Sugar Surfing Stephen W Ponder MD FAAP CDE (aka ldquodoctor juiceboxrdquo)

copy

>

Unleashing the ldquoPower Withinrdquo

Like ldquoThe Power Within by Stephen Ponder MD FAAP CDErdquo

wwwstephenpondermdcom

Dynamic Diabetes Management (DDM) requireshellip

1 Comprehending a system with basic principlesconcepts

2 Adjusting to changing or shifting conditionssituations

3 Frequent assessments and re-assessments

LIKEhellipbull Driving a carbull Flying an airplanebull Walking a tightropebull Surfing

01-01SensorHemoCue Data

(29)

50

100

150

200

27 TueMar 2001

28 Wed 29 Thu 30 Fri 31 Sat 1 Apr 2 Mon 3 Tue

Sensor Vs HemoCue (Finger) Glucose --- Sensor 6989 hCDP Output

Glu

cose

(mg

dL)

Average Blood Glucose = 98 mgdl

Note Investigational device Device not approved by FDA

Appreciate the flux of sugar levels in non-d persons

Remember Sugar Surfing is all about managinghellip

FLUXdrift

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

Unleashing the ldquoPower Withinrdquo

Like ldquoThe Power Within by Stephen Ponder MD FAAP CDErdquo

wwwstephenpondermdcom

Dynamic Diabetes Management (DDM) requireshellip

1 Comprehending a system with basic principlesconcepts

2 Adjusting to changing or shifting conditionssituations

3 Frequent assessments and re-assessments

LIKEhellipbull Driving a carbull Flying an airplanebull Walking a tightropebull Surfing

01-01SensorHemoCue Data

(29)

50

100

150

200

27 TueMar 2001

28 Wed 29 Thu 30 Fri 31 Sat 1 Apr 2 Mon 3 Tue

Sensor Vs HemoCue (Finger) Glucose --- Sensor 6989 hCDP Output

Glu

cose

(mg

dL)

Average Blood Glucose = 98 mgdl

Note Investigational device Device not approved by FDA

Appreciate the flux of sugar levels in non-d persons

Remember Sugar Surfing is all about managinghellip

FLUXdrift

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

Dynamic Diabetes Management (DDM) requireshellip

1 Comprehending a system with basic principlesconcepts

2 Adjusting to changing or shifting conditionssituations

3 Frequent assessments and re-assessments

LIKEhellipbull Driving a carbull Flying an airplanebull Walking a tightropebull Surfing

01-01SensorHemoCue Data

(29)

50

100

150

200

27 TueMar 2001

28 Wed 29 Thu 30 Fri 31 Sat 1 Apr 2 Mon 3 Tue

Sensor Vs HemoCue (Finger) Glucose --- Sensor 6989 hCDP Output

Glu

cose

(mg

dL)

Average Blood Glucose = 98 mgdl

Note Investigational device Device not approved by FDA

Appreciate the flux of sugar levels in non-d persons

Remember Sugar Surfing is all about managinghellip

FLUXdrift

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

01-01SensorHemoCue Data

(29)

50

100

150

200

27 TueMar 2001

28 Wed 29 Thu 30 Fri 31 Sat 1 Apr 2 Mon 3 Tue

Sensor Vs HemoCue (Finger) Glucose --- Sensor 6989 hCDP Output

Glu

cose

(mg

dL)

Average Blood Glucose = 98 mgdl

Note Investigational device Device not approved by FDA

Appreciate the flux of sugar levels in non-d persons

Remember Sugar Surfing is all about managinghellip

FLUXdrift

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

Remember Sugar Surfing is all about managinghellip

FLUXdrift

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

(Glucose production ndash Glucose disposal) = FLUX

Here is a picture of FLUX and DRIFT

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

To unleash your Power Withinhellip

Work to let go ofhellipbull Judgingbull Feeling defectivebrokenbull Shamebull Fearing the futurebull Isolation bull Pitybull Insecuritydenial

Embracecultivatehellipbull Acceptancebull Normalcybull Opennessbull Enjoying the momentbull Teamworkbull Empoweringsupportingbull Self-confidence

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

Diabetes care is about choices

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

ldquoChance favors the prepared mindrdquo Louis Pasteur

hellipdude

23221

Diabetes care must be individualized

Pati enceConsistencyRe

silie

nce

3 virtues of the well managed

Hang in there Donrsquot give up

ldquoYou can delegate authority but you canrsquot delegate responsibilityrdquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Diabetes care must be individualized

