JDRF TypeOneNation June 21 2014: Sugar surfing putting it all together by Stephen Ponder MD, FAAP CDE
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This document discusses principles of "sugar surfing" or dynamic diabetes management. It emphasizes that diabetes care requires comprehending basic concepts, adjusting to changing conditions, and frequent reassessment. Effective management is like driving a car or surfing, requiring an understanding of how insulin, food, and activity impact blood sugar levels over time. The document provides tips on using continuous glucose monitors to track trends and patterns, calibrate sensors, test basal insulin needs, time insulin administration with meals, and experiment with micro-bolusing and corrections.
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JDRF TypeOneNation June 21 2014: Sugar surfing putting it all together by Stephen Ponder MD, FAAP CDE
- 1. Sugar Surfing Stephen W. Ponder MD, FAAP, CDE (aka “doctor juicebox”) ©
- 2. Unleashing the “Power Within” Like “The Power Within by Stephen Ponder MD, FAAP CDE” www.stephenpondermd.com
- 3. 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
- 4. Appreciate the flux of sugar levels in non-d persons
- 5. Remember: Sugar Surfing is all about managing…
- 6. (Glucose production – Glucose disposal) = FLUX Here is a picture of FLUX and DRIFT
- 8. 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
- 10. Diabetes care is about choices
- 12. “Chance favors the prepared mind” Louis Pasteur …dude
- 13. 23% 221
- 14. Diabetes care must be individualized
- 15. 3 virtues of the well managed
- 16. Hang in there. Don’t give up!
- 17. “You can delegate authority but you can’t delegate responsibility”
- 18. Do 2 RN’s = 1 kid? = Ok? Ok to me!
- 19. 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.
- 21. You CAN influence how long it lasts diabetes treatment preserves INTERNALLY made insulin
- 22. 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.
- 23. 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
- 24. Diabetes care is best approached 1 day at a time
- 25. static vs. dynamic diabetes care static • Actions predetermined • Minimal flexibility: RIGID • Outcomes don’t immediately affect subsequent actions • Easy to teach/learn • Less time-intensive • Favors concrete thinking • Less motivation needed dynamic • Actions are dependent on situation/circumstance • Flexible and adaptable • Outcomes constantly influence subsequent actions • Training needed, plus ongoing reinforcement • More time intensive • Favors problem-solving • Requires ongoing motivation
- 28. 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 * * * * * * * *
- 29. 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)
- 30. 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”
- 31. 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
- 32. 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
- 33. 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
- 34. 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
- 35. Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate
- 36. Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert
- 37. Cal-i-bra-tion (noun ˌka-lə-ˌbrā- 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
- 38. 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
- 39. 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
- 40. Daily calibrating on a steady baseline
- 41. 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
- 42. 4 hours post start up calibration (extra)
- 43. Sensors are not always right Or is it the meter that’s off?
- 44. Dual receivers linked to same sensor 2 hours 1. Steady trend 2. In target range Remember…
- 46. Overnight basal in range (glargine)
- 49. Overnight control in range
- 50. Basal testing…
- 51. Overnight basal control - Lantus
- 52. Basal testing…
- 53. Sugar Surfing tip: midday basal testing Omitted lunch steady
- 54. Basal testing with a 3 year old
- 56. 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
- 57. Timing 101 – 20 min. match Insulin Food
- 58. Timing 101 – 45 min. mismatch Insulin Food
- 59. Why timing is everything
- 60. 3 units @6:10 28 gm @ 6:50 Timing…waiting for the bend “window”
- 61. 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike
- 62. Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the “bend”!
