Aims. Defining Sugar Surfing 8/7/2017. Dynamic Diabetes Self-Management. Based on frequent pattern management Sugar Surfing is next level self-care

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1 I have no conflicts of interests to report Stephen W. Ponder MD, FAAP, CDE Professor Sugar Surfing is a trademark of Kevin McMahon and Stephen Ponder dba Sugar Surfing. All content not otherwise noted herein copyright Kevin McMahon and Stephen Ponder dba Sugar Surfing. All rights reserved worldwide. Aims The Origins of Sugar Surfing Static vs. Dynamic Self Care Sugar Surfing Terms/Images Illustrate Sugar Surfing Methods Canada United States Mexico Puerto Rico Panama Chile Argentina Norway Finland Scotland Sweden Ireland Lithuania U.K. Belgium Poland Switzerland Romania Italy Croatia Spain Turkey Israel South Africa Russia China South Korea Malaysia Taiwan Australia We stopped counting after 65 countries...sugar Surfing is global New Zealand Defining Sugar Surfing Dynamic Diabetes Self-Management. Based on frequent pattern management Sugar Surfing is next level self-care Dynamic Diabetes Management = Glances + Omissions + Actions 1

2 Low carb eating may calm the waters, but Stress Insulin pump failures Denatured insulin Basal insulin tuning etc must be surfed Sugar Surfing isn t about controlling everything S.U.R.F. See the patterns Follow up carefully Understand their Significance Respond appropriately 1 hour Pattern anatomy 30 mg/dl 30 mg/dl 30 mg/dl This is Sugar Surfing Insulin pivot Exercise pivot I Inflection Carb pivot Stress pivot Inflection C pivot inflection 2

3 This is Sugar Surfing The point is that every day of surfing is never exactly the same: variability is expected Appreciate the flux of sugar levels in non-d persons Average BG = 5.4 mmol/l 4 day non-diabetic CGM plot Which Surfer uses an insulin pump? A Insulin pump B MDI the only person with a straight line blood sugar is a dead person Ponder,

4 A Which one is non-diabetic? non-d adult B type 1 adult Your blood glucose is ping at a rate of 2-3 mg/dl/min and your insulin pump is delivering at 1.3 U/hr. Sugar Surfing emphasizes significance YOU RE GETTING LOW!?! copyright Sugar Surfing Determining significance: take C.A.R.E. Significance is situationally dependent Current (what are you doing now) 220 mg/dl 190 mg/dl Anticipated (actions/omissions) Recent (actions/omissions) 90 mg/dl Experience (your own) mg/dl 1 hour Significance: patient determines Significance: patient determines 220 mg/dl 190 mg/dl 220 mg/dl 190 mg/dl 90 mg/dl 90 mg/dl mg/dl mg/dl 1 hour 1 hour 4

5 Example: 5:06 AM 5:56 AM Significance is subjective Sugar Surfing exists at the intersection of thinking 7 year old T1 D child 1 day after Minneapolis workshop ( pivoting ) Sugar Surfing It s Dynamic Diabetes Self Management aka Management in the Moment It s a process, not a formula/prescription Can be used with pump or injection therapy CGM not required but makes it easier Surfing leverages dynamic thinking in proactive and reactive ways Sugar Surfing is a paradigm shift in d-care 5

6 180 mg/dl 160 mg/dl mg/dl At IDENTICAL levels using a BG meter, your next actions can be ANYTHING based on the DIRECTION of FLOW Treat a high 180 mg/dl 160 mg/dl mg/dl Deflect and correct No action needed 80 mg/dl 60 mg/dl Treat a low 80 mg/dl 60 mg/dl 40 mg/dl Direction affects correction 40 mg/dl Practicing lower pivot points can/will lower the flux and lower the A1c Practice higher dosing thresholds when first learning to pivot X 180 mg/dl 160 mg/dl mg/dl X units X + 10% X + 20% X + 30% Delta wave 80 mg/dl 60 mg/dl mg/dl Once comfortable, then LOWER the pivot action threshold Shelf Delta wave Shelf Delta wave Pivot lispro 175 mg/dl food 180 Shelf Delta wave Shelf 6

7 aim small at first Units of rapid-acting insulin Then as your skills/confidence grows 180 mg/dl 160 mg/dl mg/dl nudge 180 mg/dl 160 mg/dl mg/dl 2 80 mg/dl 60 mg/dl 2 hours 80 mg/dl 60 mg/dl 40 mg/dl Learn micro-dosing at higher starting points first ( ) 40 mg/dl 2 hours Set lower action thresholds and targets Taking the Taking the 7 U lispro 35 min 90 min 75 minutes Basic Sugar Surfing Example The heart of ultra tight blood sugar control: The mini-pivot 5U lispro U Humalog Basal insulin: 12U insulin degludec Delta mmol/l L dro p 180 calibration mini-pivot duration awake sleep 2 hr awake wave T 7

