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

2. Sugar Surfing Stephen W. Ponder MD, FAAP, CDE (aka doctor juicebox) 3. Sugar Surfing* returns to Dallas! When: Saturday September 20, 2014 10AM-12:30PM Where: Tom Hunt Auditorium 10th floor Charles A. Sammons Cancer Center 3410 Worth Street Dallas, Texas 75246 Lite refreshments provided Cost: NONE RSVP: Kaye Harmon kharmon@sw.org 254-935-5048 * Dynamic Diabetes Self Management using a CGM Device Stephen Ponder MD, FAAP, CDE Endocrinologist Type 1 since March 1, 1966 Im comin back, dudes!!! 4. This is Sugar Surfing 5. And this is Sugar Surfing 6. Sugar Surfing 7. Sugar Surfing Deltec Insulin pump MDI: Lantus and Humalog 8. Sugar Surfing 9. Sugar Surfing 10. Sugar Surfing 11. Sugar Surfing 12. Sugar Surfing 13. A normal day 14. But this is Sugar Surfing too 15. Sugar Surfing is a process, not a result 16. Sugar Surfing is 17. Your blood glucose is 100 mg/dl dropping at a rate of 2-3 mg/dl/min and your insulin pump is delivering at 1.3 U/hr. YOUR GETTING LOW! Sugar Surfing emphasizes significance 18. Sugar Surfing is Fuzzy Logic in motion 19. Almost as tightas it gets 20. This is about as tight as it gets 21. 7 year old American Sugar Surfer 22. A 7 year old Sugar Surfing in Canada! 23. Dr. Ponder lines in Canada 24. Sugar Surfing is driven by The Power Within Like The Power Within by Stephen Ponder MD, FAAP CDE stephenponderMD.com 25. Kicks Diabetes SugarSurfing 26. By the end of this presentation, you will know the meaning of the following Sugar Surfing terms The Sugar Surfers credo (the 3 virtues) Flux and drift Static vs. dynamic diabetes self care Proper calibration and basal checking Timing is everything Actionable thresholds Micro-carbing and micro-blousing Knowing your DIA (IOB) Nudging, pushing and shoving sugar Pre-empting Taking the drop The trend is your friend Gluca-bunga! 27. Principles 28. Appreciate the flux of sugar levels in non-d persons 29. Remember: SugarSurfingis all about managing 30. Sugar Surfing requires the following skills 1. Understanding some basic principles/concepts 2. Adjusting to changing or shifting conditions/situations 3. Frequent assessments and re- assessments LIKE. Driving a car Flying an airplane Walking a tightrope Surfing 31. (Sugar in Sugar out) = FLUX Here is a picture of FLUX and DRIFT 32. Life is not a matter of holding good cards, but of playing a poor hand well. R.L. Stevenson (1850-1894) 33. These are classic illustrations by a famous graphic artist from the early 20th century. These specific images were taken from a handbook for new patients with diabetes. Some things NEVER change and never will. Here are 3 priceless pieces of diabetes wisdom 34. Diabetes Police? 35. To unleash your Power Within Let go of Judging Feeling defective/broken Shame Fearing the future Isolation Pity Insecurity/denial Embrace/cultivate Acceptance Normalcy Openness Enjoying the moment Teamwork Empowering/supporting Self-confidence 36. Diabetes care is about choices 37. What do these numbers mean? 23% 221 38. Diabetes care must be individualized 39. ISO and FDA allowable errors 20% for 95% of BG values 75 mg/dl 15 mg/dl for 95% of BG values < 75 mg/dl 5% outliers of ANY DEGREE of magnitude Glycemic Roulette? Diabetes Spectrum Volume 25, Number 3, 2012 ISO 15197 Standards for SMBG 40. 95 mg/dl 114 mg/dl 76 mg/dl 223 mg/dl 52 mg/dl 95% of the time Oops! Oops! 5% 5% 41. Glargine vs new long acting insulin 42. Pump basal rates wobble It takes 2 hours for a basal rate change to reach a steady level Notice the wobble in how rapid insulin works when delivered through a pump. Chaos is a trait of any injected or infused insulin delivery system 43. Chance favors the prepared mind Louis Pasteur dude 44. 