- 63. Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM)
- 64. 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
- 65. 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 ”
- 66. 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
- 67. Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl
- 68. 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”
- 69. BG 137 mg/dl and rising slowly 3 units lispro “Micro-bolusing”
- 70. 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)
- 71. BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time
- 72. 112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline 1.5 units ~ 2 hours
- 74. 4 unit lispro “push” “Course correcting for smooth sailing” Well balanced basal insulin
- 75. Hello Kitty…goodbye low blood sugar 2 Pez @ 62 mg/dl
- 76. 6 unit “shove” at 133 mg/dl “Shoving Sugar”
- 77. 3U @ 3:32 5U @ 4:50 6 @ 6:17 Gently turning a curve
- 78. Learn your own insulin duration To forge I-chains
- 79. 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
- 80. 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
- 81. Duration of insulin effect can be determined here ~ 4 hours
- 83. IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal
- 84. Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours
- 85. 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus “Inflections” calibration Tex-Mex Dinner calibration “Remember the Alamo”
- 86. 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
- 87. 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
- 88. Dealing with rising tides
- 89. “Fried-food revenge” and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours
- 90. “Revenge of the Ribeye” and “The Insulin Strikes Back” BG 167: 4 units LAG 2-3h
- 91. Slow BG rise from protein-fat laden meal
- 92. Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours
- 93. Slow overnight rise and early AM correction
- 94. 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes
- 95. Correction with 20 grams carbs 20 gm CHO
- 96. Pre-empting
- 97. 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A “random rise” in BG during a routine day. 2-3 hours
- 98. 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
- 99. 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
- 100. 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
- 101. 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 …flux?” “What the…
- 102. Duration of insulin
- 103. 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization
- 104. Two gulps of juice (15-20g CHO) “Nudging a Drift” (aka microcarbing)
- 105. 5 gram CHO “nudge” @ 66 m/dl Dropping < 1 mg/dl/min “Nudging a Drift” (aka microcarbing)
- 106. 4 gram CHO “nudge” @ 66 mg/dl 4 gram CHO “nudge” @ 70 mg/dl “Nudging a Drift” (aka microcarbing)
- 107. 5 gram CHO “nudge” @ 66 mg/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone
- 108. Late day “nudge” after no lunch with one “gulp” of fruit juice 84 mg/dl to 96 mg/dl
- 109. “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice
- 110. Leisurely walk from 7:00 to 8:30: straight line
- 111. Exercise “bump up” Moderate intensity 75 minute duration Glycogen Glucose
- 112. 2 units 1 hr walk “Walking down” a trend
- 113. 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
- 114. Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk (EXERCISE) 2 units ~ 2 hours
- 115. 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours “Pushing sugar” aka “Nudging a drift”
- 116. BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons “launch window”
- 117. 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait “Taking the drop”…
- 118. “Taking the drop” BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth
- 119. 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)
- 120. 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”
- 121. 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 time 20-30 min
- 122. “Smooth seas do not make skillful surfers”
- 123. I slipped on a banana… Large banana 7 units Humalog meal Identify the: drift lag(s) drop
- 124. Following the drop and meal… Calibration
- 125. 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!
- 126. 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
- 127. Stress effect
- 128. 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
- 129. Steroid pulse
- 130. 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
- 131. Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
- 132. 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
- 133. Fell asleep early evening after long day…woke up at 10:45PM Late dosing of Lantus (20 units @ 10:45PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION: These series of dosing actions are only possible with a CGM! 5U 6U 7U 6U9U 15 grams CHO MEAL
- 134. 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
- 135. Dislodged insulin pump site… Picked up early by CGM Pump site changed, insulin dose given, carb correction taken…$13,000 saved
- 136. Although subtle, this can be “felt”
- 137. Feel the drop and level off
- 138. This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min
- 139. This can be “sensed too” CHO A steady trend The body’s 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.
- 140. Pre-empting
- 141. “Working down” a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings
- 142. 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
- 143. One goal to aim for: pre-empt meal spikes
- 144. Closing thoughts
- 145. 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
- 146. Day vs. Night: any thoughts about why?
- 147. “nudge” from 62 mg/dl to 87 mg/dl with 8 grams fruit juice
- 148. What is this called? Answer: “taking the drop”
- 149. What is this called?
- 150. When to pull the trigger?
- 151. What is it a good time for and why?