Pati enceConsistencyRe

silie

nce

3 virtues of the well managed

Hang in there Donrsquot give up

ldquoYou can delegate authority but you canrsquot delegate responsibilityrdquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Pati enceConsistencyRe

silie

nce

3 virtues of the well managed

Hang in there Donrsquot give up

ldquoYou can delegate authority but you canrsquot delegate responsibilityrdquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Hang in there Donrsquot give up

ldquoYou can delegate authority but you canrsquot delegate responsibilityrdquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

ldquoYou can delegate authority but you canrsquot delegate responsibilityrdquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Do 2 RNrsquos = 1 kid

=

Ok Ok to me

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Concrete thinkers canrsquothellip

1 Consider a hypothesis2 Consider multiple possibilities

in a scenario3 Systematically solve a problem4 Use combinatorial logic

Lasts until 15-17 years of age25 of adults are concrete thinkers

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

You CAN influence how long it lasts

diabetes treatment preserves INTERNALLY made insulin

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Five things to remember about T1D1) Diabetes care isnrsquot a contest Itrsquos overrun with numbers Donrsquot judge2) Let the remaining guilt (if any) go NO one is perfect3) Diabetes care is not an action it is a SKILL SET Therefore it can be

practiced and improved upon4) Control is the end result of your decisions and choices This applies to

minute to minute control as well as long term control5) NO health care provider manages anyonersquos diabetes They never can

and they never will Itrsquos a self managed condition

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Five practical advanced diabetes care tips

1) Better synchronize your insulin and your meals2) Check blood sugars 2-3 hours after meals3) Correct any out of range sugar you discover (ldquotreat to targetrdquo)

4) Work to get morning blood sugars into target range (F-F-F)5) Reviewanalyze your blood sugars at least weekly

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Diabetes care is best approached 1 day at a time

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

static vs dynamic diabetes carestaticbull Actions predeterminedbull Minimal flexibility RIGIDbull Outcomes donrsquot immediately

affect subsequent actionsbull Easy to teachlearnbull Less time-intensivebull Favors concrete thinkingbull Less motivation needed

dynamicbull Actions are dependent on

situationcircumstancebull Flexible and adaptablebull Outcomes constantly influence

subsequent actionsbull Training needed plus ongoing

reinforcementbull More time intensivebull Favors problem-solvingbull Requires ongoing motivation

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

present

past future

REACTIVE PROACTIVE

Actions

Omissions

Actions

Omissions

ldquoCONTROLrdquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

exercise insulin

ldquoincomingrdquo blood sugar

External Internal

metabolism

ldquooutgoingrdquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

8 versus 1440 ldquodecision pointsrdquo703 115

933 129

1215 95

334 131

612 168

949 107

1153 114

305 132

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Donrsquot pass up an opportunity to assess a trending BG

bull Choose what you consider ldquoactionablerdquo

bull Set personal action thresholdsbull Use situational thinking consider

recent current and impending actionsbull Check your BG results over timebull ldquotreat to targetrdquo (repeat as needed but donrsquot

ldquooverstackrdquo your insulin)

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

How much sugar is in the bloodstream for a 100 mgdl BG level

Human circulatory system

165 pound (75 kg) man(51 grams)

55 pound (25 kg) girl(175 grams)

110 pound (50 kg) boy(345 grams)

= 4 gram glucose tabaka ldquoglucose transit systemrdquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey ldquowork the lagrdquo times

FOOD lagINSULIN lagSENSOR lag

Not afraid to experimentNot expecting perfection

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

To Sugar Surf set action thresholdsbull UpperLower limits

bull eg 80 mgdl and 140 mgdlbull eg 90 mgdl and 180 mgdl

bull What rates of changebull Up or down arrows

bull Factor in recentcurrentfuture events as you are able to

bull Test your skills experiment a little within reason

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Be realisticAccept that the first 6-12 months

are on a ldquolearning curverdquoSet higher and wider targetsHave low expectations to startItrsquos still a finicky technologyPLEASE BE PATIENT

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Principles of Sugar Surfing1 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 happenhellip manipulate them