3 virtues of the well managed 45. I haven't failed. I've just found 10,000 ways that won't work. Thomas Edison 46. Hang in there. Dont give up! 47. Knowledge alone does not imply understanding 48. You can delegate authority but you cant delegate responsibility 49. Do 2 RNs = 1 kid? = Ok? Ok to me! 50. Concrete thinkers* cant 1. Consider a hypothesis 2. Consider multiple possibilities in a scenario 3. Systematically solve a problem 4. Use combinatorial logic *Lasts until 15-17 years of age *25% of adults are concrete thinkers. 51. Genetic Predisposition Autoimmune process begins Trigger Measureable loss of insulin Diagnosis Residual insulin ability honeymoon Time in YEARS 100% 20% 50% How insulin ability fades in type 1 diabetes 52. You CAN influence how long beta cells last diabetes treatment preserves INTERNALLY made insulin 53. Is the future already here? 50 55 60 65 70 75 80 1964 1980 Lifespan with type 1 diabetes vs. without Average American Type 1 Diabetes Linear (Average American) Log. (Type 1 Diabetes) 1996 DX'd 1950-1964 DX'd 1965-1980 DX'd 1980--?? 54. Five things to remember about T1D 1) Diabetes care isnt a contest. Its overrun with numbers. Dont 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 anyones diabetes. They never can and they never will. Its a self managed condition. 55. Five practical advanced diabetes care tips 1) Better synchronize your insulin and your food 2) Check blood sugars 2-3 hours after meals 3) Correct any out of range sugar you discover (treat to target) 4) Work to get morning blood sugars into target range (F-F-F) 5) Review/analyze your blood sugars at least weekly (if not continually) 56. Proactive versus Reactive 57. Diabetes care is best approached 1 day at a time 58. 4 day non-diabetic CGM plot 59. A pancreas cant predict the future But it acts so fast it doesnt need to. Can shut off insulin immediately Can release premade insulin Insulin it releases start working in minutes (plus other things) Can rapidly respond to changes in sugar levels 60. static vs. dynamic diabetes care static Actions predetermined Minimal flexibility: RIGID Outcomes dont immediately affect subsequent actions Easy to teach/learn Less time-intensive Favors concrete thinking Less motivation needed dynamic Actions are dependent on situation/circumstance Flexible and adaptable Outcomes constantly influence subsequent actions Training needed, plus ongoing reinforcement More time intensive Favors problem-solving Requires ongoing motivation 61. present past future Actions Actions CONTROL 62. Proactive-Reactive 63. Proactive-Reactive 64. Proactive-Reactive 65. Largely reacting here 66. 8 versus 1440 decision points 7:03 115 9:33 129 12:15 95 3:34 131 6:12 168 9:49 107 11:53 114 3:05 132 * * * * * * * * 67. Dont 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 dont overstack your insulin) 68. Setting your targets CANT MISS! 69. Target setting tips (for actions to be considered) 1) Make them easy to hit 2) Aim high and wide at first 3) Develop confidence 4) Dont rush it 5) Lower/tighten them gradually 70. How much total sugar is in the blood for a 100 mg/dl BG level? Human circulatory system 165 pound (75 kg) man (5.1 grams) 55 pound (25 kg) girl (1.75 grams) 110 pound (50 kg) boy (3.45 grams) = 4 gram glucose tabaka glucose transit system 71. Traits of effective CGM users Wear it most of the time Check trend line often They work the lag times FOOD lag INSULIN lag SENSOR lag Not afraid to experiment Not expecting perfection 72. 