- 152. Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl
- 153. Penny stock day trading strategySugar Surfing
- 154. © “Kicks D’s Butt” Sugar Surfing
Editor's Notes
- Change “Managing “d” well with the words: Sugar Surfing requires the following skills and equipment
- Normal tides and swells in non-d humans
- It’s all about riding the waves, crests and troughs
- 15 seconds
- TitleThe carbohydrate counting in adolescents with type 1 diabetes (CCAT) study.AuthorsBishop, F. K.; Maahs, D. M.; Spiegel, G.; Owen, D.; Klingensmith, G. J.; Bortsov, A.; Thomas, J.; Mayer-Davis, E. J.Journal Diabetes Spectrum 2009 Vol. 22 No. 1 pp. 56-62 ISSN1944-7353DOI10.2337/diaspect.22.1.56URLhttp://spectrum.diabetesjournals.org/cgi/content/a...This article reports pilot study results evaluating the accuracy of carbohydrate counting among adolescents with type 1 diabetes. This cross-sectional observational study included 48 adolescents ages 12-18 years (mean 15.2±1.8 years) with type 1 diabetes of >1 year in duration (mean A1C 8.0±1.0%) who used insulin:carbohydrate (I:C) ratios for at least one meal per day. The adolescents were asked to assess the amount of carbohydrate in 32 foods commonly consumed by youths. Foods were presented either as food models or as actual food, with some items presented as standard serving sizes and some self-served by study participants. T-tests were used to assess the significance of over- or underestimation of carbohydrate content. For each meal, accuracy was categorized as accurate (within 10 grams), overestimated (by >10 grams), or underestimated (by >10 grams) based on the commonly used I:C ratio of 1 unit of insulin per 10 grams of carbohydrate. Only 23% of adolescents estimated daily carbohydrate within 10 grams of the true amount despite selection of common meals. For dinner meals, individuals with accurate estimation of carbohydrate grams had the lowest A1C values (7.69±0.82%, P=0.04). The pilot study provides preliminary evidence that adolescents with type 1 diabetes do not accurately count carbohydrates. Further data are needed on carbohydrate counting accuracy and other factors that affect glycemic control.
- Based on the principle of FPM (frequent pattern management)
- BG (mg/dl) x 75 ml/kg blood volumes x weight in kg x 1dL/100 ml = mg of BG in TBV
- April 7 2014
- Timing 3 at 6:32 28 GM at 6:52 started at 127 and are at 108
- “The Umbrella Effect”I’ve packed a lot of useful teaching points into one image here.While long-acting or basal insulin delivery(insulin glargine, insulin detemir, or the basal delivery rate on a pump) is like having a long roof over your glycemic ‘head’. Injections or boluses of rapid acting insulin have umbrella-likeproperties. Properties of any insulin include 1) time to onset of sugar lowering effect, 2) duration of peak sugar lowering activity, and 3) an effective duration of action. I always include a fourth dimension: day to day inconsistency, which can wobble or vary a bit. It’s not only helpful, but crucial that a person using insulin have a good working understanding of these properties of the insulin being taken. Without this understanding, manipulation of sugar levels as I’m about to describe are not possible. When properly applied, rapid-acting insulin protects the user (like an umbrella) from the ‘shower’ of after meal hyperglycemia that rains down for a certain period of time (a). It does so by disposing of glucose into cells. Extending the metaphor fully, basal insulin acts as a roof with gutters that continually and gradually shunts sugar into cells, but without a great capacity. So, in a sense insulin has umbrella-like qualities as I show here on my CGM sensor plot (a 12 hour display in this case). I ate late on this evening and chose one of my more challenging foods to manage: fried chicken (b). It’s a favorite and I don’t eat it regularly for this reason. Nevertheless it was my choice. Fried meals often take more time to digest into blood sugar. That time can extend well beyond the action of the meal time insulin used to cover the meal (i.e., the umbrella), as it did in this case. As you can see, my CGM device allows me to validate my duration of active insulin time, which for me is 3 hours (a). This is the actual span of my insulin umbrella in this case. After that time, the waning insulin effect is no longer able to contain the steady input of sugar coming into my blood stream from my fried meal and the basal insulin in my body can’t properly “cover” this slow influx of sugar. The end result is a slow accumulation of sugar in my blood stream, registered as the rise on my CGM plot shown here (b).Well, I awoke and looked at my sensor and noted I was at 171 mg/dl (d) but the arrow was straight, meaning a gradual upward trend of under 1 mg/dl/minute. Looking at the trend line, recalling what I ate and knowing my prior responses to fried meals, I decided to correct this trend so I would not wake up in the morning with a BG well over 200 mg/dl. Therefore, I took 6 units of insulin to accomplish this. Normally this would take about 3 units since my correction factor is between 1:25 and 1:33 most of the time. But here is another teaching point: my BG was slowly rising and had a form of “momentum” behind it. Had it been trending straight, or even downward, I would have taken very different actions. But since it was trending up, I knew from experience that I needed a greater insulin “force” to neutralize the rise, turn the BG trend downward, and back to my desired target BG of 100 mg/dl. So…I doubled it (6 units). As illustrated here, there was the customary 20 minute or longer “lag” time before any measureable effect of my correction insulin was seen (c). After the insulin lowering effect was underway, it took a full two hours to arrive and stabilize at my target (e). And by the way, I went back to sleep after I took those 6 units of lispro in the middle of the night. Crazy? I would agree with you 100% if I were not using a CGM device. I would be hesitant to take rapid-acting insulin so aggressively although I would have taken the standard 3 units. The result would have most likely been less than optimal, but it would have blunted the rise. My practice here is the end result of lots of practice and careful observation of my own unique responses. Anyone who attempts these maneuvers must find what best works for them. It’s also wise to discuss with your diabetes doctor. Although I must say that many docs might discourage such self-care independence. This is a look into how I manage the daily ebb and flow of my blood sugars. This is not child’s play and requires the input of an experienced and motivated adult. Parents of children with diabetes can master these skills and many have, but it takes patience, consistency and resilience to achieve the confidence illustrated here. I hope this teaching slide is helpful to many of you. This further demonstrates how tight glycemic control truly exists “in the moment”, as I try to illustrate all the time.
