"You can take it to another level" - Sugar Surfing with Dr. Stephen Ponder (Classic Episode)
Release Date: 04/29/2021
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Dr. Stephen Ponder coined the term "Sugar Surfing" in 2013 to describe a real-time, dynamic system of managing diabetes. In this "Classic" episode we take a deep dive into what Sugar Surfing is all about and get Dr. Ponder's perspective on everything from parenting teens with diabetes to how he feels after 50+ years of living with T1D himself.
Dr. Ponder is the medical director at Texas Lions Diabetes camp where he’s volunteered for almost 40 years and in 2018 he was named Diabetes Educator of the Year
It’s hard to believe now with CGMs and closed loop systems, but the thinking you’ll hear Dr. Ponder talk about was pretty revolutionary in the early 2000s. This interview is less than a year after he published his book.
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Episode transcription below
Stacey Simms 0:00
Diabetes Connections is brought to you by Inside the breakthrough a new history of science podcast full of did you know stuff.
This is Diabetes Connections with Stacey Simms.
Stacey Simms 0:17
Welcome to a classic episode of the show. I will be so happy to have you along we aim to educate and inspire about diabetes with a focus on people who use insulin. I'm your host, Stacey Simms, and this time around, I'm revisiting my first interview with Sugar Surfing Dr. Steven Ponder. Dr. Ponder has lived with type one for more than 50 years. He is a pediatric endocrinologist and a certified diabetes educator. Sugar Surfing is about real time management of diabetes. Dr. Ponder coined the term in 2013. But it was a long time coming, a lot of research, a lot of work.
It's hard to believe now with continuous glucose monitors and closed loop systems. But the thinking that you're going to hear Dr. Ponder talk about was pretty revolutionary in the early and mid 2000s. This interview comes less than a year after he published his book sugar surfing and by the way that is still free for newly diagnosed people, newly diagnosed families. And I will link up more information about how you can get that in the show notes over at Diabetes connections.com.
So what is Dr. Ponder up to these days? Well, he has become a frequent and welcome guest on this show. I last spoke to him for our New Year's Day episode when health care providers were getting the COVID vaccine that was such a joyful show. I loved being able to talk to them some of the first people in the country to get the COVID vaccines and he was one of them. Dr. Ponder is the medical director at Texas lions diabetes camp, where he has volunteered for almost 40 years. And in 2018 he was named the National Diabetes Educator of the Year he also founded a free medical clinic for children all children, not just those with diabetes, our original sugar surfing interview in just a moment.
But first, this episode of Diabetes Connections is supported by inside the breakthrough surprising stories from the history of science. Dan Riskin, digs deep and entertains as he connects those old stories to what modern day medical researchers are facing. As you know, 2021 is the 100 year anniversary of the discovery of insulin that is arguably the biggest scientific discovery in Canadian history. This series examines that moment and many others through the lens of Canadian researchers trying to find what's next for the fight against diabetes. I love this podcast I have listened to every episode I highly recommended search for insight the breakthrough anywhere you find podcasts, and a good time to remind you this podcast is not intended as medical advice. If you have those kinds of questions, please contact your health care provider.
Dr. Ponder, thank you so much for joining me.
Dr. Stephen Ponder 2:50
Thanks for having me today. Appreciate it.
Stacey Simms 2:52
Yeah, it's I'm excited to talk to you. But before we talk about sugar surfing and some of the listener questions 50 years with type 1 diabetes this month, how are you doing? And do you remember your diagnosis?
Dr. Stephen Ponder 3:03
Oh, very much. So I was nine years old when I went into the hospital. And I was having fairly mild symptoms, increased urination, you know, weight loss and so on. Parents were puzzled by that took me to my pediatrician. And I don't remember all the details. I do remember getting poked a few times. And lo and behold, later that day, my mom was getting was called by my pediatrician. And I was admitted to a local hospital in an old fashioned ward of all things with four beds. They were they were not separate rooms at that point in time. And I was managed for about nine to 10 days in the hospital. Interestingly, by today's standards, I never saw a pediatric endocrinologist. Of course, there were not many of them in existence in the in the 1960s outside of large, you know, academic institutions. But I was managed by a pediatrician my entire childhood.
Stacey Simms 3:55
You were managed by a pediatrician. That's fascinating. What was the treatment? What was the management like?
Dr. Stephen Ponder 4:01
Well, not unlike a lot of people today you know where you'll hear stories where the doctor or the nurse handed down a lemon or an orange to practice injections on I really fell into that classic model where that I was given a piece of fruit to inject my insulin into practice. We did have plastic needles back then but the reality was I was sent home with glass syringes and reusable needles which were about 2625 to 26 gauge which by today's standards were huge. In terms of both length and and and width. And I took one shot today of a what what doesn't exist anymore and insulin call lanti le n te the closest thing that comes to it is his mph insulin, the cloudy mph and even many of your listeners won't even know what that is anymore in this day and age but I was treated with lenta insulin for gosh about 15 years until I started medicals School in 1980. And my first endocrinologist who put me on the path to multi dose insulin therapy, and very quickly after that insulin pumps,
Stacey Simms 5:09
Wow, that's amazing how much the practice must have changed what led you to become a pediatric endocrinologist?
