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WelcomeLike “The Power Within by Stephen Ponder MD, FAAP CDE”

www.stephenpondermd.com

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

©

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Unleashing the “Power Within”

Like “The Power Within by Stephen Ponder MD, FAAP CDE”

www.stephenpondermd.com

©

“Kickin’ D’s Butt”

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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• Nudging, pushing and shoving sugar• Pre-empting• “Taking the drop”• The trend is your friend

Principles

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Dynamic Diabetes Management (DDM) requires…

1. Comprehending a system with 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

Appreciate the flux of sugar levels in non-d persons

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Remember: Sugar Surfing is all about managing…

(Glucose production – Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

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

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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?

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To unleash your Power Within…

Work to 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

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Diabetes care is about choices

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23%221

Diabetes care must be individualized

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“Chance favors the prepared mind” Louis Pasteur

…dude

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3 virtues of the well managed

Hang in there. Don’t give up!

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

Knowledge alone does not imply understanding

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

Do 2 RN’s = 1 kid?

=

Ok? Ok to me!

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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.

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You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625; data interpretation

DX'd 1950-1964

DX'd 1965-1980

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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.

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.

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Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals

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

Diabetes care is best approached 1 day at a time

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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 shifts 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

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present

past future

Actions Actions

“CONTROL”

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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 pass up an opportunity to assess a trending BG

• Choose what you consider “actionable”

• Set personal action thresholds

• Use situational thinking: consider recent, current and impending actions

• Check your BG results over time

• “treat to target” (repeat as needed, but don’t “overstack” your insulin)

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How much sugar is in the bloodstream for a 100 mg/dl BG level?

Human circulatory system

165 pound (75 kg) man(5.1 grams)

55 pound (25 kg) girl(1.75 grams)

110 pound (50 kg) boy(3.45 grams)

= 4 gram glucose tabaka “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

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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

• 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

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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 responding to 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 the enemy

11. Calibrate carefully

12. Pre-empt when you can

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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

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“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

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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

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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

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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)

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Settling in at 6 hours: wobble

Sensors are not always right

Or is it the meter that’s off?

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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…

Dual receivers linked to same sensor

2 hours

1. Steady trend2. In target range

Remember…

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Basal testing

Overnight basal testing

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Overnight basal in range (glargine)

Overnight basal testing

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Overnight in range!

Overnight control in range

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Basal testing…

Overnight basal control - Lantus

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Basal testing…

Sugar Surfing tip: midday basal testing

Omitted lunch

steady

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Basal testing with a 3 year old

Timing is everything

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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

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Timing 101 – 20 min. match

Insulin

Food

Timing 101 – 45 min. mismatch

Insulin

Food

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Why timing is everything

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

Timing…waiting for the bend

“window”

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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”!

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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

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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

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Correction and meal

6 units (161

mg/dl)

Meal(26 gm CHO)

~ 45m126 mg/dl

Micro-dosing

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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”

BG 137 mg/dl and rising slowly

3 units lispro

“Micro-bolusing”

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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

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

1.5 units

~ 2 hours

3U lispro@ 3:40AM

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4 unit lispro “push”

“Course correcting for smooth sailing”

Well balanced basal insulin

Hello Kitty…goodbye low blood sugar

2 Pez @ 62 mg/dl

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6 unit “shove” at 133 mg/dl

“Shoving Sugar”

3U @ 3:32

5U @ 4:506 @ 6:17

Gently turning a curve

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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

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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

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IOB after 6 units and fried meal

6 units

3.5-4 hours2 units

WalkFried Meal

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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”

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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

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Dealing with rising tides

“Fried-food revenge” and correction

Fried food earlier in evening @ 8PM

BG = 1946 unit correction @ 7AM

BG = 115 in 3 hours

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“Revenge of the Ribeye” and “The Insulin Strikes Back”

BG 167: 4 units

LAG

2-3h

Slow BG rise from protein-fat laden meal

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

5 units

~ 2 hours

Slow overnight rise and early AM correction

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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

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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

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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

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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…

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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

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Shoving, pushing, nudging…

…and “Taking the Drop”

Two gulps of juice (15-20g CHO)

“Nudging a Drift”(aka microcarbing)

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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)

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5 gram CHO “nudge” @ 66 mg/dl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day “nudge” after no lunch with one “gulp” of fruit juice

84 mg/dl to 96 mg/dl

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

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

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Exercise “bump up”

Moderate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

“Walking down” a trend

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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

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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”

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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

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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)

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”

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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

Stuff happens…deal with it

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“Smooth seas do not make skillful surfers”

I slipped on a banana…

Large banana

7 units Humalog

meal

Identify the:

drift

lag(s)

drop

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Following the drop and meal…

Calibration

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!

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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

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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

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

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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

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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

Anatomy of a nighttime low

A) 4 hour window

B) 24 hour window

C) 6 hour window

D) Resolution

34 mg/dl

36 grams CHO

2.5 hours

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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

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Dislodged insulin pump site…Picked up early by CGM

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

How does this feel?

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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”

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Feel the drop and level off

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

~ 1 mg/dl/min

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Pre-empting

“Working down” a rising BG

4 units @ 173 mg/dl

2 units @ 167 mg/dl

7 units @ 2PM for Whataburger and rings

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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

One goal to aim for: pre-empt meal spikes

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Closing thoughts

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

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Day vs. Night: any thoughts about why?

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

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What is this called?

Answer: “taking the drop”

What is this called?

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When to pull the trigger?

Interpret these two images

Hint: sensor is over two weeks old

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What is it a good time for and why?

Straight line trend

Straight line trend

= 10 grams carbs

60 mg/dl

90 mg/dl

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This is about as tight as it gets

Proactive-Reactive

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Proactive-Reactive

Proactive-Reactive

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Largely reacting here

Penny stock day trading strategySugar Surfing

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©

“Kicks D’s Butt”

Sugar Surfing