Dr. Steven Ponder: TLCDBU-2016

1. 4/23/2016
1
Stephen W. Ponder MD, FAAP, CDE aka “Dr. Juicebox”
Like “The Power Within by Stephen Ponder MD, FAAP CDE”
Like “Sugar Surfing” sugarsurfing.com
Concepts and Basics
The handout file for today’s talk will
be posted online …
Sugar Surfing™ materials are copyrighted

2. 4/23/2016
2
Opening prayer
Holy Father, please give me the strength to manage my diabetes or
the diabetes of my child to the best of my abilities.
Give me patience and the resilience to better understand diabetes.
Steer me away from the paths of arrogance and self righteousness.
Help me to appreciate the value of each day, each hour, each
moment.
As your servant and in your Holy Name we pray, Amen
“The two most
important days in
your life are the day
you are born and the
day you find out
why”
– Mark Twain

3. 4/23/2016
3
Sugar Surfing? Oh my! What is that?
Defining “Sugar Surfing™”
It’s a metaphor for “Dynamic Diabetes Self-Management”.
Sugar Surfing is learning and understanding how to direct or steer
your own unique pattern of glucose responses ‘in the moment’ using
frequent pattern management
Sugar Surfing goes beyond fixed insulin dosing formulas, basal rate
profiles, sliding scales, carb counts and temporary dosing
adjustments. It is not dependent on what you eat, how you take
insulin, or even how old you are.
Sugar Surfing requires patience, consistency and resilience to master.

4. 4/23/2016
4
United States
Canada
Spain
Malaysia
Norway
Australia
New Zealand
China
Finland
Sweden
Turkey
Belgium
Ireland
Scotland
U.K.
We stopped counting after 30
countries...thousands sold
Taiwan
Panama
Israel
Puerto Rico
South Africa
Italy Croatia
Lithuania
Argentina
Poland
South Korea
SwitzerlandRomania
On Amazon (book and e-book)
This is Sugar Surfing…
7.2 mmol/L

5. 4/23/2016
5
And this is Sugar Surfing…
4.9 mmol/L
4.3 mmol/L

6. 4/23/2016
6
5.6 mmol/L
6.8 mmol/L

7. 4/23/2016
7
6.6 mmol/L
5.6 mmol/L

8. 4/23/2016
8
Sugar Surfing
6.3 mmol/L
0.6 U/hour Novolog
140 mg/dl
60 mg/dl
Sugar Surfing
5.7 mmol/L
7.8 mmol/L
3.3 mmol/L

9. 4/23/2016
9
* The point is that every “day of surfing” is
never exactly the same: variance is expected
6.8 mmol/L
And some days can be “tighter” than others
5.1 mmol/L

10. 4/23/2016
10

11. 4/23/2016
11
A great day of surfing

12. 4/23/2016
12
Sugar Surfers are in many countries

13. 4/23/2016
13
mmol/L
Which one uses an insulin pump?
A B
4.54.3 mmol/L
mmol/Lmmol/L
Which person has diabetes and which one does not?
A B
5.15.1

14. 4/23/2016
14
Which user is non-d?
A B
But…this is Sugar Surfing too…
5.1 mmol/L

15. 4/23/2016
15
is a process, not a recipe
4.4 mmol/L
1.0 U glulisine
@1:15AM
2.0 U glulisine
@4:20AM
“Shaping and Steering” the BG trend line

16. 4/23/2016
16
6 U Humalog
Double burger
10U Humalog
Why Sugar Surfing is a paradigm shift!
Insulin doses based on “in the moment” BG trends
where actions are taken at “earlier” sugar thresholds
5.6
It’s amazing what you can ‘see’ when
you know what you’re looking at.
Would your doctor know how to interpret all this?

17. 4/23/2016
17
missed
delta
wave
BG 222 mg/dl
8 U Humalog
BG 219 mg/dl
7 U Humalog
Food
22 gm CHO
Re-calibrated
“Stop and drop” (advanced)
pivot
lag
shelf
drop
mmol/L
More reasons Sugar Surfing™ is a Paradigm shift
Pattern Management Logbook: Backward looking. Reactive.
No way observer (e.g., doctor) knows the “situation” at each
BG check point. Focused mainly on changing insulin doses.
This presumes data is collected and reviewed frequently too.
Sugar Surfing Trendline: Forward looking. Reactive AND
proactive. Situationally dependent based on trends. Focuses
on holistic diabetes care “in the moment”. Doc not required.
This presumes frequent glances and applying SS principles.
Forward looking…Backward looking…
Sugar SurfingPattern Control
4.3 4.3

18. 4/23/2016
18
Sugar Surfing exists at the intersection of….
thinking
static vs. dynamic diabetes care contrasted
static
• Actions are predetermined and
often based on fixed algorithms
• Minimal flexibility: RIGID
• Results don’t immediately affect
subsequent actions
• Easier to instruct/learn
• Less time-intensive
• Favors concrete thinking
• Less motivation needed
• Less aggressive
dynamic
• Actions are dependent on
situation/circumstance
• Flexible and adaptable
• Results constantly influence
subsequent actions
• Training needed, plus reinforcement
• More time intensive
• Favors problem-solving
• Requires ongoing motivation
• More aggressive

