How to Pivot

The first maneuver embraced by most people new to Sugar Surfing is the pivot. I often receive images of CGM screenshots soon after live workshops. They are sent from excited Surfers or Surfer parents illustrating a 'first pivot' move. Their skills quickly move forward from there as time and practice hones this skill. Other Dynamic Diabetes Management methods are then attempted and mastered as confidence grows.

With that background, this post is about how to start pivoting. Knowing when to pivot is based on the ability to visually identify shelves, delta waves and drops. The Surfer assigns significance to these changes before proceeding any further. This is the mental side of Sugar Surfing: assessing and making choices.

Once the decision is made to act, the next step is to choose a pivoting dose of rapid acting insulin (aspart, lispro or glulisine) to take by injection or pump. This step is where Sugar Surfing departs from static diabetes management theory. A delta wave or a drop are the results of prior actions or omissions in care. Insulin plus food, modified by exercise and/or stress may send the trend line on a path outside a desired BG range. Change happens. Let's digress a minute about deltas and drops. I have arbitrarily chosen a change in BG level of > 30 mg/dL over one hour as the classic definition of a delta wave (if change is towards higher BG levels) or a drop (if change is trending towards lower BG levels. If you use mmol/L as your unit of BG measure, I suggest a value of 2 mmol/L as the threshold. This equates to 36 mg/dL in the US. Learning 'pattern anatomy' has been discussed in a prior post. "Seeing" the geometric patterns created by the trend line is the first step in learning how to surf. The power of a CGM is its ability to reveal BG changes in real time. It's much more than a substitute for a BG meter as 34% of first time CGM tend to believe. As your skill with identifying Deltas and Drops grows, you may broaden your definition of these terms. What defines each will be situationally driven and not a static definition as I mention above. But as you begin, new Surfers must have a starting point of reference to launch their trek into the universe of dynamic diabetes management. I will address this in greater detail in future posts on micro dosing insulin and carbs. For now let's return to our focus on the basic pivot move. For safety sake, pivoting should be first attempted at higher BG treatment thresholds. The goal of a pivot is to redirect the rate of BG change into the other direction. Ultimately as your skills grow, the pivoter learns to stop a trending BG and redirect it back into a shelf. Remember that a steady trend line that remains no wider than 30 mg/dL for one hour is a basic definition of a glycemic shelf. Again this definition of a shelf can be made as tight (or loose) as the situation requires. That is the Surfer's choice to make. Setting targets that are too narrow risk frustration and burnout. The human body is was designed to operate best within a range of BG levels, not a specific value. The first question most ask when starting to pivot is "how much insulin do I take?" I suggest you consider the following: Start with a high threshold pivot point. I used 180 mg/dL (10 mmol/L) as my practice pivot threshold when first started Surfing. Later on I developed a lower threshold point (140 mg/dL) but you select your own BG "altitudes" to practice pivoting from. I use the metaphor of diving to describe this. Competitive diving boards have preset heights: 3 and 10 meters for example. Divers practice from a consistent height as they learn their moves. It's a constant which helps improve outcomes and helps with consistency. If the delta wave rises past the threshold, then consider dosing with rapid acting insulin at an amount consistent with the insulin correction factor you've been assigned. This is where I feel the static approach helps , rather than taking an arbitrary dose or starting at the lowest conceivable dose and working your way up from there over time. What about the insulin on board, or active insulin? One way to approach this is by waiting for the prior rapid acting insulin dose to pass its peak activity time, which is usually 60-90 minutes after injection. There might be some residual insulin on board, but the rising BG is not just the amount of insulin present or absent, but the total effect of food, activity and stress. Another first approach is to give an insulin correction dose as soon as a legitimate delta wave is seen. Use the bolus calculator in the pump to estimate the dose. Consider checking the BG by fingerstick to verify the CGM reading (and use it as a calibration data point in the CG'M). Allow the pump to consider the prior insulin dose and carbs previously entered into the bolus calculator. Give whatever the pump suggests, then watch the trendline periodically over the next 2-3 hours to watch where it goes. You might not see much change. But you also might see a good drop follow over the next 1-2 hours. Have rapid acting carbs available in case an aggressive drop happens and treat it at a higher threshold (150 mg/dL if dropping fast, 125 mg/dL if dropping slower). Braking on the drop is itself an acquired skill (two-step pivoting will be discussed in a future post). It requires a consistent fact acting carb source. I personally use grape juice, but you must choose your own drop 'braking' carb(s) of choice. Each attempted pivot is a personal mini-experiment. As such, try to be consistent with how you attempt, follow up, and judge each attempt. For example, if a 3 unit insulin pivot only stops a delta wave as it crosses 180 mg/dL (10 mmol/L) and results in a shelf at 230-260 mg/dL (12.8-14.4 mmol/L), try this at least 2-3 more times on different days or later in the day. Don't take a second pivot dose at first. That's an advanced move beyond the scope of this post. After you are reasonably confident that the pivoting dose needs to be stronger, then in future experiments add more insulin to the dose. This is where your conservative or aggressive side comes out. One suggestion is increasing the dose by 10% (pumps can deliver fractionated doses), or add one unit to the dose. A half unit in younger kids might be considered. Depending on your level of interest and time to practice you will gradually reach an insulin dose that pivots a rising trend line crossing your high level pivot threshold. Mastering this could take a few weeks depending on how aggressive or conservative you are with practicing. Pivoting won't always work exactly the same 100% of the time. You may need to apply the fast carb brakes if you overshoot the drop (two-step pivoting). But this is also part of Surfing. It's s bi-directional method. Sometimes you might see minimal BG change and at other times maybe more of a drop than expected. But if 75-90% of the time you turn the rise back towards your target BG range and land into a shelf in your desired target range, then you have developed proficiency in the pivot. Just remember, proficiency comes with time, practice and self confidence in your Surfing skills. Pivoting empowers you to take back control from diabetes. Steering your BG trend line, compared to watching helplessly as it meanders about, is a tangible and empowering reward of learning how to Sugar Surf. For volumes of free information on Sugar Surfing methods, or to order a book by the same name, go to www.sugarsurfing.com