SUGAR SURFING LESSON #3: EXPECT THE UNEXPECTED

As a patient (and later as a physician) I was taught to consider blood sugar management like a mathematical equation. First, gather a blood sugar value. Next, calculate the carbohydrates to be eaten, then calculate a meal time insulin dose (or snack time insulin dose) to be injected in response to the first two calculations, plus a 'correction dose' for the difference between my measured blood sugar and a 'target' blood sugar dose I should always aim towards. Finally, I would administer the insulin dose (by injection or through an insulin pump), eat the meal…and move on. And oh yes…check blood sugar 2-3 hours later to measure the outcome. Pretty straightforward, huh? Alas...also very static.

"Your pancreas can still write insulin checks during the honeymoon"

This simple cookbook-style approach often seems to work well during the early months of type 1 diabetes. Unbeknownst to many of us, the pancreas still produces small amounts of insulin in the months following diagnosis. This is known as the “honeymoon phase” (i.e., partial remission phase). “Your pancreas can still write insulin checks during the honeymoon” as I am known to say in clinic. As a result of the honeymoon, insulin management regimens prescribed after diagnosis usually seem to work quite well, based on the A1C and logbook data results. But this period of blood sugar stability is usually temporary. When blood sugar variability increases, it usually has more to do with the natural progression of loss of the ability to make insulin...and less about how well you followed your initial training. At this stage your 'static' (strict rules based) approach to diabetes self-care begins to leave much to be desired.

As an endocrinologist, time and experience brought me to the inescapable conclusion that while simple may be easy to start with, simple does not always provide the best long-term results. Once I possessed the ability to view the minute to minute trending of my own blood sugar with a continuous glucose monitoring system (CGMS), many of my long held assumptions about diabetes were swept away. A new phenomenon was discovered. It was this new world of real time glycemic viewing which gave rise to the paradigm shift in diabetes self care I coined by the name Sugar Surfing™, also known as Dynamic Diabetes Management.

Like discovering a new world in my own backyard, continuous glucose monitoring provided me the opportunity to explore and experiment in my own glycemic 'innerspace'. Previously, I could only see or estimate glycemic trends by indirect means. Until then, I gazed on my blood glucose control only in the rear-view mirror of hindsight. With CGM I could see what was happening in front and behind me as it was unfolding. No longer was I limited to knowing my glucose level just when I set aside a few minutes to prepare and gather a blood sugar reading by fingerstick.

Sugar Surfing is your guide to creating a unique path of self-discovery. Each of our glycemic innerspace universes are singular. None are completely predictable either. Like the seas, blood sugar levels do rise and fall over time. Many of these shifts are like the ocean tides. They possess rhythmicity. In most cases, we create our own splashes and waves through our actions or omissions (food and insulin). Sometimes, those waves may be tsunami-like. By applying the human virtues of patience, consistency and resilience, along with a touch of self-reflection, we can learn how to steer the waves in our own blood sugar seas. We also develop a deeper appreciation for our own glycemic undercurrents which no doctor can ever see.

Armed by Sugar Surfing, we now see insulin dosing formulas, sliding scales, algorithms and carbohydrate counting as nothing more than starting points. We might even smile when a new universal dosing formula (for insulin or food composition) is offered up to us by online experts, friends, or even our medical team. A recent study reported a sevenfold variance in standard commercial insulin preparations purchased in US pharmacies. Most insulin preparations are produced at a concentration of 100 units per mL. 95U/mL is the lower limit of acceptability. This study revealed a sample of those insulins were actually composed of anywhere from U13 to U94 with an average of U40/mL. If supported by follow up studies, this 2017 report makes a mockery of static dosing strategies used by non-Sugar Surfers. It also serves as one more validation of Dynamic Diabetes Management for the rest of us.

Only by recognizing the visual patterns of the glycemic trendline (shelf, delta wave, drop, inflections, pivots and lags) we can decide their significance (or not), then act (or choose to not act) accordingly. Finally, periodic glancing allows us to keep our trendlines moving in a direction WE choose. Sugar Surfing is not a “one and done” process. Rather, it’s “act wisely and let’s see what happens next”.

As the New Year begins, there are tens of thousands of practicing Sugar Surfers across the globe. There are still many more to be recruited and brought into the colony. Use this synopsis of Sugar Surfing and add your own impressions when you share with others interested in learning more.