8 Mini-pivoting microcarbing takes repetition to master 3 U lispro 180 mg/dl 160 mg/dl mg/dl Rx 16 g 12 g 8 g 4 g wave 2 hours 80 mg/dl 60 mg/dl 40 mg/dl Start high and work your way down Microcarbing (aka nudge ) Waiting for the bend and meal timing depends on BG trend And it also depends on the food (fast, medium or slow) I upward I M Maximal wait 180 steady downward I M M Moderate wait Minimal wait Timing insulin Example 5:06 AM 5:56 AM min 120 min 8

9 What a basal insulin is supposed to facilitate BALANCE: Incoming blood sugar (influx) Look back. Blood sugar trend line Blood sugar trend line WITH: Outgoing blood sugar (efflux) Does this person require a basal insulin change? Important basal insulin concept: the point of the basal insulin is to keep you steady, not to consistently raise or lower your BG levels. Look back. Taking the Value of basal stability Bolus insulin effect Basal insulin effect 35 min Shelf 90 min 9

10 Calibration tips 2 hours 1) Best done on a steady trend 2) Best done in preferred target range 3) The first 24 hours may be variable Dual receivers linked to same sensor 4) An extra calibration on day 1 is ok 5) Calibration on the bend 6) Re-calibrate after large swings 7) It is possible to over-do it 8) Enter the BG as soon as it s collected It s amazing what you can see when you know what you re looking at. Would your doctor know how to interpret all this? Sequential learning Z BG 222 mg/dl 8 U Humalog BG 219 mg/dl 7 U Humalog 180 mg/dl 160 mg/dl mg/dl X Y Y + Z 2 nd attempt 1 st attempt 3 rd attempt pivot Food 22 gm CHO Re-calibrated 80 mg/dl 60 mg/dl 40 mg/dl Favorite meal #4 X + Y + Z Use prior results to improve future outcomes 7U apidra 7:30AM Pre-empt 5U apidra 9:15AM 5U apidra 10:03AM Breakfast cereal challenge day 1 Take the Breakfast cereal challenge next attempt 12U apidra 7:30AM Pre-empt Take the 5U apidra 3:37PM 56 CHO 56 CHO bend Units/hour basal rate bend Units/hour basal rate 10

11 Example Breakfast cereal challenge third attempt 6 U lispro 4 U lispro 3 U lispro 12U apidra 11:48AM 56 CHO 5 units over 3 hours Units/hour basal rate Steak, salad, bread Green beans I effect d I effect mmol/l Deltas, pivots and shelves Can you see them better? This feels stable 180 s d s d s d s 60 Engine brake mmol/l Engine brake 0.0 basal rate 30 min 1 mg/dl 0.0 basal rate 1hr 11

12 Stacking Insulin vs. Use of I-Chains stacking insulin is wrong Insulin stackers Are often unaware they stack Don t follow up on their actions Lack of interest, data, or access to BG checking supplies/tech Dosing multiple doses of rapidacting insulin is overly aggressive and irresponsible UNSAFE! I-Chainers Proactively overlap insulin doses Always follow-up on actions to shape BG results Well-calibrated CGM makes this practical to chain dependent events Are empowered and engaged patients SAFE! Burger and O-rings food insulin What the flux? 8 U lispro Double Burger and O-rings 5 U lispro 4 U lispro 4 U lispro Large bowl turkey soup and 2 small pieces 6:30 Surfing a Scottish (Orcadian) Wedding Party

13 S.U.R.F. See the patterns Shelf Surfing Trendline Anatomy Follow up carefully Understand their Significance Delta/ Inflection Respond appropriately Pivot Lag insulin (± exercise) I C food (carbs) (± stress) Determining significance: take C.A.R.E. Current (what are you doing now) Anticipated (actions/omissions) Recent (actions/omissions) Experience (your own) Conceptual framework for Sugar Surfing Actions Actions IN CONTROL recent past immediate future present Dynamic Diabetes Management = Glances + Omissions + Actions Top tips for Safe Surfing Nail down your basal requirements Fewer basal rates work better than more Calibrate your CGM carefully Glance often (40-50 s a day) Finesse works better than brute force Self-experiment to understand how your body works Stop comparing your diabetes to others No shame in hard work 13

14 Thank you! SugarSurfing.com - No cost diabetes education (workshops, posts, videos, and conversation) - - Facebook.com/SugarSurfing Book Sales Fund Programs Inquiries by To: StephenPonderMD@SugarSurfing.com - Stephen W. Ponder MD FAAP CDE - Kevin L. McMahon Free ebook for Newly Diagnosed <90days 14