isn’t a contest. It’s overrun with numbers. Don’t judge.

2) Let the remaining guilt (if any) go! NO one is perfect.

3) Diabetes care is not an action, it is a SKILL SET. Therefore, it can be practiced and improved upon. 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)

Proactive versus Reactive

Diabetes care is best approached 1 day at a time

4 day non-diabetic CGM plot

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 carestatic

• 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

past future

Actions Actions

“CONTROL”

Proactive-Reactive

Proactive-Reactive

Proactive-Reactive

Largely reacting here

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’TMISS!

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

165 pound (75 kg) man(5.1 grams)

55 pound (25 kg) girl(1.75 grams)

110 pound (50 kg) boy(3.45 grams)

= 4 gram glucose tabaka “glucose transit system”

Traits of effective CGM users

Wear it most of the time

Check trend line often

They “work the lag” timesFOOD lagINSULIN lagSENSOR 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 DexcomG4 sensor tip

I’m a pump catheter tip

Turnaround Time : glycemic inertiaCorrections 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

Calibration

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

Steady trend2 hours

Calibrate your CGM…On a steady trend when you can…

In the BG range you want to be most accurate in…

Steady trend

4 hours post start up calibration (extra)

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

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)

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…

Failing Sensor after several weeks

Day 1 New Sensor Chaos

End of multi-week sensor session(dying sensor: erratic)

NEW sensor session

2nd sensor session(stop-restart)

New sensor chaoserratic

Sensors can take time to settle in

Calibration day 1 (May 21) Next day (May 22)

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 hours3) Don’t give up, breaking in a sensor takes time

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

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

Basal testing

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range!

Overnight control in range

Basal testing…

Overnight basal control - Lantus

Overnight basal testing

Overnight basal testing

Overnight basal testing

Overnight basal testing

Overnight basal testing

Basal Testing

Sugar Surfing tip: midday basal testing

Omitted lunch

steady

Afternoon basal testing

0.8 Units/hr basal rate

In the pipe

Don’t forget the basal!

Basal…Basal…Basal

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 dinnerRemington’s

Why basal testing is important

Basal testing with a 3 year old

Always keep your eyes on the basal trending

REMEMBER

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

Timing is everything

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

Timing 101 – 20 min. match

Insulin

Food

Timing 101 – 45 min. mismatch

Insulin

Food

Why timing is everything

3 units @6:10 28 gm @ 6:50

Timing…waiting for the bend

“window”

6 units Novolog@ 5:27AM

28 gm CHO@ 6:11AM

Basic Surfing: Timing

45 min

3 U lispro @ 6:22AM

28 GM CHO @ 6:52AM

Timing insulin and meals to prevent a spike

Wait for the bend!!

6U @146

mg/dl Eat here @132

mg/dl

45 minutes

Wait for the “bend”!

Stopping sugar spikes

3 units (5:32AM)

Meal(5:48 AM)

Point “A” Point “B”

sugar trend

Insulin “correction”

Carb “correction”

~ 2 hours for insulin~ 15-30 minutes for carbs

Range of possible BG outcomes

“the trend is your friend”

Blood glucose level

4U @ 5:302.1U @ 3:30

1.75 U per calc2.1 U per calcBG = 187BG = 180

IOB = 3 hours

Correction factor = 30

“Direction affects Correction”

Target= 110 mg/dl

just leveled off

Basal rate 0.650 U/hr

Noticed rising trend at 1:43 PM: 165 mg/dl

Took 5 units lispro@ 1:45 PM

4 hours

Late BG rise after the morning: no lunch eaten

135 mg/dl @ 2 hours

“Direction affects correction ”

BG = 157 mg/dlInj 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

Correction and meal

6 units (161

mg/dl)

Meal(26 gm CHO)

~ 45m126 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

Micro-dosing

1 unit Novolog@ 3:37AM

Leveling off

Microbolusingcalibration

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”

2:42AM1 unit Novolog

5:37AM1 unit Novolog

microbolusing

BG 137 mg/dl and rising slowly

3 units lispro

“Micro-bolusing”

Subtle correction• BG 125 and rising

• Took 4 units lispro

• 2 for the slow rise

• 2 for the correction

• Waited almost 2 hours (yellow arrow)

• Notice lag time before BG “turns” (red arrow)

BG 124 mg/dl injected 1.5 units lispro

@3:56AM

2 hours

Microbolus experimentation

Lag time

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

1.5 units

~ 2 hours

2 units Humalog@ BG 130 mg/dl

3 scrambled eggs@ 9:20 AM

Microdosing Humalog at Churchi

Slow protein rise?