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 (reallydots) Factor in recent/current/future events as you are able to Test your skills, experiment a little within reason 73. Be realistic Accept that the first 6-12 months are on a learning curve Set higher and wider targets Have low expectations to start Its still a finicky technology PLEASE BE PATIENT 74. BG awareness vs. alarm fatigue Set reasonable alarm thresholds Depends on your goals Avoid high spikes? Avoid lows? Toddler? Child? Teen? Adult? Make sure you can hear/sense the alarm Anticipatory action can minimize alarms 75. Principlesof Sugar Surfing 1. A CGM is no better or worse than the person using it. 2. If you can measure it, you can predict it. 3. Flux and drift happen manipulate them! 4. Keep your eye on your line. 5. The trend is your friend 6. Learn lag limits; be patient 7. Zero in on your zone 8. Master micro-dosing 9. Factor in glycemic inertia and insulin momentum 10.Dont let good enough be an enemy 11.Calibrate carefully 12.Pre-empt: stay ahead of the wave 76. This is where it all happens Im a Dexcom G4 sensor tip Im a pump catheter tip 77. Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate 78. Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert 79. THE TREND IS YOUR FRIEND CHECKING INSULIN BOLUSES WITH CGM 6 pm 8 pm 10 pm 300 200 100 60 Carb bolus Correction bolus 6 pm 8 pm 10 pm Goal: green lines 80. Calibration 81. Cal-i-bra-tion (noun ka-l-br-shn) 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 its compared toor how well the BG meter was used 82. Calibration tips The first sensor day can be erratic as it settles in Dont over calibrate! Try to calibrate on a steady trend Try to calibrate when in your target range 83. CGM calibration tip steady 2 hours Whenever possible: calibrate the CGM system when on a steady sugar trendline 2 hr wait time between turning on sensor and providing 2 calibration BG readings to start session steady baseline 84. Daily calibrating on a steady baseline 85. Steady trend 2 hours Calibrate your CGM On a steady trend when you can In the BG range you want to be most accurate in Steady trend 86. 4 hours post start up calibration (extra) 87. Settling in at 6 hours: wobble 88. Sensors are not always right Or is it the meter thats off? 89. Meter-Sensor mismatch/confusion Dropping over 75-90 minutes 1st BG check: Hmmmm 90. First recheck: re-cleaned hands 2nd recheck a few minutes later 91. 1) On a steady trend line 2) In your target range 3) Make sure initial cal samples match closely Sugar Surfing Calibration tips 1) 2) 3) 92. 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 dont give up on a session too soon. But BG meter calibration shows THIS 93. Failing Sensor after several weeks 94. Day 1 New Sensor Chaos 95. End of multi-week sensor session (dying sensor: erratic) NEW sensor session 2nd sensor session (stop-restart) New sensor chaos erratic 96. Sensors can take time to settle in Calibration day 1 (May 21) Next day (May 22) 97. Overnight basal: first sensor day wobble calibration Sensor session started Late dinner Breaking in your new surfboard Tips: 1) Give 2-3 additional BG checks in first 12 hours 2) Things begin to improve after 12-18 hours 3) Dont give up, breaking in a sensor takes time 98. Pop Quiz: What is it a good time to do here? Sensor: 127 mg/dl; meter 122 mg/dl 99. Overlapping receivers...week 2 to 3 (you need to save your receivers) End of week 2 sensor session Start of week 3 sensor session 100. Dual receivers linked to same sensor 2 hours What have we learned: calibration 1) Best done on a steady trend 2) Best done in your target range 3) Do a couple extra on day 1 4) Re-calibrate after large swings 5) You can over-do it 101. Basal testing 102. Overnight basal testing 103. Overnight basal in range (glargine) 104. Overnight basal testing 105. Overnight in range! 106. Overnight control in range 107. Basal testing 108. Overnight basal control - Lantus 109. Overnight basal testing 110. Overnight basal testing 111. Overnight basal testing 112. Overnight basal testing 113. Overnight basal testing 114. Basal Testing 115. Sugar Surfing tip: midday basal testing Omitted lunch steady 116. Afternoon basal testing 117. 0.8 Units/hr basal rate In the pipe Dont forget the basal! 