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 the target range (see second image below). Once the BG trendline passes the Surfer’s upper target range limit, consider acting on this rising trend, using activity and/or insulin. Delta waves generally reflect an imbalance between the blood sugar lowering effect of insulin and exercise in comparison to food (carbs) and/or hormonal stressors that are acting to increase sugar levels in the blood.
Allowing the trendline to pass through and above the Surfer’s target BG range opens the door for sugar spiking. If the delta wave infects or pivots within or slightly above your target range, then continue glancing until a new trend pattern emerges.
Tip: The time axis on a CGM device may be adjustable to “stretch or compress” a changing trendline. It is helpful to view a trendline in the three or 6-hour timeframe when making management decisions.
6. Deflect or pivot a delta wave if it’s above your target BG
As the trendline steadily rises above the Surfer’s upper BG target limit, it is important to consider additional insulin and/or activity to slow down (or reverse) this trend. Those new to Surfing should withhold follow up rapid-acting insulin dosing until there is enough evidence to conclude that the first insulin dose is ineffective in slowing down a rising trend. If after several observation cycles the insulin dose seems underpowered relative to the amount of food being eaten, the Surfer might choose to adjust the formula or ratio for the first dose or use an alternate dosing approach using the insulin pump (extended or combination bolus, for example). This is basic insulin pattern management practice and worthy of consideration even if its not a true Sugar Surfing method.
Besides underpowered insulin dosing ratios, many delta waves are also due to underestimated carbohydrate amounts; or protein and fat that negatively affect insulin response (temporarily create insulin resistance). When treating a rising BG after a meal, it is always best to start with smaller doses and increase the dose based on prior observed responses. Delta waves can be deflected in stages when learning an effective range of follow up insulin doses (see image below). At some point, the first dose can be increased in future situations based on prior experiences. Furthermore, the first dose might be improved through better insulin timing (e.g., waiting for the bend) along with increasing the absolute amount of the dose.
7. Know how to recognize and react to glycemic inflections
Inflections and pivots are extremely important to recognize and interpret since they usually indicate change. By seeing and recognizing glycemic infections, the Surfer better synchronizes insulin, food and exercise to allow for the least amount of rise in sugar levels after a meal. When viewed properly, inflections serve to visualize the effective duration of insulin effect, whether taken in anticipation of a meal or following correction of an out of range blood sugar level.
Any “values” calculated by use of Sugar Surfing and a CGM must be viewed cautiously. In general, the time between a dose of insulin and a trendline inflection (“waiting for the bend”) may vary across a range of time from episode to episode. Collectively the wait times will usually fall into a range that the Surfer can use to base decisions upon regarding follow up dosing (i-chaining). Tip: It is best to consider diabetes insulin dose response and duration times as ranges.
Sensor technology is still not an exact science. The Surfer must be confident that a glycemic infection if real and not an artifact (pressure low, aging sensor, interfering substance). However, once mastered the Surfer can begin to pre-empt BG trends before or as they are occurring as seen above and below.
8. Insulin wears off; food wears off; it is important to be able to tell the difference
Insulin and food are inexact regardless of how well we try to measure or deliver them in persons with diabetes. We must become comfortable with living within reasonable target ranges we set for ourselves. Sugar Surfing is learning how to steer a glycemic trendline in real time. By understanding the dynamics of food, insulin, activity and stress as they constantly interact, dynamic diabetes management is possible. Trendline inflections reveal the onset of action of insulin and food, as well as when their effects on blood sugar start to fade away.
Some people say that Sugar Surfing is too hard. I often respond by saying driving a car has all the decision making elements of Sugar Surfing, and has a much faster pace. Yet tens or millions of people safely drive cars every day.
9. Wait for the bend
A dose of rapid-acting insulin takes time to start lowering blood sugar levels in the bloodstream. In order to obtain better synchronization between mealtime insulin and food, there often needs to be a waiting period after the dose, before the meal is eaten. Carbohydrates in meals often break down into sugar faster than insulin can establish an effect in the bloodstream to counteract the rise. When insulin and a meal are dosed at the same time, there is a risk that the blood sugar level will increase rapidly before the insulin dose catches up to it. In some cases, the BG spike never comes back down or does so slowly. When such an insulin and food mismatch happen, the sugar spike that follows acts to increase the hemoglobin A1C with each successive sugar spike.
Waiting for the bend is about waiting for an inflection or pivot to occur before eating. The downward bend is strong visual evidence that the mealtime insulin dose is working to lower blood sugar. If the meal is delayed until the bend occurs, there is less chance of after meal spiking. How long to wait is based on how close to your lower BG limit you are, plus how quickly the trendline is dropping. When the bend is seen, there is usually a window of time to eat the meal which results in the least amount of rise in BG after the meal is completed.
Anytime the trend line reveals the onset of the rapid acting insulin effect, the Surfer can practice timing the meal which follows in order to best reduce the rise in BG over the next few hours. Watching for a bend (inflections) is also useful for determining if a correction dose is having any effect on a rising sugar trend. When the time has passed when a bend typically happens, aggressive Surfers might consider a follow up dose to supplement the first one. This is an advanced Surfing maneuver and should only be done by experienced Surfers who are prepared to pre-empt a rapidly dropping glucose should that occur in the next hour or two.
10.Sugar Surfing is a process, NOT a recipe
When looking for answers in the dynamic diabetes world, focus more on refining how you act and react, not the exact results you get. Dynamic thinking focuses on the process more than the product. It is a subtle distinction with profound consequences on how you think about diabetes self-care. The experienced Sugar Surfer is confident in her/his abilities but not to the point of being smug. Chaos is always around the corner. It serves to keep us vigilant...and humble.