History and literature are overrun with examples of conversions: from Saul’s journey on the Road to Damascus in the New Testament, to the overnight transformation of the miserly Ebenezer Scrooge in “A Christmas Carol”.
For the first 40 of my 50+ years living with type 1 diabetes I operated under the assumption that if I only had the right combination of insulin doses and carefully measured what I ate, then I would have the best diabetes control possible. I also told thousands of patients to do the same.
Boy, was I misinformed!
Being a 'Dr. Gadget', I of course purchased a real time continuous glucose monitor as soon as I could get my hands on one. In the early days of cgm I used the Abbott Navigator which was a great sensor but short lived. Things would never be the same. More importantly, my fundamental approach to diabetes would undergo an upheaval of seismic proportions.
Somewhere along the way I experienced a conversion to using and refining many non-traditional blood sugar management techniques. Years later I would package this toolset as “Sugar Surfing”. What I tell you next may shock you.
“I do not believe there is any need to look at a CGM readout any more than 6 or so times a day.”
- Stephen W. Ponder, (circa 2005) Static Thinking Endocrinologist & Person Living With Type 1 Diabetes
That's what I told my co-author Kevin McMahon way back when. I even went so far as to express concern that my patients would become obsessed with these data and perhaps look at their blood sugars up to twenty times per day. Oh, the misery and frustration of chasing blood sugar. I even opined that there should be a way to limit how often a person can see their data lest patients suffer burnout from constantly looking at the data.
As a board certified diabetes specialist and certified diabetes educator for over a quarter century, I taught or passed on the diabetes dogma I was taught. I was resistant to change and clung to the old ways I had been taught.
After starting my CGM, for weeks I watched my blood sugar trend line dance across the screen like a drunken caterpillar. The metabolic control upon which I prided myself in (based on A1C levels of 7.0-7.5%) was in actuality associated with many spikes and plateaus of blood sugar levels well into the 300 mg/dl [> 16.7 mmol/L] range before settling down into the mid-100 mg/dl [~8 mmol/L] range, usually before the next meal. I wasn't quite sure what to do with all of this information.
They don't teach medical students, resident doctors, or most endocrinology fellows how to apply the information you get from a CGM device, at least in real time.
Foods that I thought had no effect on my BG slowly but clearly shifted my readings well outside the target ranges I aimed for with finger stick blood sugars collected at a single point in time. Likewise, slow downward trends would happen at unexpected times too. This technology humbled me by how it revealed the shifts and drifts in my BG that often seemed inexplicable and utterly capricious. And the stress I thought would raise my blood sugar most of the time every now and then lowered it as well. I could finally see the chaos in real time.
My curiosity kicked in. As time rolled on I began to experiment with my choices as I could quickly and easily see the results from those choices on the cgm trend line. Forget the super-advanced technique of taking insulin 20 minutes before eating. What if I took insulin long enough before eating to actually see the change in my blood sugar using the sensor and use that information to choose when to eat my meal? What if I took a small dose of carbs to treat a low BG that was smaller than the usual 15 grams I was always taught? What if I took small doses of rapid-acting insulin to see how far it would shift my BG trend line? How much would a Pez® candy (2 grams of sucrose) raise my blood sugar vs. a 4 gram glucose tab? These were the origins of Sugar Surfing.
Seeing my BG in real time taught me that nothing in my diabetes self-care arsenal could be taken for granted. The insulin, my meters, food and exercise all had some amount of variability baked in.
The notion of a static world of diabetes care was shown to be nothing but a mirage. But more importantly, it was an illusion whose virtues I was guilty of promoting and preaching for years. I had not only “drunk the Kool aid”, but I dispensed it too.
Because this is how I used to think, it's easy for me to understand why so many doctors and CDEs share that same belief. They are well intentioned, but misinformed. And many existing CGM users still fall prey to this thinking as well.
I often read comments from evangelistic Sugar Surfers who encounter skeptical endocrinologists. Sadly, these medical professionals are sometimes quick to dismiss Sugar Surfing by saying things like “No one will check their blood sugar that often”. I can understand their position since I was one of them. It makes me somewhat empathetic to them. They usually mean no ill intent but, just like my former self, they are trapped in a way of thinking that is hard to break. Had I not gone through my own journey of exploration and subsequent conversion, no doubt I might still be a staunch anti-Sugar Surfer steeped in static beliefs. Thankfully those days are behind me.
Today, as an empowered Sugar Surfer, I see the world of diabetes as a constantly shifting landscape. To properly navigate my way to tight control I must manage my diabetes “in the moment”. Likewise, I advise my patients to set sail on their own journey. My CGM makes this possible, even though I know I could get there with a couple dozen finger stick checks daily, but who would ever want to do that for very long... We do hear success stories from non-CGM users. However, most of them are based on short windows of time while dealing with highly dynamic blood sugar swings. At a minimum, everyone surfer can expect to realize less stress in their life once they realize the massive variability, 'false idols' and myths in the world of type 1 diabetes.
My naïve view of static diabetes care died when I embraced the dynamic force of Sugar Surfing. I can never go back to static thinking. Is surfing more work? Perhaps. But the feeling of control and empowerment it generates in me is strangely addictive and empowering at the same time. To me, it’s worth the effort. I glance at my CGM readout often, but it takes literally just a second to view and assimilate. Contrast that with a 3 - 6 hour commitment to stabilize a roller coaster that could have been easily prevented.
Sugar Surfing is a skill, not a prescribed action or formula. To master any skill requires attention to detail. Simply glancing at my trend line does not overwhelm me or stress me. In fact it’s comforting to know where and in what direction my blood sugar might be moving and to some degree why. It gives me a tremendous advantage over finger stick blood sugars. It empowers me.
Static diabetes care is our past. We must embrace the dynamic future. Sugar Surfing IS the future. But the choice is, and must be, YOURS to pursue and develop it.
So for all you in the Surf Colony trying to break through the push-back from your endos or others whose opinions matter to you, I can understand and utterly relate to your situation. The solace I can offer is that more and more endos ARE starting to understand the power of Dynamic Diabetes Management. Many of them are not advertising it, but I know some who do. Our collective journey to change hearts and minds of the diabetes establishment will not be easy, but the virtues of patience, consistency and resilience apply just as much here as they do in our daily practice of Sugar Surfing.