Dr. Stephen Ponder 5:15
Well, I think that diabetes camp when I went to camp in 1981, it was kind of interesting. The person who ultimately would become my mentor was doing a research study for one of the insulin companies that were just rolling out biosynthetic human insulin, up until then we were using animal insulins. And during that study, his research nurse asked me this innocent question about diabetes camp. And she said, Oh, by the way, Steve, we have this camp for kids with diabetes. And I had actually gone to camp, not the same one. But I'd gone to a camp a couple of years after I was diagnosed. So I said, Sure, why not. And I said, it was about that much commitment. And after I went to the camp, in 1981, I just found my calling, I went back every year, and I have been going back every year since and, and about 25 years ago, actually became the medical director of the children's diabetes camp in Texas at the Texas lions camp. And that pretty much sealed my fate in regards to becoming a PDA, pediatric endocrinologist. The friendships I made, and the people I was able to, in some ways, I suppose influence. And it's been something I'll continue to do until I can't do it anymore. And I go back every year, I've spent several years of my life in the town where this camp is located. In fact, we recently, about 10 years ago, they just recently purchased a home not too far from there, which I may well retire to at some point in the future. You know,
Stacey Simms 6:52
this is the time of year when a lot of families have already signed up for summer camp for diabetes camp, but there may still be people on the bubble trying to figure out is this the year we do it? What would you say to them? Why is it good for kids? And what about the reluctance of cash? You know, I think it'd be home sick, are they gonna be taking Well, you know, care for as well as I can do at home?
Dr. Stephen Ponder 7:12
Well, I think it depends on the camp, the camp that I work at, serves children with special needs during the rest of the summer. And so they're very accustomed to taking children whose parents are, have been generally reluctant to let them out of the home. And these are children and they have visual problems, hearing problems, physical disabilities, cerebral palsy Down syndrome. And so they're extremely capable and competent. And getting the young boys and girls involved very quickly. In fact, as soon as the children are dropped off, they're whisked away to be, you know, to a playground to be active, to get settled into their, their banks and so on. They have really taken it to a fine art to the ability to keep kids from being homesick. Now we take kids that are aged eight to 15. At this camp, and, and yes, there's always a little bit of that at the beginning. For some of the eight year olds, not always, but some of them may struggle a little bit. But they are generally within a day or so just right in the swing of things if not just in a matter of hours into the swing of things. So I think we've we've not had to worry so much about that. Now my medical staff, we take about 75 people on the medical staff and we have 220 campers in two separate sessions. So 440 total, and we have a very high level of competency in that group too. Many of them are former campers, their medical professionals, nurses, doctors, you know, endocrinologist and volunteers. So we I think we've done a pretty good job over the last 35 years refining the methods to keep kids engaged, happy and active to the point that when they go home a week later, there are many of them or would like to say a little bit a few days longer.
Stacey Simms 8:52
I think diabetes camp is fantastic. My son is going to have his fourth year fifth year he'll be he'll be a fifth year camper this year. And it's been amazing the friendships he makes the the kids he stays in contact with and the empowerment this camp is where he did his first inset it's where he moved his Dexcom to a different location it's it's just so great for those kids to kind of figure out who they are I think two away from their parents. I'm a huge supporter of summer camp I think that's great.
Dr. Stephen Ponder 9:20
It's a wonderful experience all the way around and and and it forges some great friendships as you've already mentioned, that can continue well after camp especially I suppose in this day of social media era of social media. The the campers can stay in touch but you know,
Stacey Simms 9:34
don't get me started on the group texting that goes on my kids go to a different a longer summer camp later in the summer to them the group texts that are going it's crazy. But let's let's talk about sugar surfing. You have really hit a nerve I think in a great way with so much of the diabetes community. Sugar surfing and I'll ask you to better explain it but it seems to me is about learning how your body reacts and really Staying on top of your diabetes, more so so that you're I guess less reacting less to what's going on trying to predict more. And instead of making big changes all day long, trying to kind of nudge your blood sugar here and there, am I am I even close?
Dr. Stephen Ponder 10:15
Oh, you're absolutely right. That's exactly what it's about. It's management in the moment, as I say, in the book, once you look at blood sugars in a dynamic fashion is something that's constantly shifting and changing, you come to the same conclusion that you have to make anticipatory judgments as well as reactive judgments. And in a perfect world, half of your control is what you plan. The other half is what you have to react to what you have to do based on unexpected occurrences. And that's just life in general. So I think you can take a lot of the things you know about life in general and apply them to diabetes, you just have to be comfortable, or develop a sense of comfort with the various forces that you have at your disposal, that can move your blood sugars around whether it's insulin activity, the food you eat, the types of foods, the amount you eat, when you eat them. And when you boil it down. Diabetes Care is nothing more than a series of informed choices. At the beginning, those choices are in some ways made for you, or at least you're instructed to make these choices a certain way. But many people find that very limiting, and they want to break free of that. And many of them have and have done that well before I wrote this book. And whether they call it sugar surfing or have some other term for it. They're making more management decisions in the moment, which really improves their control and helps him better steer their their glycaemic trend lines in a more normal fashion.
Stacey Simms 11:43
Well, let's see if we could get kind of specific if you don't mind. I'm curious, like, how would you tell someone, here's how we're going to use sugar surfing to make your morning and your breakfast, a little bit more smooth, would you mind maybe taking us through that, like you wake up at a certain blood sugar and you're going to eat something for breakfast and how you might handle that?
