A new technique of using insulin is causing quite a buzz within the T1 community. Some think it will become the new standard of care, replacing DAFNE. Read why Afrezza greatly simplifies this method.
Also called Dynamic Diabetes Management, Sugar Surfing is an intensive glucose management technique for tight glucose control that requires a continuous or flash glucose monitor. It de-emphasises the traditional insulin-to-carb and correction ratios, and introduces a whole new lexicon derived from surfing such as shove, nudge, drift and flux.
Timing is the most important part of Sugar Surfing, more important than dose size. The technique involves learning the lags of your insulin and each type of food and taking into account the delay of the glucose monitor. The goal is to optimally time more frequent interventions. High glucose is treated immediately, rather than waiting until the next mealtime. In practice, the approach tends to result in about 9 pump boluses or injections of mealtime insulin in a typical day, which the author compares to the 11-12 waves of insulin each day in a non-diabetic.
Afrezza users who are posting the amazing A1C results have most likely mastered a simplified variant of Sugar Surfing without realising it. Although I’ve only recently discovered Sugar Surfing, I’m amazed how it resembles how I have ended up managing my diabetes, using Afrezza and the Freestyle Libre…. except the Afrezza way is, again, far simpler.
At first, the technique looks quite daunting. It involves a lot of trial and error – and “low expectations” are advised for the first 12 months. However, Afrezza greatly simplifies Sugar Surfing, and precisely addresses some of its weaknesses. Surprisingly, this means that less doses of Afrezza per day are needed to achieve the same glucose control.
When using injected insulin, the technique requires “pre-empting” dosing as long as 45 minutes before every meal, then waiting to start eating at the optimal time for each meal – once a curved pattern appears on the glucose meter display. With Afrezza, pre-dosing isn’t required with any meal, which greatly reduces the scope for timing errors.
The frequent dosing of injected insulin brings the challenges of stacking doses, that increase the likelihood of hypos. Sugar Surfing introduces the “i-chain” concept to deal with this problem, but the lack of a long tail of action makes Afrezza so much easier.
With Sugar Surfing, in addition to interventions triggered by CGM alarms, the next intervention decision is to be made 2-3 hours after dosing insulin at the latest. At this point, a decision whether additional carbohydrate “nudges” or additional insulin “shoves” is to be made. Additional injected insulin at this stage is problematic, as additional carbs will be required later to avoid hypoglycaemia. Afrezza eliminates this problem, as it is finishes its action so much sooner. Post-meal lows requiring “nudges” seem non-existent with Afrezza, presumably for the same reason.
A single basal rate is recommended for Sugar Surfing, making Tresiba the perfect basal for it. Tresiba is equivalent to a pump set to a fixed basal rate all day, and takes out a whole host of variables, further simplifying management.
As the technique requires taking into account the lag in the glucose monitor, the FreeStyle Libre is brilliant – with changes showing six minutes before the Dexcom G5. Although the Libre lacks alarms, Sugar Surfing highlights how its factory calibration is not just for convenience. Each calibration required every 12 hours with the G5 introduces variability and often reduces accuracy.
If you’re considering using Afrezza, it’s worth checking out the book. It will introduce you to the mental leap that you will have to make with Afrezza – that timing is more important than dose size. You can begin applying the principles with your existing regime – and see how labor-intensive the technique is. I would think that after a few months Sugar Surfing with injected insulin, it would be obvious why you would want to upgrade to Afrezza.
Users with a background in Sugar Surfing would hit the ground running with Afrezza, without the learning curve and “unlearning” that I encountered. A simplified Dynamic Diabetes Management protocol would serve as the best protocol for Afrezza use in Type 1 diabetics. Most users would eventually figure this out themselves within 6-12 months, as it becomes quite obvious when using Afrezza with a CGM.
However there’s no reason to keep new users in the dark. Unhelpful in-box instructions fixated on unit conversions to injected insulin should instead introduce basic dynamic management techniques. I hope to develop a simplified set of these principals for those starting Afrezza.
From the sample chapter of Sugar Surfing:
“Did you know that when you use your insulin pump to bolus 1 unit of insulin it can be off by a range of plus or minus 30% – 200%? “
“Personally, I found this obsession with ultra-precision in insulin dosing a bit unnerving since I didn’t usually see any improved control in patients who practiced it. “
“Stuck on the idea that you are only going to inject X number of times per day and no more? As I said above, the pancreas of a non-diabetic is known to unleash 11 internal insulin bolus events per day How can you expect to have the blood sugar profile of a non-diabetic if you’re not even open to the possibility of giving yourself half that many injections? “
“the human body produces on average 11-12 waves of insulin from the pancreas each day. This is actually consistent across all persons without diabetes. I’m not advocating 11-12 insulin doses a day, but if non-diabetics produce insulin between meals but if non-diabetics produce insulin between meals, then maybe learning how to do that properly isn’t a bad idea “