118. BasalBasalBasal 119. Why basal testing is important 120. Basal testing with a 3 year old 121. What have we learned: basal testing 1) You are always scanning over your basal control 2) Especially in the morning 3) A steady basal insulin effect is important to successful surfing 4) Keep basal insulin as simple as possible Basal checkingalways 122. Timing is everything 123. Learning from the Line Graph Insulin Timing 8a 10a 70 140 210 350 280 8a 10a 70 140 210 350 280 TodayYesterday Insulin bolus: 7:30 AM Breakfast: 7:30 AM Insulin bolus: 7:10 AM Breakfast: 7:30 AM M I MI 124. Timing 101 20 min. match Insulin Food 125. Timing 101 45 min. mismatch Insulin Food 126. Why timing is everything 127. 3 units @6:10 28 gm @ 6:50 Timingwaiting for the bend window 128. 6 units Novolog @ 5:27AM 28 gm CHO @ 6:11AM Basic Surfing: Timing 45 min 129. 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike 130. Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the bend! 131. Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM) 132. Point A Point B sugar trend Insulin correction Carb correction ~ 2 hours for insulin ~ 15-30 minutes for carbs Range of possible BG outcomes the trend is your friend Blood glucose level 133. 4U @ 5:302.1U @ 3:30 1.75 U per calc2.1 U per calc BG = 187BG = 180 IOB = 3 hours Correction factor = 30 Direction affects Correction Target= 110 mg/dl just leveled off 134. Noticed rising trend at 1:43 PM: 165 mg/dl Took 5 units lispro @ 1:45 PM 4 hours Late BG rise after the morning: no lunch eaten 135 mg/dl @ 2 hours Direction affects correction 135. BG = 157 mg/dl Inj 4 U lispro @3:15 2-3 hours 20-30 minA B C Correction tips (on a steady trend) A. Remember the lag time before insulin starts to effectively lower BG B. Remember the length of time it takes to accomplish the desired task C. Patience and practice make these kinds of results possible 136. Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl 137. What have we learned: timing 1) Watch your lag times 2) Inflection points matter 3) Wait for the bend 4) Know insulin peaks 60-90 minutes 5) Know the duration of insulin effect 138. Micro-dosing 139. 1 unit Novolog @ 3:37AM Leveling off Microbolusing calibration 140. Micro-bolusing (dosing) Steady baseline BG trend BG 136 mg/dl 2 units lispro Wait 2 hours Target zone Very advanced CGM needed! Note flat BG baseline trend Calibration good Not correction per se More of an adjustment 141. 2:42AM 1 unit Novolog 5:37AM 1 unit Novolog microbolusing 142. BG 137 mg/dl and rising slowly 3 units lispro Micro-bolusing 143. Subtle correction BG 125 and rising Took 4 units lispro 2 for the slow rise 2 for the correction Waited almost 2 hours (yellow arrow) Notice lag time before BG turns (red arrow) 144. BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time 145. 112 mg/dl to 78 mg/dl after 1.5 units by injection on a steady BG baseline 1.5 units ~ 2 hours 146. 2 units Humalog @ BG 130 mg/dl 3 scrambled eggs @ 9:20 AM Microdosing Humalog at Churchi Slow protein rise? 147. 8:39AM 1 unit Novolog nudge via pump Micro-dosing insulin Basal rate constant here 148. 2 units via pump 160 mg/dl Pump nudge 149. CGM 125 mg/dl 2 U Novolog 5:40 AM via pump Calibration CGM: 123 mg/dl Meter: 123 mg/dl Nudging 150. 3U lispro @ 3:40AM 151. 4 unit lispro push Pre-empting Well balanced basal insulin 152. 8 gm juice nudge 8 gm juice nudge 8 gm juice nudge Micro-carbing practice dinner Any other suggestions? 153. Hello Kittygoodbye low blood sugar 2 Pez @ 62 mg/dl 154. 6 unit shove at 133 mg/dl 155. 3U @ 3:32 5U @ 4:50 6 @ 6:17 Gently turning a curve 156. 0.8 Units/hr basal rate 6 6 4 Combo bolus experimenting Manicotti and 2 Rolls Combo bolus Carb nudgesMeal 157. 