Dr. Stephen Ponder 12:03
Well, a lot of the principles behind sugar surfing are things have been taught for many years, they include, you know, waiting a sufficient time after you take your insulin, to better time it or get it in synchrony with the food you're about to eat. Also understanding the glycaemic or the the fingerprint, if you will, of the meal of the food you're about to eat as well. So you have to match those two things up, you know, I use metaphors a lot. And I will say this to the young children, that, you know, a football quarterback that's throwing a football to the wide receiver is actually throwing the ball to a spot that there's no person at at that particular point, it's released. And you're trying to do the same thing with between timing food and insulin. If If food is the ball, and the wide receiver is the insulin, you know, the the quarterback, that is the patient needs to lead, you know, lead the inflammation of the lead a little bit before you throw the food at it. And in a practical way, what's your surfing, when you're looking at the trend line on your continuous glucose monitoring device, you will often want to wait for a band or an inflection point downward. That generally occurs anywhere from 10 to 15 to 20 minutes, maybe longer, maybe shorter. After that insulin dose is given such that the downward force that insulin is being seen on the glucose trend line, then the when the food is consumed, then it's more likely to be matched up or synchronized with the rising force, if you will, of the sugar that comes from that particular meal, assuming there is a lot of carbohydrates and you have to then adjust that insulin dose according to what you understand about those that particular food. And to be more specific for breakfast, I promote the concept of the top 10 list. And this is not David Letterman perspective. There, everyone has a top 10 favorites, everything you have a top 10 favorite breakfast, the top 10 favorite lunch and dinner. And that can easily be determined over the span of several weeks, you could actually count well how much how many times they this person he decided the other thing anyway, focus on your top 10 list. So if you if you enjoy a certain type of cereal, or oatmeal or toast or pancake or whatever you have for breakfast, then determined over time. And this is through observation, determine what effect those nosepieces meals have in general on your blood sugar, how soon they respond, how how aggressive they tend to be. And then you design an insulin regimen that best matches those and you use your trend line on your sensor to give you the best idea of how well you're matching those two things up to the point that you minimize the rise in the blood sugar. You want to prevent the spike that occurs after the after you eat what most people make the mistake of doing and they've been taught this and it's not always their their fault is they've been told it is to take their insulin at or after they eat. Now while that works fine for a child or toddler who you don't know will finish their meal if it's an older child or an adult who can easily you know, complete the whatever they've been had food put in front of them, then they should be timing their insulin with their food better with the goal to be to minimize the rise that occurs afterwards. Now, that's what the a one c elevations come from. And most people that are down in the six, seven and 8% range is what happens to their blood sugar after the not so much what they are before the. And I'll use this example a lot with people, if I was teaching somebody how to hit the golf ball, and I gave them the proper stance and positioning and so on the right clubs and all that, and I left and strike the ball and 100 times, yet, I never let them see where the ball landed, I'm not sure I'd make them a very good golfer. And that's in a sense what you're doing, you need to see where all that effort really leaves you. And if you're not checking a blood sugar in the next two to three hours after a meal, which a lot of people don't, or they've never been told to do, then you're setting people up in some ways to fail, because the assumption is that the doctor has given you some sort of ratio or some sort of formula. And they've told you to measure certain amount of food. And if you only do those two things correctly, you'll basically hit a hole in one every time and I think anybody who's done this for any period of time knows that that's just not true. And you need to have a different way of looking at this and that you may have to steer it even as it's moving. And that's a more advanced sugar surfing method is is trying to steer the direction of your your trend line after you've already taken your insulin and after you've already taken your food. But I'll tell you I do it all the time. You know,
Stacey Simms 16:31
I use it a little bit because that is you say that, and I'll put this back in here. It's a little bit more advanced, you want to be careful with this stuff. But how do you do that?
Dr. Stephen Ponder 16:39
Oh, well, you know, it's observation, it constant observation, I glanced at my sensor track anywhere between 40 and 50 times a day. It's not unlike you glancing at the dashboard of your car, when you're driving home, or looking in the rearview mirror, you're constantly scanning your surroundings as you're moving forward. And you have to take that same principle with you. When you sugar syrup. I mean, if you're surfing, you have to be well aware of your of your surroundings. So you just can't act three or four times a day. When you take an insulin dose and or eat food and expect to have the tightest control possible. You have to decide how willing Are you are her how able are you to be more aware of what's going on in the moment. As you see something trending up or trending down, keep us keep more of an eye on it and decide do I need to step in and alter the direction of my my trend line. I mean, as we're talking right now I'm looking at my sensor and I'm straight line at 96. On my particular sensor I've been I've been in my zone between 70 and 140. For the last several hours, I'm pretty much a straight trend line. But when I start to slowly drift down or slowly drift up, I pay a little bit more attention to that. And I want to see if it is is it approaching a threshold that I've decided in advance that I'm going to act upon. And I change those thresholds all the time based on the circumstances if I'm outside doing lots of intense work, I may want to run a little bit higher, and I'll tolerate a blood sugar of 161 7182. So I'll have a bit of a buffer underneath me if I'm if I'm you know doing a lot of yard work or doing a lot of exercise. Yet when I'm in the office like I am now I like being around 100 between 80 and 120. And I did steer the line in that fashion. And I do it through frequent glances and audit. A lot of times it's just looking at the sensor plot. And that's it, I do nothing else. I just stopped looking at it a couple a few seconds ago. And but if I saw something trending down, I'm going to preempt or act in advance of developing a low, I'll do the same thing in advance of what I think will become a high. Now do I sometimes over treat or prevent do too much? Yes, I've done that in the past. That's when I was just beginning this. But I've learned to use much smaller quantities of both insulin and carbohydrates to steer this line, I don't have to take 15 grams treated low, I can prevent a low with four grams. And I use things that are easily available. sips of juice, glucose tablets that have four grams of carbohydrates. So I've used these units of currency if you will. And I've learned how to use these to make small steering moves in the direction of the line of blood sugar. And that's really what sugar syrup is all about is steering that line, which everyone has. And nobody has a straight line blood sugar everybody, everybody's blood sugar line moves with or without diabetes. And I say this in the book, I say it in my workshops. The only person with a straight line blood sugar is a dead person, always on the move. And you just have to learn how to steer it. And the continuous glucose monitoring technology is a paradigm shift in diabetes management.
