What lies behind the lines of your most problematic sugar level patterns?

“Trouble Lines” are the sugar level patterns people with diabetes dread to see. Whether you see them clearly drawn on the screen of your continuous blood glucose monitoring (CGM) device, or pieced it together from your blood glucose monitor, these are the lines you as someone living with diabetes are likely doing all you can to avoid. Trouble Lines can happen to anyone living with diabetes at any time.

Keeping track and having records of your insulin dose volume and its timing can provide you with some guidance on how best to proceed. This is where smart insulin pens can be of help. Smart insulin pens provide reliable dosing information, which together with sugar level information could give an insight into what lies behind these trouble lines. Knowing what lies behind the lines is the best tool available for returning to safe numbers and to prevent similar patterns from emerging in the future. The patterns and symptoms of trouble lines can be unique for everyone living with diabetes. We take a closer look at four typical trouble lines that people with diabetes regularly encounter.

The most infamous trouble line for many is probably the Sugar Rollercoaster. The ride consists of a series of exhausting sugar level highs and lows that can be very difficult to stop.  As your sugar levels plummet you might be feeling fuzzy-headed as if everything is in slow motion, making it impossible to focus. You might feel hot, clammy, and uncomfortable, or have a tingly feeling in your tongue, lips, and chin. You might also be feeling cranky, and ready to snap at the next person who crosses your path. When you test, you realise that your blood sugar is low, so you eat some carbs to increase your sugar levels, but half an hour later you’re feeling faint and become concerned that your sugar level has swung too high. You then take some insulin, but you over-estimate how much you need, and the next moment you’re slammed down by yet another sugar low. This is the Sugar Rollercoaster – it’s the ride that no-one wants to go on.

The challenge of this trouble line is to treat the high or low just right to stabilise yourself within a safe range. However, after one or two surges and dives it can be difficult to know how much insulin might still be active from treating your last high, or how much carbs your body still has to absorb, taking into account the two chocolate bars you threw down in a hurry to treat the last low.

Keeping records of your insulin dose volume and its timing can provide you with some guidance on how best to proceed. Knowing how many previous doses you’ve had can help you calculate the amount of “on board” insulin you still have in your system. This can then help you better adjust the next correction dose to avoid diving into another low. Stepping off this rollercoaster is not always easy, but the more information you have at your disposal the better the odds.  

Have you ever experienced your sugar levels going up and up no matter what you do? That’s the Mountain Climber at work. It is driven by situations that are somehow out of your normal routine such as:

• Fighting an illness or cold that can have your body working in a different gear than usual and be impacting your insulin sensitivity.
  
• An important meeting or date that flushes your system with stress and hormones causing your blood glucose to rise and behave unpredictably.
  
• A meal that might have contained substantially more carbohydrates than you expected. For example, a very sugary or oily dressing; or a sugary soda mistaken for a sugar-free version. See our article on Lifestyle Factors for more.
  

Insulin – or rather the lack of it – can also be directly responsible for your rising sugar levels. A forgotten dose, a too small a dose or a faulty product due to improper storage can leave you with much less insulin in your body than expected, leaving your sugar level free to rise. Mountain Climbers can be extremely frustrating, as all your usual tricks and corrections suddenly just don’t seem to work.

Being able to review when your last few doses were and how much insulin you administered can help you figure out whether too little insulin may be the culprit, or if you should look elsewhere for an explanation.

You are starting to feel a little fuzzy and test your blood sugar just to check - 14 mmol and rising! You immediately correct with a shot of bolus insulin and get back to what you were doing. Twenty minutes later you check again – 17 mmol/L (306.31 mg/dL) and still rising! – what? But that can’t be true? You quickly add one more correction dose. There! That ought to do it. Thirty minutes later you casually check again – 4.2 mmol/L (75.68 mg/dL) and dropping fast! – Argh! What just happened?

A Crash Landing is when you dive straight into a low from a very high sugar level. The art lies in landing in the safe zone and then transitioning into a steady line. Easier said than done right? It is very easy to overcorrect when facing a stubborn high, which can be caused by forgetting how much active insulin you might still have left in your system from previous correction doses. A smart insulin pen can provide you with reliable information on how your body’s sugar levels have responded to the insulin dose, helping to give you a better understanding of what to do next and how to respond to a similar situation in the future.

Some days are packed with business meetings or other pressing events, making it hard to have lunch. So you have a snack before the meeting, confident that you’ll make it through. But the meeting goes on much longer than you anticipated, and after a few hours you start to lose focus. This is the Creeper, when your sugar level stealthily and unexpectedly creeps down much lower than you anticipated.

The Creeper is caused by a steady decline in your sugar level that ends up catching you by surprise. In the scenario above, the decline is caused by a missed meal and an extended meeting. Prolonged light physical activity such as a long walk in the forest or a marathon shopping session can also lead to a continuous drop in sugar levels.

Some CGMs have the ability to send alert notifications if your sugar level comes close to being too low - thus calling out “The Creeper” before it turns into a hypo. If Creepers are a recurring trouble line for you, you will need records to provide insight into whether your insulin dosage might be causing them. A too high basal dosage might be pressuring your sugar levels during the day, or your lunch bolus insulin dose might need to be calibrated better to suit your lunch time routine.

Sometimes you know exactly what’s caused your trouble line. You just couldn’t resist having a slice of cake, or your insulin dose was too small or too large. Sometimes the cause of the change in your sugar level is less clear. But, if you combine your sugar level information (high or low, stable, rising or falling), with your insulin dosing information you can accurately identify trends and triggers.

Novo Nordisk has introduced new smart insulin pens to make it possible and easier for patients, and their caregivers, to track insulin dosing behaviour. This information can be viewed side by side with sugar level data and will help you better understand how your body responds to insulin doses and timing of doses. When you share this information with your doctor or nurse, it will allow them to make more informed treatment decisions and in the end, help you to better cope with or even completely avoid, these trouble lines!

You can also read our Caregiver article which shows how smart insulin pens can help you manage someone else’s diabetes.