4 Keep your eye on your line5 The trend is your friend6 Learn lag limits be patient

7 Zero in on your zone8 Master micro-dosing9 Factor in glycemic inertia

and insulin momentum10 Donrsquot let ldquogood enoughrdquo

be the enemy11 Calibrate carefully12 Pre-empt when you can

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

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

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Goal Try to stay between the lines

As your skills improve lower the glucose for the upper alert

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)bull Comparing the sensor to an

accepted ldquostandardrdquo valuebull The accepted ldquostandardrdquo value is

a fingerstick BG levelbull So the sensor itself can be no

more accurate than the BG meter itrsquos compared tohellipor how well the BG meter was used

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Calibration tips

bull The first sensor day can be erratic as it ldquosettles inrdquo

bull Donrsquot over calibratebull Try to calibrate on a steady trend bull Try to calibrate when in your

target range

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

CGM calibration tiphellip

steady

2 hours

Whenever possible calibrate the CGM system when on a ldquosteadyrdquo sugar trendline

2 hr ldquowaitrdquo time between ldquoturning onrdquo sensor and providing 2 calibration BG readings to start session

steady baseline

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Daily calibrating on a steady baseline

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Steady trend2 hours

Calibrate your CGMhellipOn a steady trend when you canhellip

In the BG range you want to be most accurate inhellip

Steady trend

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

4 hours post start up calibration (extra)

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Sensors are not always right

Or is it the meter thatrsquos off

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Dual receivers linked to same sensor

2 hours

1 Steady trend2 In target range

Rememberhellip

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight basal testing

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight basal in range (glargine)

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight basal testing

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight in range

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight control in range

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Basal testinghellip

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Overnight basal control - Lantus

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Basal testinghellip

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Sugar Surfing tip midday basal testing

Omitted lunch

steady

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Basal testing with a 3 year old

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Learning from the Line Graph ndash Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus 730 AM

Breakfast 730 AM

Insulin bolus 710 AM

Breakfast 730 AM

MI MI

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Timing 101 ndash 20 min match

Insulin

Food

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Timing 101 ndash 45 min mismatch

Insulin

Food

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Why timing is everything

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

3 units 610 28 gm 650

Timinghellipwaiting for the bend

ldquowindowrdquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

3 U lispro 622AM

28 GM CHO 652AM

Timing insulin and meals to prevent a spike

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Wait for the bend

6U 146 mgdl Eat here 132

mgdl

45 minutes

Wait for the ldquobendrdquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Stopping sugar spikes

3 units (532AM)

Meal(548 AM)

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Point ldquoArdquo Point ldquoBrdquo

sugar trend

sugar trend

sugar t

rend

Insulin ldquocorrectionrdquo

Carb ldquocorrectionrdquo

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

Range of possible BG outcomes

ldquothe trend is your friendrdquo

Blood glucose level

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Noticed rising trend at 143 PM 165 mgdl

Took 5 units lispro 145 PM

4 hours

Late BG rise after the morning no lunch eaten 135 mgdl 2 hours

ldquoDirection affects correction rdquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

BG = 157 mgdlInj 4 U lispro 315

2-3 hours

20-30 minA

B

C

Correction tips (on a steady trend)

A Remember the lag time before insulin starts to effectively lower BG

B Remember the length of time it takes to accomplish the desired task

C Patience and practice make these kinds of results possible

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Correction and meal

6 units (161 mgdl)

Meal(26 gm CHO)

~ 45m126 mgdl

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Micro-bolusing (dosing)

Steady baseline BG trend

BG 136 mgdl

2 units lisproWait 2 hours

Target zone

bull Very advanced bull CGM neededbull Note flat BG

ldquobaselinerdquo trendbull Calibration goodbull Not ldquocorrectionrdquo

per sebull More of an

ldquoadjustmentrdquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

BG 137 mgdl and rising slowly

3 units lispro

ldquoMicro-bolusingrdquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Subtle correctionbull BG 125 and risingbull Took 4 units lisprobull 2 for the slow risebull 2 for the

correctionbull Waited almost 2

hours (yellow arrow)

bull Notice lag time before BG ldquoturnsrdquo (red arrow)

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

BG 124 mgdl injected 15 units lispro

356AM

2 hours

Microbolus experimentation

Lag time

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

112 mgdl to 78 mgdl after 15 units by injection on a ldquosteadyrdquo BG baseline

