SUGAR SURFING LESSON #4: WHEN TO "DOUBLE TAP" A DELTA WAVE

Sugar Surfing™ requires “out of the box” thinking. Traditional diabetes education often discourages taking between meal rapid-acting insulin doses, except perhaps for a 2 hour after meal “correction”. This image exemplifies when you can consider taking another rapid-acting insulin dose when the first dose did not result in a desired effect (i.e., an insulin ‘pivot’).

A 50 mg/dL [2.8 mmol/L] delta wave (red triangle) is observed (96 to 146 rise over 1 hour, 5.3 to 8.1 mmol/L). A decision is made to take a small rapid-acting insulin dose to ‘pivot’ (i.e., turn the trendline downward). After about 90 minutes, the rate of rise is slowed a bit, but no pivot (trend reversal) is seen. At the 188 mg/dL [10.4 mmol/L] level, the decision is made to inject a second rapid-acting insulin dose. In this case the second dose is slightly larger (4 units) than the first dose (3 units). After a 1 hour ‘shelf’ (period of glycemic stability), the trendline inflects and a glycemic ‘drop’ occurs over the next 90 minutes. As the two rapid-acting doses dissipate, the trendline inflects into a new shelf (101 mg/dL, 5.6 mmol/L).

The teaching point here is that after a ‘reasonable’ waiting period (1 hour) following an attempted pivot, it is reasonable to attempt a second pivoting insulin dose at a slightly higher level (or even the same as the former dose). Of note, the meal eaten on the prior evening was a high carb-protein-fat meal (Mexican food). Sugar Surfers consider the forces driving a delta wave upwards (like, food or stress) when choosing which options are best to use when trying to slow or reverse the trend.

The working assumption was that this meal was having a more prolonged glycemic impact and was inducing short term insulin resistance. Hence, a bolder pivoting dose was easier to justify. It’s interesting to note that a full hour elapsed before the trend line infected (purple arrow) and the subsequent drop (orange triangle) ensued.

One more caveat. As shared a in a prior post, a recent study suggested that insulin potency can vary dramatically. So, one other possible explanation for the results above might be "impotent" insulin. It's one more reason to expect chaos and not be surprised when it happens. Have a rational plan to address it.

If you are now thinking to yourself “that’s a lot more than just a dosing for a blood sugar level”, you are well on the path to thinking like a Sugar Surfer! Remember that written instructions on how to walk on two legs might take pages to explain, but most of us figure it out before we're a year old. Sugar Surfing just takes patience, consistency, and resilience.

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