6 6 units extended (5 hours - 6:26-11:26PM) 2 nudge Sugar Surfing on the Rio Grande Tacos al carbon, queso and chips: 80-100 gm CHO 50-50-5 158. ++ = 45 minutes 60 minutes 75 minutes 90 minutes 105 minutes 120 minutes 25 cc water 25 cc vinegar 2 bowls Rice Krispies + meal insulin dose before eating Vinegar Challenge NOPE! 159. What we have learned: microdosing 1) Experiment with insulin and carbs safely. Keep them both handy 2) Aim smallmiss small 3) Develop skills at higher targets first 4) Practice, practice, practice 5) Prior skills must be mastered first 6) This is at the heart of Sugar Surfing 160. Learn your own insulin duration To forge I-chains 161. Mealtime insulin @ 8:30PM 7 units lispro Duration of insulin 3hr Insulin correction dose @ 2:53AM 6 units lispro lag 2 hours to correct Teaching points a. Know your insulin umbrella b. Slow carbs cause unexpected highs c. Insulin onset of action = lag time d. Rise in BG levels has vector qualities e. It takes time to correct a high a b c d ea b 162. 6:53PM BG 108 inj 6 units 7:15-7:35 9:52PM BG 125 inj 4 units Effective duration of insulin action: 3 hrs Active insulin Example: Slow carb meal (fried food) e.g., Chicken fried steak, cream gravy and 3 onion rings and 8 French fries Estimated 60 grams: 6 units: inject 6 units lispro NO rise in BG for 3 hours, then rapid ascent Time until rise reflects active insulin effect Must do this many times and take the average 163. Duration of insulin effect can be determined here ~ 4 hours 164. IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal 165. Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours 166. 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus Inflections calibration Tex-Mex Dinner calibration Remember the Alamo 167. 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Slow carbs Experimented here: Ate a pasta meal at the Olive Garden Took a single insulin shot (70 gm = 7 units) Sugar dropped at time of usual peak insulin action: ~60-90 minutes BG recovered without treatment Late rise in BG required second injection Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro 168. 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Fast insulin + slow carbs = low BG Ate a pasta meal at the Olive Garden Took a single insulin shot (70 gm = 7 units) Sugar dropped at time of usual peak insulin action: ~60-90 minutes BG recovered without treatment Late rise in BG required second injection Notice the insulin-food balance and how it effects BG levels Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro Insulin effect Food effect 169. What have we learned? DIA and I-Chains 1) Slow carbs can expose your duration of insulin action 2) Learn how to find it 3) Overlap your DIA like chains to mimic an extended insulin bolus 170. Dealing with shifting tides 171. Fried-food revenge and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours 172. Revenge of the Ribeye and The Insulin Strikes Back BG 167: 4 units LAG 2-3h 173. Slow BG rise from protein-fat laden meal 174. Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours 175. 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes 176. Correction with 20 grams carbs 20 gm CHO 177. What have we learned? Slow Trends 1) Slow up and down trends happen 2) Some can be explained, others cant 3) Bend the trend with insulin or carbs and be patient 178. Pre-empting 179. 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A random rise in BG during a routine day. 2-3 hours 180. Working it(i.e., glucose control exists in the moment) ~ 2 hours Oops! I Ate an EXTRA breakfast taco! BG 142 : took 5 units hypothetical real 181. And thirdly, the correction and carb ratios is more what youd call guidelines than actual rules Most of our assumptions have outlived their usefulness Marshall McLuhan 182. TIGER: Im 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 its blowing from the south at less than 10 miles an hour Tiger and his caddy talk golf Huh?, What an idiot 183. ENDO: You just need new pump settings: Carb ratio 1:5 Correction 1:45 Basal rate 1.2 U/hr Target 110 mg/dl IOB: 3.5 hours. See you in 3 months! TEEN: Why am I having trouble with my diabetes? Endo and the teen Huh?, What an idiot 184. 