- “Playing Chicken” with a CGM, blood sugar and insulinI have a weakness for fried chicken. I try not to indulge myself with it often since it requires some extra work to manage the after effects on my blood sugar. The other night I had two pieces of chicken, a roll, cole slaw and green beans (not shown) around 7PM. By midnight, the slowly digesting meal (lots of fat and carbs) combined with the waning effect of my suppertime insulin, could no longer contain the rising tide of glucose entering my bloodstream and hence the levels began to rise after midnight. I woke up and noticed this rise at 2:06 AM. I of course knew what I had eaten the night before, my typical BG pattern with foods like this (a slow steady rise after my meal insulin wears off), plus I realized that some chicken remained in my stomach and was waiting to get into the gut (fatty foods linger in the stomach longer, not a lot of glucose absorption happens there). Knowing this, plus my response to prior doses of insulin to offset these sorts of rises, I took 5 units of rapid-acting mealtime insulin (lispro), then went back to sleep. If I was still on my insulin pump, I would have taken a combination (dual-wave) bolus, but that is another discussion.Let me say that I would NEVER have taken 5 units of insulin at 132 mg/dl and then gone back to sleep. At least not before I had my Dexcom G4. My graphic shows what would most likely have happened if I had just slept through the night and done nothing. Waking up the next morning my BG would be over 200 mg/dl even though at bedtime I was in range. In fact, it is possible I would have taken a snack at bedtime on top of all this, further driving the reading up overnight. The training and understanding of health care providers has some catching up to do in regards to using dynamic versus static data sets created by CGM technologies. The preference is to have a machine make the call (the artificial pancreas or AP). That makes the most sense for the most people I agree. But cruise control is rarely used in rough terrain. I find that a well practiced working knowledge of one’s own body and responses, combined with experience and judgment, can allow some of us now to benefit from a “manual” version of the AP of our own creation. But I agree this isn’t anything kids are able to do quite yet. But IMO the principles used to do this can help everyone in their daily problem-solving and trouble-shooting situations. Anyway, notice that over the next 2-3 hours, I was able to “bend” the glucose curve back the way I wanted it to go. The waviness in the line might have been the sensor on it’s final day since I changed it the next day, but when I calibrated at 5:30, the sensor said 97 mg/dl and my meter said 102 mg/dl. Thank you, Dexcom G4!The power to safely experiment with otherwise forbidden or dangerous practices like taking a dose of 5 units rapid-acting insulin and then going back to sleep is something that is not discussed enough about CGM’s. This is like practicing a high wire trapeze act with a big safety net underneath me: it’s hard to get hurt too badly. Of course I have ample sources of fast sugar (juice) by my bedside (or car or at work) when I do this. My CGM gives me the ability to see highs or lows coming from a distance, not when they are right upon me. This is a tremendous benefit of these devices. When patients ask me, I tell them that a CGM can serve two functions. One the one hand it can serve as a “burglar alarm” that will buzz or beep at alert me when hypo or hyperglycemia is entering my body. On the other hand, it can also be a surveillance system that scans the horizon for possible intruders, allowing you to pick them off before they get too close. As you can see, I use it very proactively, but I am also still reacting to what is happening to me (the fried chicken on this occasion). But a CGM is also a biodfeedback device. I teaches me what different BG levels FEEL LIKE. I can now reliably predict when my BG is shifting…up or down. What an added benefit indeed. I hope this post teaches a few things about knowing yourself, safely experimenting new approaches, and always looking at diabetes self care as a practicable skill, which in my opinion is exactly what it is. As always, feel free to share this post with others who might benefit. I hope you all turned your clocks BACK last night before going to bed. That includes all your diabetes devices too: pumps, sensors and meters.