Stacey Simms 19:43
Let's talk about the CGM. I have to tell you in the last we've used it for a little bit more than two years and it really has changed our management and just like what you're going to talk about here in that when you see it going up. You can take a little bit of action or when you see it going down. Do you need a CGM of some kind of sugar, surf and You know, is that something that really has changed your way of even looking at management.
Dr. Stephen Ponder 20:06
When I first came into sugar surfing through the concept of what I call frequent pattern management, we did a research project a few years ago, we published in 2012, and diabetes care. This is a randomized control trial, where we developed the technology which would share information every night, with families, electronically, they their blood glucose meter was a wireless ahead of wireless modem, it would upload to the cloud, and every night, it would send all the information back in a very colorful format for families to look at. But we did a year long study where we wanted to see what the impact of that that frequent feedback would have on on on behaviors. And we found that we saw improved control. with patients who got that regular feedback rather than taking the time and effort themselves to go download or print something out or write things down in a logbook. And such, we use a control group where they everyone else just did that, they just they would do that whenever they felt like it. But that frequent follow up that frequent exposure to the data, improved control by a full percentage point, if there anyone sees or over 8%, at the beginning of the study, after a year, it had dropped and stayed stayed down about 1%. If it was seven and a half, or below, I'm sorry, it is below eight. That is they improved by about a half a percent. And this was with zero physician interaction with just getting information back in their hands. So this is a very, very preliminary version of what you could call CGM, which is, and that's really hyper frequent pattern management, because you're glancing down at that sensor. Now, that depends on the human being that using that data, you know, yes, it's recording every several minutes, it's giving you a data point, but somebody still has to look at it. And somebody still has to make decisions about what to do with that information. And then they need just like Kenny Rogers, you know, you know, walk away, run, hold and fold, and that sort of thing. That's what you're doing with with this information, you're making decisions in the moment. The fact of the matter is, they see that people are making decisions all day long with your diabetes. This is in the book, there's a study a few years ago that showed the average person without diabetes makes 221 choices a day about food. And so that's just about food, much less whether you have diabetes, and you're worried about food. So choices are the currency of control. And as you're making these choices, you're not always going to make the best choice, you're always gonna make the right choice. But you hopefully you're somebody that's wise enough to learn from those choices, and make better choices the next time. So it's a constant series of self improvement steps that you're doing with sugar surfing, it's not that the doctor gives you or issues you a set of directives that are somehow magically going to keep you in control. Those are starting points Don't get me wrong, I think dosing algorithms and so on, are all right, but they're not an end all be all. In fact, I have a hard time giving them out to patients now because I don't believe them or use them myself, other than just as a starting point. And I can't and I say that as a caveat, the family that said, Listen, I'm going to have to do this because you have to have your school orders for your child that a nurse will have to administer, I can't expect the nurse to be able to nuance things like you can as a mom or a dad or as a teenager. But I have to do this, it's part of what I have to do now. But it kind of pains me a little bit that I have to do this because I don't believe in it anymore, like I did a number of years ago, because of the dynamic nature of how diabetes can be controlled. Now you can get reasonable controls, don't get me wrong with with your with your algorithms, your carb ratios and your correction factors and so on. But, but you really can, you can take it to a whole nother level. And I get my keep it once he's down to 5% range. Now, by doing this in a dynamic fashion, you can get a good respectable 6% to 10% a one c by doing it old school, you want to call it that way. But you want to take it to a higher level and get down to the five or even to the normal. Below that it takes a lot more, you know, attention to detail. And and and sugar surfing.
Stacey Simms 24:00
Well let's let's grab a couple of questions that I took from social media for you about that exact point. This one is these are mostly about kids. But I think they're they're relevant overall. So this person says, if you want to employ just a couple of techniques with a child to increase in range time, what would they be? I don't this is her. These are her words. I don't want to go insane and spend every moment thinking about and evaluating my child's diabetes we want to live but I'm willing to make some changes.
Dr. Stephen Ponder 24:29
Absolutely. That's a great question. The first thing that I find with any patient I see when they come to see me new and they've been taken care of somewhere else is that they do the they don't do as good a job in timing the insulin and we touched on touched on that a little bit earlier. Many folks will come in and they may have been very well trained. They're very well motivated, but there's still dosing insulin after the fact. And if you see the impact of impact of that, on the rise of blood sugar that occurs after the meal, you will quickly say well, we need to do something being different, we need to take that infant ahead of schedule and we can. Now depending on the child, if there's somebody you, you know, who will reliably consume the meal they have in front of them, then then go for it. If it's somebody, you're not sure that they'll eat the whole meal, if they're on an insulin pump, there's some tricks you can play, like, extend the bolus over 30 minutes or 45 minutes. That said, once you know that, they're not going to complete the meal, you can still aboard the rest of that dose, and they can get about half of it that way. So there are all sorts of tricks you can play if you're using pumps. Now, if you're doing shots, you have to just be certain that that child is going to be able to consume the carbohydrates that are put in front of them. And, and I think that's an important that's an important tip and sugar surfing, is timing, timing is everything. The other is checking blood sugar Two hours later, whether it's with a sensor with a meter, and correct anything that's out of range, and you want to use a golf metaphor for that. That's what that's like having part three part four Whole Again, my feeling is nobody has a hole in one with every every insulin meal combination, that two hour reading gives you an opportunity to do a corrective dose to steer that blood sugar back toward your your, your target number, which in turn will lower that a one c because you'll spend less time up in the higher range which again, will contribute to a higher a one c value.