15 units

~ 2 hours

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

3U lispro 340AM

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

4 unit lispro ldquopushrdquo

ldquoCourse correcting for smooth sailingrdquo

Well balanced basal insulin

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Hello Kittyhellipgoodbye low blood sugar

2 Pez 62 mgdl

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

6 unit ldquoshoverdquo at 133 mgdl

2 hour correction

ldquoShoving Sugarrdquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

3U 332

5U 4506 617

Gently turning a curve

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Learn your own insulin duration

To forge I-chains

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Mealtime insulin 830PM 7 units lispro

Duration of insulin 3hr

Slow BG rise fro

m fried meal

Insulin correction dose 253AM 6 units lispro

lag

2 hours to correct

Teaching pointshellip

a Know your insulin ldquoumbrellardquo

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

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

653PM BG 108 inj 6 units

715-735952PM BG 125uarr inj 4 units

ldquoEffective durationrdquo of insulin action 3 hrs

ldquoActive insulinrdquo bull Example Slow carb

meal (fried food) bull eg Chicken fried steak

cream gravy and 3 onion rings and 8 French fries

bull Estimated 60 grams 6 units inject 6 units lispro

bull NO rise in BG for 3 hours then rapid ascent

bull Time until rise reflects ldquoactive insulinrdquo effect

bull Must do this many times and take the average

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Duration of insulin effect can be determined here

~ 4 hours

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

IOB after 6 units and fried meal

6 units

35-4 hours 2 units

WalkFried Meal

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

Rising BG trend (132 mgdl) 206AM

5 units lispro 212

Fried Chicken

25 hours

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

8 U 6 U 5 U 5 U3 U Lispro

20 Lantus

ldquoInflectionsrdquo

calibration

Tex-Mex Dinner

calibration

ldquoRemember the Alamordquo

121 mgdl 3 units 1004PM

80 mgdl 7 units lispro 636PM

Meter 55 mgdl 756PM

My estimated duration of insulin action 35 hours

Slow carbs

bull Experimented herebull Ate a pasta meal at the

Olive Gardenbull Took a single insulin shot

(70 gm = 7 units)bull Sugar dropped at time

of usual peak insulin action ~60-90 minutes

bull BG recovered without treatment

bull Late rise in BG required second injection

Leveling off

Olive Garden2 salad

servings 1 breadstick

and Lasagna

Slow BG rise

lispro

121 mgdl 3 units 1004PM

80 mgdl 7 units lispro 636PM

Meter 55 mgdl 756PM

My estimated duration of insulin action 35 hours

Fast insulin + slow carbs =

low BGbull Ate a pasta meal at the

Olive Gardenbull Took a single insulin

shot (70 gm = 7 units)bull Sugar dropped at time

of usual peak insulin action ~60-90 minutes

bull BG recovered without treatment

bull Late rise in BG required second injection

bull Notice the insulin-food ldquobalancerdquo and how it effects BG levels

Leveling off

Olive Garden2 salad

servings 1 breadstick

and Lasagna

Slow BG rise

lispro

Insulin effect

Food effect

Dealing with rising tides

ldquoFried-food revengerdquo and correction

Fried food earlier in evening 8PM

BG = 1946 unit correction 7AM

BG = 115 in 3 hours

ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo

SLOW RISE

BG 167 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

121 mgdl 3 units 1004PM

80 mgdl 7 units lispro 636PM

Meter 55 mgdl 756PM

My estimated duration of insulin action 35 hours

Fast insulin + slow carbs =

low BGbull Ate a pasta meal at the

Olive Gardenbull Took a single insulin

shot (70 gm = 7 units)bull Sugar dropped at time

of usual peak insulin action ~60-90 minutes

bull BG recovered without treatment

bull Late rise in BG required second injection

bull Notice the insulin-food ldquobalancerdquo and how it effects BG levels

Leveling off

Olive Garden2 salad

servings 1 breadstick

and Lasagna

Slow BG rise

lispro

Insulin effect

Food effect

Dealing with rising tides

ldquoFried-food revengerdquo and correction

Fried food earlier in evening 8PM

BG = 1946 unit correction 7AM

BG = 115 in 3 hours

ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo

SLOW RISE

BG 167 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Dealing with rising tides

ldquoFried-food revengerdquo and correction

Fried food earlier in evening 8PM

BG = 1946 unit correction 7AM

BG = 115 in 3 hours

ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo

SLOW RISE

BG 167 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquoFried-food revengerdquo and correction