8 U @ 9:30AM 7 U @ 10:54AM 6 U @ 12:29PM 60 grams carbs Ultimately 21 U lispro Insulin to carb ratios are only a start 185. 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 flux? What the 186. Duration of insulin 187. 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization 188. Working down a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings 189. Mexican food standoff 9 U 7 U 6 U 5 U Basal rate good Basket of chips and Mexican Plate 190. 4 units Humalog @ 11:07PM BG rising after insulin effect iswaning. BG = 146 mg/dl Dinner (soft tacos, refried bean and chips/salsa); 7 units lispro taken 20 minutes premeal at 7PM My DIA = 3-4 hours Notice the obligatory lag time! Anatomy of a preemptive correction 191. One goal to aim for: pre-empt meal spikes 192. Advanced Sugar Surfing: Engine Braking with a pump Back to normal 0.8 U/hr20% to 0.64 U/hour for 2 hr BG 102 mg/dl 11:49 PM 1:49 AM 193. What have we learned? Pre-empting 1) Watch the trend line more often after a meal 2) Wait for a clear trend (up or down) 3) Use your action thresholds 4) Preempt on the rise or fall 5) Rapid rises or falls often require greater force to neutralize or turn 194. Shoving, pushing, nudging andTaking the Drop 195. Two gulps of juice (15-20g CHO) Nudging a Drift (aka microcarbing) 196. 5 gram CHO nudge @ 66 m/dl Dropping < 1 mg/dl/min Nudging a Drift (aka microcarbing) 197. 4 gram CHO nudge @ 66 mg/dl 4 gram CHO nudge @ 70 mg/dl Nudging a Drift (aka microcarbing) 198. Advanced Sugar Surfing calibration tip 2 units Novolog @ 5:06AM A. Slight upward drift B. Nudge bolus C. Calibrate at the bend A B C C before after 199. Managing in the moment Proper basal 8 GM = 2 gulps 60 mg/dl 200. Carb nudge BG 60 mg/dl: 6-8 grams fruit juice = 1 swallow (40-50 cc) 201. nudge from 62 mg/dl to 87 mg/dl with 8 grams fruit juice 202. Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl 203. 5 gram CHO nudge @ 66 mg/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone 204. Late day nudge after no lunch with one gulp of fruit juice 84 mg/dl to 96 mg/dl 205. nudge from 62 mg/dl to 87 mg/dl with 8 grams fruit juice 206. Leisurely walk from 7:00 to 8:30: straight line 207. Exercise bump up Moderate intensity 75 minute duration Glycogen Glucose 208. 2 units 1 hr walk Walking down a trend 209. Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE) 4 units ~ 2 hours 210. Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk (EXERCISE) 2 units ~ 2 hours 211. 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours Pushing sugar aka Nudging a drift 212. BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons launch window 213. 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait Taking the drop 214. Taking the drop BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth 215. 6 units 6:23AM at 171 mg/dl Lag 2 hours Taking the drop Wedding Reception and dinner (Mexican food and cake/ice cream: slow carbs, slow rise) 216. 6U bolus Result of basal testing Taking the drop 2-3 hours 217. Woke up at 3:55AM at 184 mg/dl Took 4 units lispro Wait (slept) about 3 hours Bingo! Tamale Soup at dinner (slow carbs, slow rise) Livin la vida Gluco 218. 182 mg/dl : 7 units lispro Insulin lag time 30-40 min Eat breakfast here Food lag time 124 mg/dl Timing is everythingdo you have the patience or the time? Slow BG rise overnight from fried meal BG drop time 20-30 min 219. 164 mg/dl 3.5 U Novolog @ 5:43AM 2 hours 85 mg/dl Slept on sensor Quality basal rate lag calibration 220. 