Stacey Simms 26:20
I like all the golf metaphor is you got to come to Charlotte and I'll take you out we'll play some golf, do you? Alright, so the next question is, can I ask? She says, Can you ask Dr. ponder about basil rates and we didn't talk about this yet at all. But she goes on to say I know he doesn't advise we use too many. But I find that my child a teen does better with about five basil rates, especially at least two overnight to account for the morning rise. Can you address that?
Dr. Stephen Ponder 26:49
Well, basal rates are our habits have a purpose behind them that sometimes they have. Some people use them in a different way. Let me just try to explain this. In the way a basal rate should work is just to keep you steady at whatever level your blood sugar is after your mealtime insolence, or your corrective insolence have gone away have dissipated. In other words, he just keeps you steady. However, some people use basil rates to offset indiscriminate eating and snacking that people don't vote for. And so as a result in in the Western world, we tend to run basil heavy, as opposed to maybe in some other parts of the world. In Japan, for example, they run rather basil light, there's less between meal snacking that goes on in some cultures. And there was a study done a few years ago that looked at basil insulin needs in and Japanese children, it found that they were about 30 to 35% of their total daily insulin dose, which flies in the face of you know, the general rule of thumb, which is you take about half of your daily insulin dose is a basil, insulin. So I think that I think there's a general tendency for people to look at blood sugar patterns, and just try to adjust basal rates rather than just to steer them around in a moment. There are there are increases that occur in blood sugar's overnight. And I agree, growth hormone and cortisol, which is another hormone that you produce early in the morning upon awakening can steer your blood sugar's up. And if you're trying to anticipate those in advance and, and and give additional infant espressos that has been something that's been done for many, many years, but generally speaking, most people can do well with either one, two or three basil rates. And a good friend of mine who you may have interviewed Steve Adelman is notorious for saying that anyone with more than three basil rates needs a new endocrinologist. And he can say that he's an he's a, he's an adult endocrinologist with type 1 diabetes almost as long as I've had it, and very well known and respected in the community. And I certainly adhere to his recommendation. Now if I if I see a new patient, it's on five or six basil rates, if I can tell them if you don't eat breakfast, which is what you should be able to do and your your blood sugar's in range. If your base rate set correctly, you'll stay in range more times than not over the next several hours until the next meal. But if all of a sudden you're you start dropping or start going up, well, your basal rate may not be set, right? You may be thinking that it is but it really isn't. But just think about the original intent of a baby, right is to keep you steady. It's not supposed to bring you down, it's not supposed to let you go up. It's just supposed to keep you at where you're at. As soon as the other insolence that would move you up and down, have gone away. And so if I wake up if I'm if I'm traveling through the night at 200, you know, between, say, I go to bed and I go up to 200 at midnight, and I'm at 200 in the morning, my basil rates, okay, that's perfectly fine. It's just that I didn't correct that that height and bring it down. It wasn't that it was going from 200 to 300 to 400. That would have said it was not enough or it was going from 200 to 100 to 50. Over six hours, that would be too much, but that it would just stay steady. That's the purpose of the base rate. It's different versus a bowl with insulin. So the the individual injections of fat that the insulin I know blog, blogger Piedra that used to maneuver up and down another metaphor, a pilot told me that they perfectly understood this concept of sugar serving. He said, you know, he's cruising at 30,000 seats. And you know, he that's what he's that's his cruising altitude. And if he wants to go down to 28,000 feet, he has to take action to make that happen or go up from 28,000 to 32,000 feet in his in his jet airplane, he said, I totally understand the concept of maneuvering, various levels in the base rate is just maintaining altitude, that's all it is. So these rates are sometimes misunderstood. And they're, they're overdone and some people, but I've gotten to the point of just letting people play on the rates they are. And if they can, if they live up to the original intent, and CPU steady in the absence of food, or exercise, then then that's fine. But I find a lot of people don't find that's the case, they find it when they don't add the foods and all the facts in there that the base rate really isn't what they need, they need to be on something more simple. And I try to simplify that whenever I can.
Stacey Simms 31:06
That's really interesting. And while we were talking there, I grabbed my phone, because I take pictures. Anytime I change a pump setting, I take a picture of it, because then I always have it with me, even if my kids pump is not with me, I have I have six programmed into my son's insulin pump. But the funny thing is that three of them, well, four of them really are about the same as the one you know before. So I really, if I really wanted to, I could get it down to three. Tomorrow. That's funny, I never even thought for some reason I never even thought about that. But they're but they're separated by point 0251 of
Dr. Stephen Ponder 31:39
them very subtle, it remember, it takes about an hour and a half to two hours before any, any rate change has a significant effect on blood sugar. So what happens is, if these are very close together, they may essentially just be blending into each other. And there's there's wobble in a pump rate the pump is not, you know, it's accurate up to a point. But even it has some variability built in. And if you factor in air bubbles, and you know, the sides may be leaking, there's there all sorts of things that, that make our diabetes prone to having variants in it, and plus the meters themselves, the sensors aren't 100%, but they at least give you a trend. foods are digested differently every day. There's so many variables. And it's in chapter five of the book, you know, false idols, there's so many variables in our control that you have, you can do nothing but just steer within a range. And I think that's the bottom line whether my blood sugar is exactly right now as I speak 93, or whether it's 95, or whether it's 90, Israel irrelevant to me, it says I'm trending straight, I'm in a zone, which allows me to function normally do my job, have this conversation with you, and not have a worry that I'm going to be dropping in the next 15 minutes or start spiking up in which time I'd have to excuse myself and take a small dose of insulin to prevent that.
