Sugar Surfing Lesson #15: "Maxim"-izing your control

Sugar Surfing™ is a method of diabetes self-management based on categorizing groups of blood glucose (BG) information into sets of recognizable geometric patterns. Effective Sugar Surfing encourages learning to identify these patterns as they are forming or taking shape, then making decisions about them "in the moment".

The ability to recognize BG patterns combines with the Sugar Surfer’s “situational awareness” of the person’s recent, current and anticipated actions. This allows the Surfer to assign significance (or non-significance) to any given trending pattern or series of patterns. Through ongoing practice, experience, and experimentation the Sugar Surfer develops proficiency in acting or not acting while watching the glycemic trend line. The ultimate aim of Sugar Surfing is to “steer” the BG trendline by manipulation of activity, food and insulin.

Sugar Surfing defies simplification into mathematical formulas, carbohydrate counts, or standardized protocols. Real life variables (e.g., stress, the speed of digestion, inconsistent insulin action, etc.) do not convert well into equations. Sugar Surfing transcends formulaic and static methods of diabetes self-care. It is a 'next level' approach to diabetes self care.

The word “Meta” as defined by the Urban Dictionary means “about the thing itself. It's seeing the thing from a higher perspective instead of from within the thing, like being self-aware.” By this definition, Sugar Surfing is arguably a “meta-therapy” for persons with type 1 diabetes.

Maxims are rules for good or sensible behavior. The following are helpful maxims to consider and apply when viewing recognizable trend line patterns and structures. Specifically, these maxims are useful when deciding when or not to act on a BG trend line pattern “in the moment”.

This above image summarizes the shapes of the basic features from a blood sugar trendline as displayed on a continuous glucose monitor.

1. Watch a drop if well over your target BG.

If a BG trendline is falling for any reason and you are well above the upper target range, its best to wait and watch. If the blood sugar is trending downward and it is not near a level considered low or hypoglycemic, then it is usually wise to continue periodically following the trendline by glancing, not act with any additional insulin. There may be several reasons for a high drop, starting with a prior insulin dose which is now starting to kick in, a change in basal insulin delivery rate (if using an insulin pump), or increase in physical activity (exercise). Any or all of the above might combine to create a drop and should be considered. Sometimes there is no easily defined reason. Nevertheless, always go through your mental checklist first before attributing a BG change to chaos or chance.

Watch to see if the high drop inflects (bends) into a relatively level period of glucose trending (i.e., a shelf), or continues to drop past a glucose level you feel is worthy of treating with food or fast acting carbohydrates (see image below). If a high trending shelf occurs, then after a sufficient period of waiting and watching, it is worth considering an insulin dose (and/or added exercise) to reduce the blood sugar further. This is called “taking the drop” in the book (see image below).

Lag time is important to consider when acting to change a BG trend. Depending of what and how much carbohydrate is eaten, the trendline may take longer than you think to show the desired effect. This is partly due to the time it takes for the food to convert to sugar in the body, plus the time it takes for the sugar level to change in the interstitial fluid where the sensor detects it. Make a mental (or written) note of how long it takes to "turn" (inflect) a trend with an insulin dose. For example, it may take 30-45 minutes for evidence of insulin action to be seen on the trendline. This knowledge is invaluable to help you better synchronize insulin and meals in future efforts.

The speed that the sugar level is changing will also influence how soon you act on a drop (or delta wave). Timing is as much an art as it is a science and the more you practice it, the better you get. When BG is dropping rapidly, treat with fast carbs at higher threshold. A gradual drop may be finessed with less fast carbs and at a lower BG threshold.

When the rate of BG drop is very slow (a gradual downward drift), you might still choose to boost the drop with a supplemental dose of rapid acting insulin or a temporary basal rate increase. Remember, any insulin dosing action requires periodic glances of the trendline over the following hours.

2. Inflect or pivot BG “drops” which approach your lower BG limit

If during a blood sugar drop the sugar level approaches the upper level or middle level of your desired target range, you should consider acting to slow it down (infect level) or reverse it (pivot upward, see above image). Determine the amount of rapid-acting carbohydrates to achieve this effect by prior trial and error experimentation (described in the book Sugar Surfing). When in doubt, it is best to err on the side of a larger carbohydrate dose to infect or pivot a drop, especially if it is a rapid drop (arrows down). The art of Sugar Surfing is in learning your unique responses to different rapid acting carbohydrates and applying this to situations described here.