8:39AM 1 unit Novolognudge via pump

Micro-dosing insulin

Basal rate constant here

2 units via pump

160 mg/dl

Pump “nudge”

CGM 125 mg/dl2 U Novolog

5:40 AM via pump

CalibrationCGM: 123 mg/dl

Meter: 123 mg/dl

Nudging

3U lispro@ 3:40AM

4 unit lispro “push”

“Pre-empting”

Well balanced basal insulin

8 gm juice nudge 8 gm juice nudge 8 gm juice nudge

Micro-carbing practice

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 @ 4:506 @ 6:17

Gently turning a curve

0.8 Units/hr basal rate

6

64

Combo bolus experimenting

Manicotti and 2 Rolls

Combo bolus

Carb nudgesMeal

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”

++ =

45 minutes

60 minutes

75 minutes

90 minutes

105 minutes

120 minutes

25 cc water25 cc vinegar

2 bowls Rice Krispies +meal insulin dose before eating

Vinegar Challenge

NOPE!

7U apidra7:30AM

5U apidra9:15AM

5U apidra10:03AM

bend

56 CHO

Pre-empt

Take the drop

0.650 Units/hour basal rate

Breakfast cereal challenge day 1

0.650 Units/hour basal rate

12U apidra7:30AM

5U apidra3:37PM

56 CHO

Pre-empt

Take the drop

bend

Breakfast cereal challenge next attempt

Breakfast cereal challenge third attempt

12U apidra11:48AM

56 CHO

0.650 Units/hour basal rate

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 durationTo forge I-chains

Mealtime insulin @ 8:30PM 7 units lispro

Duration of insulin 3hr

Insulin correction dose @ 2:53AM 6 units lispro

lag

2 hours to correct

Teaching points…

a. Know your insulin “umbrella”

b. Slow carbs cause unexpected highs

c. Insulin onset of action = lag time

d. Rise in BG levels has vector qualities

e. It takes time to correct a high

a

b

c

d

ea

b

6:53PM BG 108 inj 6 units

7:15-7:35

9:52PM BG 125↑ inj 4 units

“Effective duration” of insulin action: 3 hrs

“Active insulin” • Example: Slow carb meal

(fried food)

• e.g., Chicken fried steak, cream gravy and 3 onion rings and 8 French fries

• Estimated 60 grams: 6 units: inject 6 units lispro

• NO rise in BG for 3 hours, then rapid ascent

• Time until rise reflects “active insulin” effect

• Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

3.5-4 hours2 units

WalkFried Meal

Rising BG trend (132 mg/dl) @ 2:06AM

5 units lispro @ 2:12

Fried Chicken

2.5 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

“Inflections”

calibration

Tex-Mex Dinner

calibration

“Remember the Alamo”

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 Garden2 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 Garden2 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

Dealing with shifting tides

“Fried-food revenge” and correction

Fried food earlier in evening @ 8PM

BG = 1946 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

Pre-empting

3 units lispro

Breakfast

BG 173 mg/dl 5 units lispro

Meeting

A “random rise” in BG during a routine day.

2-3 hours

Working it…(i.e., glucose control exists “in the moment”)

~ 2 hoursOops! I Ate an EXTRA breakfast

taco!

BG 142 ↑ : took 5 units

hypothetical

real

And thirdly, the correction and carb ratios is more what you’d call ‘guidelines’ than actual rules

“Most of our assumptions have outlived their usefulness”Marshall McLuhan

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 1:45Basal rate 1.2 U/hrTarget 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”

8 U @ 9:30AM

7 U @ 10:54AM

6 U @ 12:29PM

60 grams carbs

Ultimately 21 U lispro

Insulin to carb ratios are only a start

7

5

4

5

Large bowl turkey soup and 2 small pieces cornbread @ 6:30

…flux?”

“What the…

• 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

Duration of insulin

9 units lispro for 90 gm Mexican food lunch @3:30

6 units lispro @ 6:30PM for rising BG after 3 hr IOB

Stabilization

“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

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

5.3 U3.0 U

3.0 U2.0 U

2.7U

Chicken Fried SteakLarge rollFried okraGreen beansFrench friesFried cod

Bending the trend

One goal to aim for: pre-empt meal spikes

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

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

Two gulps of juice (15-20g CHO)

“Nudging a Drift”(aka microcarbing)

5 gram CHO “nudge” @ 66 m/dl

Dropping < 1 mg/dl/min

“Nudging a Drift”(aka microcarbing)

4 gram CHO “nudge” @ 66 mg/dl

4 gram CHO “nudge” @ 70 mg/dl

“Nudging a Drift”(aka microcarbing)

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

Straight line trend

= 10 grams carbs

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

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

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

Exercise “bump up”