Stacey Simms 32:58
Let me ask you another question. And this will be more of a personal one. For me. I did get a question about teenage boys. This one wants to know, what should a teenage boys a one c be? And I'll let you answer that. I think there's a lot of variability there, too. That's so personal. But my question is about teenagers. My son is 11. And he was diagnosed before we turn to so of course, we went through many years, and we did everything. He has a lot of independence. He takes care of himself beautifully when he's on his own. But the last year, really less six months, we've seen some of this teenage goofiness that I've heard from other people sneaking in, in terms of well, I forgot to check. I didn't bring my stuff. And you know, with the hormone levels, we're seeing blood sugars that we haven't seen in quite some time. I'm curious what you tell parents in your practice, you know, what do you do when you're super enthusiastic kid who is very responsible? And does everything suddenly? Is this stinky teenager who's in a different mindset? Frankly, it really it does seem to happen to so many people.
Dr. Stephen Ponder 33:55
Oh, it's actually very normal. That's that's the normal process of adolescence, you know, they, they're no longer you're smiling little kid, they're they're trying to establish their own identity. And one of the first things they do is to start to you know, they're spending more time out of the house or spending time with peer groups, they get into that phase where they want to be like everybody else, and then you don't know what you're talking about. It goes you go through that phase. Now, some people go through that more than others. Some don't seem to go through much at all. But you know, the listeners here are going to, if not in their own families, no other families for you know, the teenagers were just doing great as children, and then they just totally lost interest in any of their diabetes care or their diabetes management No matter how much they knew. And intelligence is not really the issue so much. It's, it's it is a lot of things that that are very unique and very individually as you said, even within a family you can have two or three responsible adolescence and then one that's just totally, you know, irresponsible, even though they they grew up very well adjusted, and they We're very well supported. That's just the normal process of of growing up as a team. I'll say one other thing, though, and I want to make this point clear. You know, a lot of people can can get comfortable with the two year old that grows up to be 11, doing all these things and and the parents can then start to be backing off of it, perhaps more than they should. And I always use this this example. And it's kind of silly example, but I tell parents, would you let your 11 or 12 year old kid with diabetes, pay your bills for you? or drive a car? I mean, some of these 13 year olds are physically capable of reaching all the pedals and driving a car, they have better reflexes in the rest of us. Would you trust them to do that? Well, most parents who say, Well, of course not. And my comeback is, well, you'll trust them with a life threatening disease, but you won't let them pay your bills, you won't let them drive your car. And so it's kind of an interesting conundrum there. It's because you've been lulled into a sense of security, that they've been doing this so long that because they can do the act of doing this, the actions of doing this, the sound of how they had the maturity to do it. It's like me saying, you know, because I hammer a nail a sock aboard, and I'm a carpenter, the carpenter is a set of skills and experience. It's not individual actions, all strung together in diabetes, because it's involving actions like taking a shot, checking a blood sugar, logging something, and even recognizing something higher low, that's a little bit different than organizing things and working through a problem and solving a problem. Most kids are concrete thinkers, up till about age 16. Now, a lot of them can be shown how to do things. And through practice, and coaching, they can learn how to solve most problems. But if you feel a raw concept that a teenager, without any background, just the concept, most will struggle very, very hard to kind of put an answer together to that all but just a small few. That's because kids are concrete thinkers, and about 25% of adults are concrete thinkers as well, that's been proven in the medical literature for years. Diabetes Care, especially surfing does require a lot of abstract thought, you know, those lines that you see on your sensor plot represents something that you can't see feel or touch, you know, if you're measuring the amount of sugar that's, that's present in the four liters, five liters of your blood, and how it's coming and going. And there, there are entry points and exit points. And that's a very abstract thought when you think about it. And you're trying to say, what are the forces that I can use to influence the rate of entry or exit of glucose into that closed space called the bloodstream, even though knowing the body for sugar and other places you're not measuring the sugar in the liver, you're not measuring the sugar in the in the muscles, and that's where some of your sugar pops up in your blood. It's when you stress, you're shoving sugar out of your liver and muscles in your blood. Likewise, it doesn't measure the count the amount of carbohydrates in your gut because they're still in your gut being absorbed and digested, you're just measuring within that bloodstream. In a sense, that's what matters, obviously, because your brain needs drawn sugar, but you're just not you're a flux manager in Sugar Surfingall about managing flux, and drift. And I say that in the workshops, it's in the book. That's what you're doing flux is a rapid upward or downward swing, a blood sugar's drift if something more gradual or slow, and how you learn to do that over time. And as you develop more skills and confidence is what determines your abilities as a sugar surfer. In the end, Dr. Ponder,
Stacey Simms 38:19
let me devil's advocate for just a moment about the the advice to parents. And I guess I'm going to ask you to play a little psychiatrist here. It hardly seems fair to parents, that at the time, when you say they're not ready to drive a car, right at 11, or 12, or 15, or or operate heavy machinery, why would you let them handle their diabetes? It's not fair that that's the age at which they seem the most resistant to input from parents. So as a parent, we know how do you balance that kid who wants to, you know, who's saying to their parents leave me alone, I've got this. And I get dumber as my kids get older, apparently, I know, a lot less than I used to know, according to them, how do you do that? As a parent? How do you say I'm going to help you I'm going to oversee this just when they're pushing back?
