Lesson #21: Microdosing. It's just a "day in the life" of the Sugar Surfer.

Stephen W. Ponder MD, FAAP, CDCES

2018 ADCES Diabetes Educator of the Year

Over treating a low blood sugar can be frustrating. It starts a glycemic roller coaster that can take hours to stabilize. Sugar Surfing™ approaches the correction of lows by first using a quick trend line glance before any action is taken. It is more than just a number that you should consider before deciding how to treat a low or even a ‘trending and impending’ low sugar level.

Look at the annotated 12-hour trend line above. On the far left is an example of what I call a “nudge”. It is a core Dynamic Diabetes Management maneuver I use all the time. My blood sugars often skim along between 70-120 mg/dL [3.9-6.7 mmol]. Using a CGM allows me to trend steady not too far above hypoglycemia ranges. It requires more frequent, albeit quick, glances of my trendline during the day to maintain it. Still, a slow blood sugar dip can happen even when my basal insulin dose is balanced, or “neutral”, as I have written about many times before.

Here I was approaching 60 mg/dL [3.3 mmol]. After glancing at the trend line in the 3-hour time window view, I intuitively knew this was a slow drift downward and not a rapid fall. I also knew there was no recent fast insulin on board or prior intense activity I had just finished. Basically, I sized up the situation, not just the number or the arrow direction. This is what experienced Sugar Surfers do.

As I knew I had some time, that meant I would be able to ‘finesse’ the management of this “slow low” by nudging this one. So, rather than a full 15 grams of fast acting carbs, I drank 8 gm of grape juice (my personally preferred liquid fast carb). Sugar Surfers refer to this as “microcarbing”.

Sugar Surfing has taught me that patience is key in managing these gradual drops (and rises). Not overresponding allows me to better manage the ‘ebb and flow’ of my blood sugar trending levels across a busy day, between mealtime insulin doses. I was also confident that the situation associated with this mild low blood sugar occurrence was not going to quickly get ahead of me. So, I patiently waited and worked on something else to pass the time. As you can see, I rose by 60 mg/dL [3.3 mmol] in 30 minutes using only 8 grams of carbs.

There is always a lag time after any fast carb is consumed and when first the tangible sense of mental relief is felt in my head. That almost always precedes when the CGM shows visible increases in the blood sugar levels on the trendline. And like all my prior experiences, patience pays off. My blood sugar rises back into my target range without a major overshoot.

Microcarbing is certainly faster than microbolusing insulin but the principles are similar. This image illustrates how I use these methods to gently steer the glycemic trendline each day between meals and overnight. I did eat a low-carb breakfast here at 7:15AM (Omelet, bacon, and avocado) and took no bolus for it. Although I would say the 2 U lispro microbolus about an hour later was really my late meal bolus to cover the slow sugar rise from the protein and fat in my breakfast.

You see another example on the right-hand side of the image of microbolusing a slow sugar rise approaching 140 mg/dL [7.8 mmol]. Past that is seen a microcarb of 7 grams for a slow downward drift, followed by a 90-minute, 5-mile walk.

That’s microdosing: just another “day in the life” of the Sugar Surfer!

Go to sugarsurfing.com to learn more about this and other Sugar Surfing self-management maneuvers using a CGM as your glycemic “compass”. And of course, the book teaches these actions very well too.