Fried food earlier in evening 8PM

BG = 1946 unit correction 7AM

BG = 115 in 3 hours

ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo

SLOW RISE

BG 167 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo

SLOW RISE

BG 167 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Slow BG rise from protein-fat laden meal

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Correction at 245 AM after slow post dinner rise with 5 units

5 units

~ 2 hours

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Slow overnight rise and early AM correction

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

5 units 543AM 25 gm CHO 623AM

5 units

Meal(25 gm CHO)

40 minutes

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Correction with 20 grams carbs

20 gm CHO

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Pre-empting

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

3 units lispro

Breakfast

BG 173 mgdl 5 units lispro

Meeting

A ldquorandom riserdquo in BG during a routine day

2-3 hours

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Working ithellip(ie glucose control exists ldquoin the momentrdquo)

~ 2 hoursOops I Ate an EXTRA breakfast

taco

BG 142 uarr took 5 units

hypothetical

real

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

And thirdly the correction and carb ratios is more what yoursquod call lsquoguidelinesrsquo than

actual rules

ldquoMost of our assumptions have outlived their usefulnessrdquo

Marshall McLuhan

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

8 U 930AM

7 U 1054AM

6 U 1229PM

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 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

7

5

4

5

Large bowl turkey soup and 2 small pieces cornbread 630

hellipfluxrdquo

ldquoWhat thehellip

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Duration of insulin P

iz

za

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

9 units lispro for 90 gm Mexican food lunch 330

6 units lispro 630PM for rising BG after 3 hr IOB

Stabilization

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Two gulps of juice (15-20g CHO)

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

5 gram CHO ldquonudgerdquo 66 mdl

Dropping lt 1 mgdlmin

ldquoNudging a Driftrdquo (aka microcarbing)

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

4 gram CHO ldquonudgerdquo 66 mgdl

4 gram CHO ldquonudgerdquo 70 mgdl

drift

ldquoNudging a Driftrdquo (aka microcarbing)

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

5 gram CHO ldquonudgerdquo 66 mgdl

Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Late day ldquonudgerdquo after no lunch with one ldquogulprdquo of fruit juice

84 mgdl to 96 mgdl

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Leisurely walk from 700 to 830 straight line

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Exercise ldquobump uprdquoModerate intensity75 minute durationGlycogen Glucose

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

2 units

1 hr walk

ldquoWalking downrdquo a trend

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4 units insulin lispro by injection (NO EXERCISE)

4 units

~ 2 hours

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Correction 151 mgdl to 103 mgdl with 2 units insulin lispro after walk (EXERCISE)

2 units

~ 2 hours

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

127 mgdl 447AMInjected 3 units lispro

15 hours

ldquoPushing sugarrdquoaka ldquoNudging a driftrdquo

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

BG 137 mgdl dose 5 U lispro

Lag time

Eat breakfast here

Timing insulin and food is like shooting clay pigeons

ldquolaunch windowrdquo

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

6 U lispro 145AM 170 mgdl

30 min lag

3 hour wait

ldquoTaking the droprdquohellip

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquoTaking the droprdquo

BG 160 mgdl 147AMInjected 5 units lispro

Lag time

Drop time 2-3 hrs

perfect bottom turn

froth

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

6 units 623AM at 171 mgdl

Lag

2 hours

ldquoTaking the droprdquo

Wedding Reception and dinner (Mexican food and cakeice

cream slow carbs slow rise)

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Woke up at 355AM at 184 mgdl

Took 4 units lispro

Wait (slept) about 3 hours

Bingo

Tamale Soup at dinner (slow carbs slow rise)

ldquoLivinrsquo la vida Glucordquo

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

182 mgdl 7 units lispro

Insulin lag time 30-40 min

Eat breakfast here

Food lag time

124 mgdl

Timing is everythinghellipdo you have the patience or the time

Slow BG rise overnight from

fried meal

BG drop time20-30 min

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquoSmooth seas do not make skillful surfersrdquo

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

I slipped on a bananahellip

Large banana

7 units Humalog

meal

Identify the

drift

lag(s)

drop

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Following the drop and mealhellip

Calibration

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Missed 9PM basal dose (glargine)

Normal timeLantus taken (9PM)

Detected rising sugar level 2AM

Humalog dose (7U) AND usual Lantus taken (20U)