Dr. Stephen Ponder 39:03
I think the hardest part is when somebody's managing a child from age two onward. The person who really owns that diabetes is at that point is the parent. And when you're trying to make that transition and letting them manage that, oftentimes, the parent may may take an emotional response, like, well, gosh, you're messing up my diabetes that I've worked so hard to take care of all these years, and they're going to make mistakes, they're going to fall off the bicycle, you got to put them back on. The thing to do is, and I'm not saying you, the parent does everything until they're 16. In fact, on the contrary, that parent needs to become a sharer, they need to be sharing those responsibilities with the kid. And in fact, they should be there with them not to not to lecture them, not to tell them what they're doing wrong, just to be there to support them. And that's that's a very difficult balancing act for some parents who become accustomed to handling all the decision making, judging everything that goes down and in telling the child what to do and child's obviously pushing back. That's the whole point of adolescence is to break away from the family. And diabetes is caught in the middle of that. So the research and this is this is work that's been done by Barbara Anderson and others, good friends of mine is that shared responsibility up until around age 16 is the key doesn't mean doing things for them. But being there with them, you're still providing them the supplies, you may still be reminding of the things, but you need being there and letting them do it with your you know, with your guidance, or maybe your just your presence is all as necessary, especially, for example, in your case, your 11 year old sounds very capable and very potentially independent. But he would still benefit from having you there in the room, when you're when you're, you know, checking blood sugars and our dosing or making dosing decisions inside you have any questions and he doesn't well, then fine, but at least you know, it's been done. And it's and it's a shared responsibility. He also knows you care, at that point is as well, as opposed to saying, Hey, this is your responsibility, you gonna live with this rest of your life, I've heard that a million times from people that, you know, parents would want to drop that off and a 10 or 11 year olds lab, expect them to man up or woman up to do this. And all they're doing is, is setting a kid up to fail long term. Yeah, they may do it for a few months, or maybe a year or two. But at some point, that adolescent phase kicks in, and they start taking they started risk taking doing some, some experiments and so on. And that's what adolescence is about it is about risk taking. And that risk taking could include skipping insulin doses, eating more food, not checking blood, sugar's all those things, you know, and it can, if the parents aren't there, at least to support them, that's more likely to occur. That's, that's what I've seen over the 30 years, I've been doing this.
Stacey Simms 41:43
Thanks for talking about that. I think that is a really, really important piece of information to keep in mind. And you know, you are a pediatric endocrinologist. I know so many adults do so well with sugar surfing, but I want to pick your brain for one more question if I could, for the parents. And that is, it seems to me, you know, I am I am not a medical professional. But it just seems to me that there is more fear out there for parents than evolute when my son was diagnosed nine years ago. And I think some of that has to do with social media and how things kind of get spread and and rumors get started and different things get out there. But what do you tell your patients, parents about fear? And I guess I'm talking about, you know, overnight, checking every hour or letting kids go on sleepovers or things like that, or even just the the kind of fear that isn't specific in that way? Do you talk to your parents, your patients parents about that?
Dr. Stephen Ponder 42:34
Oh, yeah, I completely agree with you. The rise of social media allows one isolated story at any point in the globe, to go viral, and then frighten everyone else on the planet. You know, in regards to the you know, the one that everybody worries about is the severe hypoglycemia, the so called dead in bed syndrome thing. And then I see this all the time on social media. In fact, I've gotten out of several groups for that out there, because it just does nothing more than whips people up into, into a frenzy that this is going to happen to their child. I've been taking care of kids for 35 years, and I have had people that have passed away from diabetes that are friends that were adults, and some of them that are from two or three of them are eight to say this, we're from suicide. Another was from another was was from severe hypoglycemic event, this individual also had some other hormone deficiencies that made them more prone to have a problem, they were an adult as well. But in general is exquisitely rare. In some cases, and this is never discussed, you never see the details and the stories. Sometimes, some of these kids, these kids can have struggle with their control may not have the proper education or training. Some have some haven't. But you never know. And you really can't question that when when when you get a story like that online. So you have to just take it at face value that such and such loss your life and in there's no way of escaping the fact that that's tragic, completely, totally agree nobody should lose their life to this disease under any circumstances in childhood or even young adulthood In my opinion, but it does happen. People, you know, people have bad outcomes, but it's not something that hangs over my head every night. I try not to hang it over anybody else's head in my practice, and but it really does define people's concerns. I do know that that same fear is oftentimes leveraged as in a way to raise funds for diabetes as well. That's something I've been long critical of. And I've said that to many parents in the privacy of the clinic room that that you know, being told it we're gonna save you from disease we're gonna kill your kid really upsets me quite a bit because my goal for anybody with diabetes is to live a normal life you know, it has nothing to do with a one sees it's really being able to be the person you want to be the God meant you to be. And that's what What I aim for and anything I can do to help you achieve that through coaching knowledge, that's sugar serving whatever, people have to make their own choices, but I've not found fear to be a good motivator. In the long term for for achieving that goal. It's really trying to empower people to teach people they can take charge of this if they want to. But it's their choice. And I'm totally a believer in choice. It's all riddle to the book. It's all choice choice choice. I managed people who have chosen to do only so much with their diabetes, as much as many people listening to this and think that was the otter crazy, it happens all the time. And there are other people who, who spend their whole day managing this. And, to your question earlier about, you know, maintaining sanity, yes, you have to maintain a balance in your life, you know, watching your diabetes constantly throughout the day is not normal. You've got to have some balancing point out there, whether you're a parent or an adult with diabetes, but but fear is my one of my greatest
enemies. And, you know, the, quote, the famous, you know, Roosevelt, you know, you know, all we have to fear is fear itself. And that's very true. My parents were not fearful of hypoglycemia when I was a kid, but we didn't maintain the kind of control we're trying to maintain now, either. And so there was never a thought given about passing away. The fear back then was complications. And privately, my parents, and I even thought that I wouldn't live to see, you know, young adulthood. That was what they knew back in the 60s, because it's all based on information from the 20s 30s and 40s, which was not terribly good at that point. But over the years, I've learned what that was all, you know, that was all just myth and misconception on my part, because now, you know, now I've had it for 50 years, and I hope to have it you know, for many more years to come, I have beat this disease, anybody who's lived any length of time has beat this disease. In fact, I use this I say this to parents all the time, in the in the natural world order, I should have died 50 years ago, I should have you know, without insulin, but thank God that we I live in the era that I live in, I live in the country la live ended, I have access to the supplies I need. And I have the intelligence and the access to the resources, not that not everybody has I realized in this world to take charge of this but but missing element is that desire to do so. And I've been fortunate to have that desire. And I try to, I try to promote that, that attitude with anybody I come into contact with, whether it's a patient or a friend, or an acquaintance that has diabetes, but ultimately, we all have to make our own choices. And we all have to live with the consequences of those choices.