- FFA Field trip home at 10PM. BG shot up at 2PM. Ate pizza for dinner at 8PM. Unknown insulin dose taken relative to meal Meter says 420 at 379 on sensor. Went to 56 by 10:45AM next AM
- May 11 2014
- Bad pump site…
- May 6 2014
- At sensor calibration time, sensor read 103 mg/dl and meter read 101 mg/dl. After calibration it reset to 99 mg/dl
- Straight line trends need more subtle corrections
- Requirements of Penny Stock InvestorsYou should not get involved with day trading unless you are able to effectively monitor your holdings and can commit with the proper mind set and outlook. This strategy takes time, research, and a good deal of money (I suggest at least $4,000). Otherwise, you may not be able to benefit from such a trading methodology.You need to be able to check the prices of stocks on a moment's notice, and get an accurate and up-to-the-minute quote. Having internet access or a computer connection to your broker from work or home is generally best. When day trading, you may need to check stock prices frequently, possibly watching their prices all day. Using a computer it takes only a few minutes each time, you can get current prices, and can alter or submit new orders on-line after checking the penny stock's activity.Most of all, you need patience. Although day trading in penny stocks is probably the quickest profit and loss method in the financial world, patience still comes into play. The best day trading strategies involve often going a week or so without a trade, because you must wait to get the best prices. Impatience immediately negates the effectiveness of the day trading strategy.Finally, you need a strong stomach. You should understand that day trading in penny stocks can result in one week gains that are monumental, or can set you up for a loss. Whether making a big profit or taking an ugly loss, you should be able to handle both the good and bad stress that will come with this method of trading. Otherwise, you may make moves for the wrong reasons and compromise your objectives.What Day Trading IsDay trading is simply an attempt to capitalize on short term fluctuations in stocks. For example, with penny stocks it is possible to buy an issue at $0.12 and sell it the next week, day, or even a few hours later at $0.15, giving you a 25% short-term profit on your investment.If a profit of more than 20% to 25% presents itself, you often take it. Do this a few times and you are looking at a highly successful investment strategy.The downside of day trading comes into play when you buy an issue and it drops in value. At that point you either take a quick loss to keep your money available, or you sit and wait for a profit opportunity that may arise later, in which case your money is tied up until that time. This becomes less of a concern for traders who have more assets at their disposal, because while only a portion of their money is temporarily tied up in a stock that has fallen in value, the rest of their portfolio could be actively used.Now, let me tell you how to take advantage of day trading without significant risk, and with maximum profit potential. If you are going to begin day trading, read this section a few times through and adjust your own investment style accordingly.Goals of Day TradingThis is very important if you intend to be successful at day trading. Your overall goal is to make several hundred of percent on your investments on a year by year basis. However, this is to be done 40% and 30%, even sometimes 10% at a time. That is where most day trading strategies fall apart - investors don’t understand that taking the smaller gains more frequently will actually be more effective than the larger gains less frequently!Your goals for an effective day trading strategy should be as follows:•Keep on top of your open buy and sell orders, and the trading activity of the underlying stocks so that you are rarely surprised by a penny stock’s action.•To take small profits when they present themselves. You will find that you have the opportunity for small 15-25% profits very frequently.You won’t often be in a position to be taking the larger 30%-50% profits, because you already would have sold when your shares first began to rise. Therefore, as backwards as it sounds, if you find that you are taking 50% profits more often than 25% gains, you are probably doing something wrong. In the long run, you would likely make more money by grabbing the 25% gains again and again, instead of holding out for the larger returns.Effective Strategies and ConsiderationsThe first consideration of this trading method compared to others is that you will be taking commissions more frequently. If you are not already with a discount broker, or are paying more than $20 per trade, you probably should switch to a cheaper broker. You can read all about penny stock brokers, and get my list of the top ones earlier in this site.With penny stocks, you may often find that a buy or sell order goes partially filled. For example, you may only get $200 worth of shares and be stuck with a $20 commission. To avoid this, keep track of your orders during the trading day - you may pick up a portion of your order at the price you want, then have to adjust the purchase or sell price to make sure you get the rest of the order filled. Changing