The other day, I was discussing Sugar Surfing™ with a t1d teen in clinic. She is a competitive softball player; a pitcher. As I reviewed blood sugar levels on her CGM, most were elevated. Her glucose readings before breakfast were generally in range. But during the day they tended to go up and stay up.
I asked her how many insulin doses she injected each day. Her answer was immediate: “I dose with each meal”. Next, I inquired how often she checks her BG level. Again, she responded “I check before each meal with my meter”. The logbook data I reviewed affirmed this and did not appear to be fabricated or altered.
Next, the blood sugar meter readings I reviewed showed a trend of out of range (high) blood sugars before lunch, dinner and bedtime. The CGM summary report confirmed this. As she reported, the morning blood sugars were generally the lowest. She had reported no significant low blood sugars and I could locate none in her logbook or readout. She was taking a rather large dose of long acting insulin for her age and weight. Her in clinic A1C that day was 10.3%.
Depending on your point of view, she was doing much of what she had been taught. She checked blood sugars before meals and bedtime. She took a dose of insulin with meals. It was never clear whether she consistently added insulin at mealtime for out of range blood sugars (or subtracted for low pre-meal blood sugars). However, she rarely to never checked blood sugars after or between meals. She would see the high BG trends on her CGM, but did not act on them in a proactive fashion.
I will also add that she tended to snack frequently. She has had several visits with the diabetes dietitian. As you might suspect, meal planning and food selection remain challenging for her.
To discuss with her in terms she was comfortable with, I used the metaphor of “stolen bases”. I said, “Your opponents are always trying to advance their position on the playing field”. If a pitcher is unaware of this or fails to act aggressively, then she/he risks sacrificing points needlessly by allowing a runner to "steal a base". Not checking blood sugar between meals (or even before a meal) is like not keeping an eye on a first or second base. It opens the door for a high (or low) “stolen base”.
All persons with diabetes have allowed ‘stolen bases’ at some time. In a sense, we do it all the time. The point is not to eliminate all base steals. Rather, it’s about keeping a eye on what goes on between meals and insulin doses. If you are a Sugar Surfer, you can actually “see” base steals starting (i.e., identify a significant delta wave...or drop). When you master the glycemic (or carb) “pivot”, you will be able to force the runner back to their original base (a steady trend line or "shelf").
Finally, make sure that additional insulin is taken as needed for between meal snacks. Plus continue to practice smart meal planning and carbohydrate counting. Not paying attention to meal and snack planning allows an easy base steal under most cases.
Glycemic base stealing is largely a consequence of omission. It requires nothing to master. Literally, doing nothing allows it to happen.
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