Moderate intensity75 minute durationGlycogen 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 @4:47AMInjected 3 units lispro

1.5 hours

“Pushing sugar”aka “Nudging a drift”

BG 137 mg/dl : dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

“launch window”

6 U lispro @ 1:45AM @ 170 mg/dl

30 min lag

3 hour wait

“Taking the drop”…

“Taking the drop”

BG 160 mg/dl @ 1:47AMInjected 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

“Taking the drop”

Wedding Reception and dinner (Mexican food and cake/ice

cream: slow carbs, slow rise)

6U bolus

Result of basal testing

“Taking the drop”

2-3 hours

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”

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 time20-30 min

164 mg/dl3.5 U Novolog

@ 5:43AM

2 hours

85 mg/dl

Slept on sensorQuality basal rate

lag

calibration

1.00 U Novolog2.00 U Novolog

28 CHO 4 CHO 4 CHO

“Bend a trend”

12 hour view

Surfing Skills needed:morning basal reviewtrend recognitionmicrobolusingmicrocarbingmeal timingcarb counting

1.00 U Novolog

TTD

6 U glulisine 5:53

Stuff happens…deal with it

“Smooth seas do not make skillful surfers”

4U @ 5:35AM3U @ 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

3U Apidra@ 6:52AM

28 grams carbs@ 7:09AM

Steady baseline

lag

Minimal BG rise

Managing in the situation the next day: notice the difference a day makes

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

Nudge @2:34

Basal confidence

Engine brake 40%↓

11:44PM-1:44AM

Basal rate 0.48 U/hrBasal rate 0.8 U/hr Basal rate 0.8 U/hr

Micro-experimentation*

6U

5U

4U

6U

Tomato/Caprese1 16oz Blonde beerLarge Cobb SaladHalf-slice bread

“Unexpected” late BG rise

Pre-emptive insulin stacking(alt: Superbolus)

Sugar SurfingFull 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

102 mg/dl

Midnight BG checks at camp

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)

Normal timeLantus 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!

What happens when a basal insulin dose is missed

Usual time Lantus

dose is taken: 9PM

Rising BG

discovered here

Insulin correction given

If not treated: high

BG and ketones

Treated: In range

BG and NO ketones

Stress effect

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

3 units

Staff Meeting Stress

“Hollow Highs” are more common from 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

Steroid pulse

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

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!

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1. Stacked insulin + delayed eating2. “Hyper-treated” severe low3. Fought “rebound” high BG all night4. Took the drop and timed meal

Dislodged insulin pump site…Picked up early by CGM

Pump site changed, insulin dose given, carb correction taken…$13,000 saved

Slept on transmitter

Barely out of range

Overlapping receivers to maintain continuity

• Once you have a second Dexcomreceiver (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?)

How does this feel?

This can be “sensed too”

CHO

A steady trend

The body’s defenses against low blood sugar

include the brainDownward 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”

Feel the drop and level off

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

~ 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 day of Sugar Surfing

A day of surfing

Basal checking…always

1 unit Novolog@ 5:07 AM @120 mg/dl

A small micro-bolus nudge

3 units Novolog@ 6:29 AM @106 mg/dl

28 gm CHO@ 6:52 AM (92)

Timing a dose and meal

The “bend”

2 unit Novolog@ 8:02 AM @126 mg/dl

76 mg/dl

4 gm9:19

65 mg/dl

4 gm10:45

69 mg/dl

4 gm10:30

“Overnudging” and micro-carbing

2 unit Novolog@ 12:19 PM @ 71 mg/dl

28 gm CHO@ 12:25PM (70)

Timing a dose and meal

81 mg/dl

4 gm3:05PM

82 mg/dl

4 gm4:11

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 gm4:11

1.5 units Novolog@ 7:51 PM @ 113 mg/dl

A day of surfing

2U @ 5:54

1U @ 4:447.5U @ 7:52

3U @ 11:283U @ 6:52 2.5 U over 5 hr

Combo bolus

Fajitas, chips & queso dip

?

0.650 U/hour pump basal rate (Apidra)

28 g 28 g

8 448

Calibrations (in range)

Basal (in range)

Micro-dosing (carbs/insulin)

Mystery BG surges (?)

Combo bolus used

Sugar Surfing™“In cruise mode”

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

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

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

Closing thoughts

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

Quiz

Day vs. Night: any thoughts about why?

What is this called?

Answer: “taking the drop”

What is this called?

What’s the message of this image?

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

What’s this image tell you?

What is this called?

When to pull the trigger?

Interpret these two images

Hint: sensor is over two weeks old

What is it a good time for and why?

A good time to calibrate

Penny stock day trading strategySugar Surfing

©

“Kicks Diabetes”

Sugar Surfing