If you discover a glycemic drop after it has passed below your lower BG limit, the use of smaller or more subtle doses of fast acting carbohydrates is lost and a standard dose of carbs is needed (maybe more). This might include the standard “Rule of 15” or more to reverse a rapidly dropping trendline. If you rebound afterwards, consider this in future similar situations and use smaller amounts of carbs. Most significant low blood sugar events tend to get over treated with carbs. It is a human tendency to continue eating something until ‘feeling’ a rise in the sugar level. Unfortunately, this feeling usually occurs after consuming too many carbs. Nonetheless it is always better to be safe than sorry.

As you can see in the above image, patience is very important. The 4 grams of rapid acting carbs served to "brake" the end of a slow BG drop and inflect the trend into a shelf. It does take at least 15 minutes for most fast acting carbs to work. Tip: look at the glycemic index of your favorite low BG treatment of choice. For example, not all juices are the same. For example, apple juice has a relatively low glycemic index compared to pure grape or cranberry juice. Knowing the speed of your carbs can be useful in making smart choices to "brake" a rapid or slow BG drop.

3. Glance at shelves when in your range

If the trendline is flowing relatively steady within a desired BG range, the best course of action is occasional glancing at the trendline to ensure stability of the trend. The frequency of glancing is individualized, but many Surfers look every 30-60 minutes, maybe less often. Experienced Surfers may be able to “feel” upward or downward shifts in blood sugar. These “feelings” differ from person to person. They are great prompts to glance at the trendline. Whether or not to glance more frequently depends on seeing any upward or downward trending that looks significant to the Surfer. Remember, shelves do not always last or persist. A good rule of thumb is to glance at least every 1-2 hours.

Upon awakening after a good night’s sleep, it is a good habit to first look at the trendline for overnight BG stability. This should be a daily practice. Any upward or downward trending requires attention. Consider possible causes for higher trending such as illness, medications, and late-acting foods eaten the evening before (especially uncovered late night snacks). If there are no obvious reasons, the basal insulin (by injection or pump) might require adjustment.

Lower trending overnight patterns might suggest previous activity or exercise the day before. About 1/3 of persons with diabetes experience post-exercise hypoglycemia in the evening or night after a busy exercise day. If this is suspected, a temporary change in basal dosing might be considered (or lower temp rate via pump) as opposed to making wholesale changes in basal dosing (see next tip below). If the exercise is going to be a daily event, then making reductions in basal insulin dosing or rates should be considered.

Basal insulin 'neutrality' is very important to effective Sugar Surfing. The purpose of basal insulin is to maintain balance between incoming and outgoing sugar levels in the blood, under non-extreme conditions. A steady basal effect is essential for getting a good night’s sleep. Poorly set basal insulin doses or settings result in upward or downward BG drifting, assuming the absence of other forces that could move the trendline up or down. Most Sugar Surfing methods depend on a steady and reliable basal insulin effect running in the background. Tip: don't change basal insulin doses or pump settings based on one or two days of observation. Look for trends over several days time before making adjustments changes. Even the best set basal doses can be off on a given day or two.

4. Inflect shelves up or down based on the situation

When the trendline is moving relatively level, the Surfer must decide if the glucose level is 'desirable' or not. For example, a steady trendline between 65-80 mg/dL (3.6-4.4 mmol/L) may be too low for some persons or under certain situations. Conversely, a steady trend pattern between 150-180 mg/dL (8.3-10 mmol/L)might be too high for others. Things to consider when deciding the appropriateness of a shelf BG range include age, activity and ability to recognize low or dropping blood sugar levels. Maintaining a shelf below 100 mg/dL (5.6 mmol/L) usually requires more glancing.

Proper microcarbing inflects a shelf upward to a new level. Taking the drop lowers the trendline by 30 mg/dL (2 mmol/L) of more. 'Nudging' the shelf is moving the trendline down less than 30 mg/dL (2 mmol/L). These maneuvers rely on a having a steady basal insulin effect in place (“basal neutrality”).

5. Watch a delta wave if it’s under your target BG

A rising BG trend line (i.e., delta wave) seen beneath the middle region of the Surfer’s preferred target range is usually a reason to glance carefully to determine if and when the trendline infects (or pivots) within