1.00 U Novolog 2.00 U Novolog 28 CHO 4 CHO 4 CHO Bend a trend 12 hour view Surfing Skills needed: morning basal review trend recognition microbolusing microcarbing meal timing carb counting 1.00 U Novolog 221. Stuff happens deal with it 222. Smooth seas do not make skillful surfers 223. Nudge @2:34 Basal confidence Engine brake 40% 11:44PM-1:44AM Basal rate 0.48 U/hr Basal rate 0.8 U/hr Basal rate 0.8 U/hr Micro-experimentation* 6U 5U 4U 6U Tomato/Caprese 1 16oz Blonde beer Large Cobb Salad Half-slice bread Unexpected late BG rise Pre-emptive insulin stacking (alt: Superbolus) Sugar Surfing Full throttle lag 224. BG 186 mg/dl @3:38AM: 5U aspart Lag 2-3 hours Battle of the O-rings hoorah 225. Unexplained high explained Culprit: bad pump site First discovered Corrected all by injection 226. Tunneling and CGM pickup 154 mg/dl 5 units Novolog tunneling 30 degree angled site is 2 days old 227. Long low and late high in 7 yo 228. Long low and late high in 57 yo 229. Overnight high in 9 y.o. pumper 230. 102 mg/dl Midnight BG checks at camp 30 gm CHO 231. I slipped on a banana Large banana 7 units Humalog meal Identify the: drift lag(s) drop 232. Following the drop and meal Calibration 233. 4 units @ 167 mg/dl 2-3 hours 234. Missed 9PM basal dose (glargine) Normal time Lantus taken (9PM) Detected rising sugar level @ 2AM Humalog dose (7U) AND usual Lantus taken (20U) Sensor gap!! dinner Fell asleep! All back in range by morning! 235. What happens when a basal insulin dose is missed Usual time Lantus dose is taken: 9PM Rising BG discovered here Insulin correction given If not treated: high BG and ketones Treated: In range BG and NO ketones 236. Stress effect 237. Endocrinology Board Exam taken every 10 years Stress and Sugar Strong emotional stress triggers release of a several hormones These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body Stress hormones also make the liver produce sugar from substances like protein and fat This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood CGM allows for more aggressive anti-stress treatment of rising sugars 238. 3 units Staff Meeting Stress Hollow Highs are more common from stress adrenaline 239. 3 units Tx Overtreatment of a stress high Stress EPI 240. Recovery from overtreatment of a stress high 3 units Tx Stress EPI 241. Rest of the day after a stress high overcorrection B A S A L 242. Steroid pulse 243. Crossing 140 mg/dl @ 3AM and a 2.5 U lispro correction ~ 2 hours Lag time Why act? Slow upward BG trend (red arrow) Crossed personal action consideration threshold: 140 mg/dl in my case (yellow line) Knew the CGM would alert me to a rapidly dropping BG later if I over treated Have done this many times before: practice, practice, practice 244. Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery) 245. Awakened by CGM alarm to a BG below 60 mg/dl Lag time 20gm Rationale Slow downward BG trend (red arrow) Crossed personal action consideration threshold: 60 mg/dl in my case (yellow bottom line) Drank 20 gm grape juice and went back to sleep Knew the CGM would alert me to a rapidly rising BG later if I over treated Have done this many times before: practice, practice, practice 246. Fell asleep early evening after long daywoke up at 10:45PM Late dosing of Lantus (20 units @ 10:45PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION: These series of dosing actions are only possible with a CGM! 5U 6U 7U 6U9U 15 grams CHO MEAL 247. 6 U 4 U 4 U 4 U 5 U 6 U 28 GM 90+ GM 1. Stacked insulin + delayed eating 2. Hyper-treated severe low 3. Fought rebound high BG all night 4. Took the drop and timed meal 248. Dislodged insulin pump site Picked up early by CGM Pump site changed, insulin dose given, carb correction taken$13,000 saved 249. Slept on transmitter 250. Barely out of range 251. Overlapping receivers to maintain continuity Once you have a second Dexcom receiver (after replacing the first one), you have a spare receiver. Program the receiver to the frequency of the new transmitter and overlap their use. At least 2 hours before the current session ends, start up the other receiver and start the countdown process. No data gaps in weeks 2 and 3 (maybe 4?) 