Sensor ldquogaprdquo

dinner

Fell asleep

All back in range by morning

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

What happens when a basal insulin dose is missed

Usual time Lantus dose is taken 9PM

Rising BG discovered here

Insulin correction given

If not treated high BG and ketones

Treated In range BG and NO ketones

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Stress effect

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Endocrinology Board Exam taken every 10 years

Stress and Sugarbull Strong emotional stress

triggers release of a several hormones

bull These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body

bull Stress hormones also make the liver produce sugar from substances like protein and fat

bull This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood

bull CGM allows for more aggressive anti-stress treatment of rising sugars

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Steroid pulse

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Crossing 140 mgdl 3AM and a 25 U lispro correction

~ 2 hours

Lag time

Why actbull Slow upward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 140 mgdl in my case (yellow line)

bull Knew the CGM would alert me to a rapidly dropping BG later if I over treated

bull Have done this many times before practice practice practice

Slow gradual overnight rise in blood sugar

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Microbolus at 755AM when BG was 151 mgdl took 2 units (after surgery)

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Awakened by CGM alarm to a BG below 60 mgdl

Slow gradual overnight fall in blood sugar

Lag time

20gm

Rationalebull Slow downward BG trend

(red arrow)

bull Crossed personal ldquoaction considerationrdquo threshold 60 mgdl in my case (yellow bottom line)

bull Drank 20 gm grape juice and went back to sleep

bull Knew the CGM would alert me to a rapidly rising BG later if I over treated

bull Have done this many times before practice practice practice

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Fell asleep early evening after long dayhellipwoke up at 1045PM Late dosing of Lantus (20 units 1045PM ) normally taken at 9PM Also missed follow up lispro for high GI meal earlier in evening (Tacos al Carbon) CAUTION These series of dosing actions are only possible with a CGM

5U6U

7U

6U9U

15 grams CHO

MEAL

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

6 U

4 U

4 U 4 U

5 U

6 U

28 GM

90+ GM

1 Stacked insulin + delayed eating2 ldquoHyper-treatedrdquo severe low3 Fought ldquoreboundrdquo high BG all night4 Took the drop and timed meal

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Dislodged insulin pump sitehellipPicked up early by CGM

Pump site changed insulin dose given carb correction takenhellip$13000 saved

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Although subtle this can be ldquofeltrdquo

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Feel the drop and level off

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

This rise can be sensed

This feels stable This also ldquofeelsrdquo stable

gt 1-2 mgdlmin

~ 1 mgdlmin

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

This can be ldquofeltrdquo

This can be ldquosensed toordquo

CHO

A steady trend

The bodyrsquos 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

Rationalebull Blood sugar control is

complex it includes the brain and nervous system

bull Long term damage to the autonomic nervous system can result in loss of classic signssymptoms of low blood sugar

bull But the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (eg lt 50 mgdl)

bull A CGM device can serve as a ldquobiofeedbackrdquo device of sorts in adults willing to develop the ability over time

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Pre-empting

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquoWorking downrdquo a rising BG

4 units 173 mgdl

2 units 167 mgdl

7 units 2PM for Whataburger and rings

Rise

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

4 units Humalog 1107PM

BG rising after insulin effect isldquowaningrdquo BG = 146 mgdl

Dinner (soft tacos refried bean and

chipssalsa) 7 units lispro taken 20 minutes

premeal at 7PM

My ldquoDIArdquo = 3-4 hours

Slow drop over 6 hours

Notice the obligatory ldquolag timerdquo

Anatomy of a preemptive correction

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

One goal to aim for pre-empt meal spikes

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Closing thoughts

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

6 month CGM data summary

Average BG = 103 mgdlStandard deviation = 34 mgdl

Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Day vs Night any thoughts about why

