ONE AND DONE?
Traditional static diabetes principles teach that insulin is dosed at or before a carbohydrate containing meal. Using preset ratios and formulas, the insulin dose is calculated by the patient based on the carb amount to be eaten and the pre-meal blood sugar level. This is what the vast majority of persons with diabetes are taught as dogma. Those on insulin pumps have more options to alter the timeline of how their device delivers a dose (combination or dual wave bolus; extended or square wave bolus). However, many pump users infrequently use these advanced dosing features.
This example illustrates that dosing insulin is often not a “one and done” proposition. This is a good example of advanced Sugar Surfing. I don’t advise this for beginners. Let this example from a Pro (that means several years of practice) highlight what is possible with a little effort and self-awareness about your own body and how it responds to favorite foods and rapid-acting insulin. For my friends using mmol just keep in mind that the yellow line represents 140 mg/dL (7.8 mmol) and the red line represents 70 mg/dL (3.9 mmol). [The conversion factor is 18 mg/dL : 1 mmol] Now let's walk through this.
First, I chose to eat a meal that I eat occasionally: a double meat and cheese hamburger with a side order of onion rings and unsweet iced tea. Total carb load (per the restaurant’s website) is 94 grams (62 for the sandwich and 32 for the O-rings). In classic Sugar Surfing fashion, I take my mealtime dose and “wait for the bend”…or at least 15-20 minutes. This was also how long it took my meal to get prepared and served to me in the store.
I enjoyed the meal. No judgment please! This is NOT low carb or “healthy” to do on a regular basis. But I chose to eat this and I “own” that choice. It was more of a treat and it was fast and convenient.
My first dose of mealtime insulin kept my blood sugar from rising as I began to digest this hefty meal for about an hour at least.
Next, notice the uptick in the trend line. It’s subtle, but I’ve already determined by careful trial and error that this is when a meal time insulin dose starts to lose some of its dominance over a large carbohydrate load like the one I’ve just eaten. This is where my actions might surprise you.
I chose to take a smaller “secondary” dose of rapid-acting insulin, then keep a frequent eye on the trend line.
After about 45 minutes I was not seeing a pivot. It appeared at best to be leveling off the BG trend line. I call this phenomenon “shelfing”. So based on this shelf effect, I chose to take a third dose of rapid-acting insulin. I know what you are thinking: “How did he know how much and when to do this?” This is where Sugar Surfing comes in. It's not a button on your pump. This is only possible due to frequent practice and experimentation. That's how I knew that a dose that was lower than the first primary insulin dose would not put me at risk for a rapid BG drop. And if it did, I was already well stocked with rapid carbs (grape juice) to slow a fall as verified by frequent glances at my sensor display. However, stopping a rapid fall was not needed here, again most likely because I have practiced this move countless times before.
In about 30 minutes a pivot drop emerged and I began to see my trend line move downward. I leveled off in a range I’m very comfortable with: between 80-100 mg/dl. I remained stable through the night without significant shifts or drifts during the night, indicating the stability of my choice of basal insulin (12 U insulin degludec [Tresiba] by injection every night). Yes, Sugar Surfing works great with pump or MDI. My moves are a little different depending on which 'player' is in the game but my results are consistently similar.
Had I been using an insulin pump, my choice of insulin delivery would be a combination or dual wave bolus strategy. But prior experience with that unique meal combination would be more likely to drive my choice of insulin. The insulin to carbohydrate ratio would only be the start of that process.
"Yeah, but what about the late rise I get when I eat like this" you ask:
To those of you who are thinking “this is too much work”, I say the following. If I were to write down the process for backing your automobile out of the garage, it could take several paragraphs of text with several decision points built in. But no one reads a book to back a car out of the garage. They carefully practice this action. Repetition and practice are incredible teachers. We use them in every aspect of life. So why not our diabetes self care?