252. BG bump up (10 mg/dl rise) after waking at 4:45AM (real or not?) 253. How does this feel? 254. This can be sensed too CHO A steady trend The bodys defenses against low blood sugar include the brain Downward shifts, even small, can be sensed by the conscious brain Once sugar levels off, the brain senses stability Rationale Blood sugar control is complex, it includes the brain and nervous system Long term damage to the autonomic nervous system can result in loss of classic signs/symptoms of low blood sugar But, the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (e.g., < 50 mg/dl) A CGM device can serve as a biofeedback device of sorts in adults willing to develop the ability over time. 255. Although subtle, this can be felt 256. Feel the drop and level off 257. This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min 258. Watch the dots, not just the arrow 259. Watch the dotsnot just the arrows Just 22 minutes later 260. What have we learned? Sensing changes 1) You can learn to sense drops and rises. Practice guessing 2) Use your inner sensations to complement your sensor and meter, they will always be ahead of the screen readout 3) The arrows are least helpful: watch the dots! 261. A day of Sugar Surfing 262. A day of surfing 263. Basal checkingalways 264. 1 unit Novolog @ 5:07 AM @120 mg/dl A small micro-bolus nudge 265. 3 units Novolog @ 6:29 AM @106 mg/dl 28 gm CHO @ 6:52 AM (92) Timing a dose and meal The bend 266. 2 unit Novolog @ 8:02 AM @126 mg/dl 76 mg/dl 4 gm 9:19 65 mg/dl 4 gm 10:45 69 mg/dl 4 gm 10:30 Overnudging and micro-carbing 267. 2 unit Novolog @ 12:19 PM @ 71 mg/dl 28 gm CHO @ 12:25PM (70) Timing a dose and meal 268. 81 mg/dl 4 gm 3:05PM 82 mg/dl 4 gm 4:11 micro-carbing 28 gm CHO @ 12:25PM (70) 269. 6.0 units Novolog @ 8:08 PM @ 113 mg/dl 3.0 units Novolog @ 8:54 PM @ 89 mg/dl Dinner: Soft Shell Crab/Roll 82 mg/dl 4 gm 4:11 1.5 units Novolog @ 7:51 PM @ 113 mg/dl 270. A day of surfing 271. Do I need to be on an insulin pump before using a CGM? No, you can be on injections (MDI) too Must my diabetes be present for a period of time first? No Do I have to wear it all the time? Can I take a break? Yes, certainly Can I reuse a sensor? Yes. I will explain later CGM Frequently Asked Questions 272. Can children use these devices? Yes. FDA has approved them for as young as age 2 CGM Frequently Asked Questions Do insurance companies cover these? Yes. Usually Does Medicaid/Medicare cover these devices? Not generally but there have been some successes reported Do I need special training to start using a CGM? Ideally yes. There are tutorials for how to get started. But a live trainer is best 273. 6 month CGM data summary Average BG = 103 mg/dl Standard deviation = 34 mg/dl Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value 274. Closing thoughts 275. Sugar Surfing principles to live by Get out in front of the sugar wave or drop (be aware) Practice micro-dosing at higher baselines to start Remember your successes, memorize your failures If the wave (or a drop) gets in front of you, be patient, attack it and take the drop or the rebound Rearrange your food order based on the glucose situation Master nudges and shoves: they are at the heart of surfing Set and refine your personal action thresholds Calibrate and basal test daily 276. Quiz 277. Day vs. Night: any thoughts about why? 278. What is this called? Answer: taking the drop 279. What is this called? 280. Whats the message of this image? 281. Whats this image saying? (hint: look at the time) 282. Whats this image tell you? 283. What is this called? 284. When to pull the trigger? 285. Interpret these two images Hint: sensor is over two weeks old 286. What is it a good time for and why? 287. A good time to calibrate 288. Penny stock day trading strategySugarSurfing 289. 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