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

ldquonudgerdquo from 62 mgdl to 87 mgdl with 8 grams fruit juice

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

What is this called

Answer ldquotaking the droprdquo

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

What is this called

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

When to pull the trigger

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

What is it a good time for and why

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Straight line trend

Straight line trend

= 10 grams carbs

60 mgdl

90 mgdl + 30 mgdl

Penny stock day trading strategySugar Surfing

Penny stock day trading strategySugar Surfing

copy

ldquoKicks Drsquos Buttrdquo

Sugar Surfing

• Sugar Surfing
• Unleashing the ldquoPower Withinrdquo
• Dynamic Diabetes Management (DDM) requireshellip
• Slide 4
• Remember Sugar Surfing is all about managinghellip
• (Glucose production ndash Glucose disposal) = FLUX
• Slide 7
• To unleash your Power Withinhellip
• Slide 9
• Diabetes care is about choices
• Slide 11
• ldquoChance favors the prepared mindrdquo Louis Pasteur
• Slide 13
• Diabetes care must be individualized
• Slide 15
• Slide 16
• ldquoYou can delegate authority but you canrsquot delegate responsibili
• Do 2 RNrsquos = 1 kid
• Concrete thinkers canrsquothellip
• Slide 20
• You CAN influence how long it lasts
• Five things to remember about T1D
• Five practical advanced diabetes care tips
• Diabetes care is best approached 1 day at a time
• static vs dynamic diabetes care
• Slide 26
• Slide 27
• 8 versus 1440 ldquodecision pointsrdquo
• Slide 29
• How much sugar is in the bloodstream for a 100 mgdl BG level
• Traits of effective CGM users
• To Sugar Surf set action thresholds
• Be realistic
• Principles of Sugar Surfing
• Turnaround Time glycemic inertia
• Goal Try to stay between the lines
• Cal-i-bra-tion (noun ˌka-lə-ˈbrā-shən)
• Calibration tips
• CGM calibration tiphellip
• Slide 40
• Slide 41
• 4 hours post start up calibration (extra)
• Sensors are not always right
• Slide 44
• Overnight basal testing
• Overnight basal in range (glargine)
• Overnight basal testing (2)
• Overnight in range
• Overnight control in range
• Basal testinghellip
• Overnight basal control - Lantus
• Basal testinghellip (2)
• Slide 53
• Basal testing with a 3 year old
• Slide 55
• Learning from the Line Graph ndash Insulin Timing
• Timing 101 ndash 20 min match
• Timing 101 ndash 45 min mismatch
• Why timing is everything
• Slide 60
• Slide 61
• Wait for the bend
• Slide 63
• Slide 64
• Slide 65
• Correction tips (on a steady trend)
• Correction and meal
• Slide 68
• Slide 69
• Subtle correction
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Learn your own insulin duration To forge I-chains
• Teaching pointshellip
• ldquoActive insulinrdquo
• Duration of insulin effect can be determined here
• Slide 82
• IOB after 6 units and fried meal
• Slide 84
• ldquoRemember the Alamordquo
• Slow carbs
• Fast insulin + slow carbs = low BG
• Dealing with rising tides
• ldquoFried-food revengerdquo and correction
• ldquoRevenge of the Ribeyerdquo and ldquoThe Insulin Strikes Backrdquo
• Slow BG rise from protein-fat laden meal
• Correction at 245 AM after slow post dinner rise with 5 units
• Slow overnight rise and early AM correction
• 5 units 543AM 25 gm CHO 623AM
• Correction with 20 grams carbs
• Pre-empting
• Slide 97
• Working ithellip(ie glucose control exists ldquoin the momentrdquo)
• ldquoMost of our assumptions have outlived their usefulnessrdquo
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Leisurely walk from 700 to 830 straight line
• Slide 111
• Slide 112
• Blood sugar correction 160 mgdl to 100 mgdl in 2 hours with 4
• Correction 151 mgdl to 103 mgdl with 2 units insulin lispro
• Slide 115
• Slide 116
• Slide 117
• Slide 118
• Slide 119
• Slide 120
• Slide 121
• ldquoSmooth seas do not make skillful surfersrdquo
• I slipped on a bananahellip
• Following the drop and mealhellip
• Missed 9PM basal dose (glargine)
• What happens when a basal insulin dose is missed
• Slide 127
• Stress and Sugar
• Slide 129
• Why act
• Slide 131
• Rationale
• Slide 133
• Slide 134
• Slide 135
• Slide 136
• Feel the drop and level off
• Slide 138
• Rationale (2)
• Pre-empting (2)
• ldquoWorking downrdquo a rising BG
• Anatomy of a preemptive correction
• Slide 143
• Closing thoughts
• 6 month CGM data summary
• Day vs Night any thoughts about why
• Slide 147
• What is this called
• What is this called
• When to pull the trigger
• Slide 151
• Slide 152
• Penny stock day trading strategy
• Slide 154