The double-tap pivot

True Sugar Surfers understand that they're actually steering a glycemic trend line and not just responding to a single point in time BG value. Rather than watching helplessly as their blood sugar trends chaotically rise and fall, Surfers take charge. The tools of the Sugar Surfer are numerous and well described in the book Sugar Surfing ™

The double tap pivot (i.e., multi-tap pivoting) is a sound method to consider when you are either

a) just learning how to pivot, or b) seeking to minimize the risk of taking too large a BG drop from a larger corrective insulin dose. In this example I demonstrate a double tap pivot used to steer a late and slow nighttime BG rise (i..e, delta wave) which crossed my preset upper alert BG threshold.

I have not annotated the delta wave in this image. You can see how the trend wave slowly crossed the "high" threshold alert (set here at 140 mg/dL or 7.8 mmol/L). Once that occurred, a choice was made to take a small (for me) rapid-acting pivot dose (insulin lispro). Keep in mind this was done at night, hence the more conservative dose). After over an hour following the initial dose, there was no good evidence of a glycemic bend (pivot), so a repeat dose was taken (both by injection, the basal insulin at work here is 14 U Tresiba taken at 8PM). Could I have waited longer? Certainly. Remember, this is a choice. Many of you might not have acted at all until a higher BG threshold was reached . I certainly respect that. We must be comfortable with our decisions and be able to follow up on them.

The second insulin tap did the trick and a slow BG decline began over the next 2 hours, gradually steering towards the BG target of 80-120 mg/dl. (4.4-6.7 mmol/L)

The first response by some readers might be "didn't you just stack insulin?" The answer is yes, but this is intentional stacking with a defined purpose. Never mind that if I was wearing an insulin pump and programmed a combo (dual wave) bolus to do this, that in essence I would be stacking insulin too. And of course the basal insulin is always being stacked upon no matter what the circumstances. I could have also used a sleep bolus if I was wearing an insulin pump (described in the book).

Stacking insulin is a powerful tool. It demands respect and reflection whenever it's considered. Stacking insulin has sadly been vilified by many as a negative diabetes self care action. If done haphazardly and without careful consideration I agree 100%. This example does not apply to that description. If you've already read the book this move actually borders on what I describe as an "I-chain".

Pivoting is to the Sugar Surfer as a forehand is to a tennis player. It's a basic and essential move that is critical to Surfing success.

Happy Holidays and New Year 2017!