an existing order to get all the shares you want on one day, instead of over two or three days, means that you will only be subject to one commission.The beauty of day trading is that company fundamentals and overall market action become less significant. You are playing the day by day fluctuations instead of hoping the market will rise or the company will increase its earnings. Buying at the low end of volatility and selling at the high end equals success, despite monthly trends, company fundamentals, or the market outlook.Therefore, it doesn’t matter if the companies you invest in have a positive future or are bad long-term purchases. What’s important is that you keep an eye on the trading activity of the issue in question, try to pick its higher and lower trading ranges, then execute buy and sell orders accordingly.With day trading you need to realize that most of your buy orders should go unfilled, because your bid price needs to be lower than the going trading price of the stock. Buy on the dips and you will have success - put in orders to acquire shares at or below the current bid price. If you put in ten buy orders over the course of a month, you may wind up only getting one of the buys you had wanted, but those shares will be yours at a great price, making it easier to unload them for a quick profit.When tigers hunt, they only catch a meal one out of ten attempts.Deciding on appropriate buy and sell prices at which to submit your orders is relatively simple. Look at a stock that has both high volume of bid lots, and high volume of ask lots. Many people are trying to buy at one price and many people are attempting to sell at another. Look at the spread between the bid and ask prices. If it is about 15% or more, you may want to put in a buy order at the bid price, and if it gets filled immediately put in a sell order at the ask price.Of great importance is the number of bid lots compared to the number of ask lots. There is a very different stock price outlook if the number of bid shares vastly outnumber the ask shares, or vice-versa. The more bid lots, the greater the buying pressure and price strength at that level. In other words, if there is a large level of demand, the price will likely solidify at that level and begin to climb, unless there are enough shares for sale to meet the demand.When getting a stock price quote, look at the number of bid lots and ask lots to get an idea of the demand and supply. This will give you a relatively accurate indicator of the direction the penny stock price will travel in the day, and perhaps throughout the following few days. Use the bid lot and ask lot volumes to help you come up with a price range that the penny stock will trade within.Day trading will prove most effective when you trade in penny stocks that you have been watching for a long time. You will be able to produce better results since you have developed a feel for the upper and lower price ranges. This is not a requirement for success, but rather an advantage.Hedging and Averaging DownAs a more advanced strategy, you may want to incorporate hedging into your day trading practices. When buying, this involves putting in buy orders for the same stock at different prices.Let's use an example: You put in an order to buy 4000 shares of OCN @ $0.23 and a separate order to buy 4000 shares of OCN @ $0.17. Now consult the chart below to see the possible outcomes of your strategy.Possible Hedging Outcomes•Outcome #1: If the price falls to or below $0.23, your first order gets filled. Now if the price drops further, you may get your second order filled at a lower price, averaging the price of your 8000 shares to $0.20. Profits could be realized now by selling at $0.22 or greater. If the price climbs, you will make a profit. If it continues to fall you will take a paper loss. This becomes an actual loss if you sell the shares, or if the shares never return to their $0.22 levels. However, in all likelihood the price will bounce around and will present an opportunity to profit or at least break even at some point in the future.•Outcome #2: The price falls to or below $0.23 and your first order gets filled. The price then rises, leaving your second order unfilled, but providing you with the ability to profit on the 4000 shares you did buy.•Outcome #3: The price does not fall low enough to fill your buy order. You don’t get the shares, but you are no worse off. You can extend your order, adjust your prices, or move on to a different penny stock. Again we must stress that an unfilled buy order means that you probably have the right idea. It is better to have an unfilled buy order than to get shares at too high of a price.These hedging strategies can also apply in the same manner when selling penny stocks.Of course, you are also getting exposed to extra commissions with this strategy.Day Trading SummaryDay trading penny stocks is as straight forward as it sounds. However, you will need a little luck, a lot of patience, and the ability to take the profits that present themselves. By keeping a close eye on the markets and following a simple strategy such as the one outlined above, day trading becomes a straight-forward technical process that requires little thought, yet can provide impressive penny stock returns.