Stacey Simms 47:37
That's fantastic. I mean, what a statement as you're celebrating or marking, I'm not quite sure what the word is. But I'll say celebrating 50 years with type one, what when, when you look to the future here, what excites you? I know, are you testing a new kind of insulin? Do you look at different kinds of equipment, what what excites you about diabetes care, and in the next 50 years,
Dr. Stephen Ponder 47:59
my feeling is that the more we can educate, teach and provide support to people with diabetes, the better off the world will be, I'm seeing a troubling trend of late have more of an emphasis on technology and devices and new drugs, as opposed to investing more time and quality education, self management education, because it said before, you know, it all comes down to the choices we make, hey, I'm using a new insulin now that just happened to come out recently. It's an insulin degludec it has a much smoother action curve for me as a type one adult, I don't have any glows at night are even close to lows at night, which is one of the known consequences of that medication. downside is it's a new drug, which means it's more expensive. I'm excited about all the work that's going on with you know, encapsulation projects for islets were for artificial pancreas is and so on. My only concern is cost of these things and costs in terms of investment in time to the patient as well as money, and who will pay for these things. And I foresee there being almost this this multi tiered level of patience in the future of people, the haves and the have nots, as as our cure, quote, unquote, you know, becomes more and more costly. But you know, I say this to parents all the time about the word cure. The word cure is Latin, it comes from the word Curie, which actually means to care, that to be concerned for or to attend to. And in that literal sense of the word cure. I've been curing diabetes for 50 years and anybody who's still alive listening to this, and has diabetes has cured diabetes since they were diagnosed. The Romans never really understood disease in the sense that we understand it today. So they just felt that if they just took care of you just you know attended to your needs, that you would your body would would heal itself. And in a way, you know, the daily care I've been taking since March 1 1966. In terms of insulin dosages, checking my blood sugar or urine sugar back in those days in some fashion and making some decisions primitive as they were back in the 60s 70s and 80s, more advanced as they are now in the in the in the in the new millennium, is why I'm still here. And that plus the grace of God that I've not had an accident or had some other illness befall me. Those are the things that and I'm very thankful that I'm just happy I wake up every morning, I really am grateful when I get up every day, knowing that I beat this disease for half a century, and there are people that never had diabetes that haven't lived that long. And I live longer than so I have nothing but grateful I am nothing but grateful. I don't waste my time, being resentful being mad at this disease. I'm totally at peace with it. I know people still struggle with it, who are listening to this. I can't tell them they should be at peace. That's something yet that's a very personal thing to say. But I am I'm very much at peace with this. And if I pass Tomorrow, I will say I thought that my life was well lived with or without diabetes.
Stacey Simms 51:05
Dr. Ponder, I can't thank you enough for joining me, I was looking forward to an interesting discussion about blood sugar maintenance techniques. And instead, I just feel like talking to you has been a light today. Thank you so much for sharing so much time with me and with my listeners. I really appreciate it.
Dr. Stephen Ponder 51:23
Thank you. Thank you much for your time as well.
You're listening to Diabetes Connections with Stacey Simms.
Stacey Simms 51:36
I told you at the top of the show that Dr. Ponder has a free copy of sugar surfing for newly diagnosed families for newly diagnosed people. And that information is at Diabetes, Connections calm or hopefully linked up in the show notes as you listen on different podcast apps. One of the funniest things for me going back and listening to these older episodes. This is five years ago now is the terror in my questions about the teen years and Benny Benny is 11 years old when this interview happened. He is now 16. And I gotta tell you, middle school was the hardest. You heard me talking about there but is a Wednesday inching up and it's insolently it's going way up and his brain fog. And that was all in middle school. I can't say it's been completely smooth sailing since then. Because when is diabetes ever smooth sailing, but it certainly wasn't the, quote teen years as much as the tween years for us that were an issue. Of course, we're not at the teen years yet. So I probably shouldn't say anything, I'll knock some wood and will knock on my head and all that good stuff. All right, coming up next week, I'm going to be talking to a family with a child diagnosed during the pandemic. Can you even imagine? It's hard enough to have your toddler she was three years old, this little girl diagnosed at all. But when you can't meet up with other families in person, you can't go to conferences, you're isolated at home. There's so many families that this happened to in the last year. And I'm grateful that they decided to share their story. So we will be talking about that next week. thank you as always to my editor, john Buchanan. It's from audio editing solutions. Thank you so much for listening.
Unknown Speaker 53:02
I'm Stacey Simms.
Stacey Simms 53:03
I'll see you back here in just a couple of days until then, be kind to yourself.
Diabetes Connections is a production of Stacey Simms Media. All rights reserved. All wrongs avenged