19. 4/23/2016
19
Sugar Surfing: Myth versus Reality
Myth
• It’s only for adults (or kids)
• Requires an insulin pump
• Doesn’t apply to low carb users
• You must own a CGM to Surf
Reality
Persons of ALL ages Sugar Surf
Works with shots (MDI) or a pump
Works with any food preference
Works with frequent BG checking
Replace ‘static diabetes thinking’ with
‘dynamic diabetes management’ (aka Sugar Surfing)

20. 4/23/2016
20
present‘recent’ past ‘immediate’ future
Actions Actions
“IN CONTROL”
Conceptual framework for Sugar Surfing™
Example: Proactive-Reactive

21. 4/23/2016
21
Proactive-Reactive
P P P P RR
R = Reactive
P = Proactive
MDI: Lantus/Humalog
Proactive-Reactive
P P P R R
R = Reactive
P = Proactive

22. 4/23/2016
22
Largely reacting here
R = Reactive
P = Proactive
P P P PRRR
What have we learned?
• It’s “Dynamic Diabetes Self Management”
• aka “Management in the Moment”
• It’s a process, not a formula
• Insulin is required, but how you take it is totally
up to you (pump or injections)
• CGM not required…but makes it MUCH easier
• Surfing leverages dynamic thinking in both
proactive and reactive ways
• Sugar Surfing is a true paradigm shift in d-care

23. 4/23/2016
23
So…can kids sugar surf too?
Toddler with T1D 6 weeks
Next morning after stopping bedtime
Lantus the night before
Next morning 2 days after stopping
bedtime Lantus (off insulin)

24. 4/23/2016
24
7 year old American Sugar Surfer
5.7
“KDA not DKA”
6.8

25. 4/23/2016
25
13 yo Sugar Surfer
14 y.o. surfer at diabetes camp

26. 4/23/2016
26
A 7 year old Sugar Surfing in Canada!

27. 4/23/2016
27
Yes…type 1 d-kids CAN surf

28. 4/23/2016
28
4 Basic CGM Elements
1.Transcutaneous sensor
(penetrates skin)
2.Wireless transmitter on sensor
3.Display unit/receiver
• Gives readings every 1-5 min
• Trend lines for 1, 3, 9, 24 hrs showing BG path
• Trend arrows
• High and low alarms
4.Software to download &
analyze data
4.7
mmol/L
I’m a CGM
sensor tip
I’m an insulin
pump catheter
tip

29. 4/23/2016
29
Sensor size
8 versus 1440 “decision points”
7:03 115
9:33 129
12:15 95
3:34 131
6:12 168
9:49 107
11:53 114
3:05 132
*
*
*
*
*
*
*
*

30. 4/23/2016
30
But this is also where the data can go to now…
Or here…

31. 4/23/2016
31
Or here…
Delta wave
’X’ units rapid-
acting insulin
‘Y’ grams of
fast-acting carbs
steady steady
Sugar Surfers learn how to fill in the ‘X’ and the ‘Y’ to steer the trend line

32. 4/23/2016
32
100 mg/dl
120 mg/dl
140 mg/dl
160 mg/dl
180 mg/dl
80 mg/dl
60 mg/dl
40 mg/dl
“Direction affects correction”
At IDENTICAL
levels using a BG
meter, your next
actions can be
ANYTHING based
on the DIRECTION
of FLOW
Treat a high
No action needed
Treat a low
time
Point
“A”
Point “B”
sugar trend
Insulin “correction”
Carb “correction”
~ 2 hours for insulin
~ 15-30 minutes for carbs
Range of possible
BG outcomes
“the trend is your friend”
Blood glucose level

33. 4/23/2016
33
100 mg/dl
120 mg/dl
140 mg/dl
160 mg/dl
180 mg/dl
80 mg/dl
60 mg/dl
40 mg/dl
“Deflect and correct”
2
4
5
7
Practicing lower pivot points can/will lower the flux
…and lower the A1c
time
Important concept : turnaround time
Corrections often need to be adjusted 10-20% to compensate
13.9
4.4
13.9
4.4

34. 4/23/2016
34
Goal: Try to stay between the lines
As your skills improve, adjust your action thresholds…

35. 4/23/2016
35
Basic microbolus
1 U Novolog
@ 4AM
120 mg/dl
[6.7 mmol/L]
0.65 U/hour basal rate via pump
1.75- 2 hrs
6AM calibration
read 93 mg/dl
[5.2 mmol/L]
5.2
22
18
14
10
6
2
Basic microbolus
1 U Novolog
@ 4AM
120 mg/dl
[6.7 mmol/L]
0.65 U/hour basal rate via pump
1.75- 2 hrs
6AM calibration
read 93 mg/dl
[5.2 mmol/L]
5.2

36. 4/23/2016
36
Basic pivot
4 U Novolog
@ 10PM
Steady basal
0.65 U/hour basal rate via pump
lag
2-3 hrs
140 mg/dl
[7.8 mmol/L]
5.4
Correction or
“nudge”/drop
dose “X” units
lag
SUGAR SURFING ESSENTIAL: “TAKING THE DROP”

37. 4/23/2016
37
Basic drop
0.65 U/hour basal rate via pump
3 U Novolog
@ 4AM
6:27AM calibration
read 90 mg/dl
[5.0 mmol/L]
2.5 hrs
lag
5.0
140 mg/dl
[7.8 mmol/L]
4 U at 4:08AM

38. 4/23/2016
38
“X” Units rapid
insulin
2 hours
lag
Steady basal effect
Classic Sugar Surfing maneuver: “taking the drop”
0.65 U/hour basal rate via pump
1.5U Novolog
@ 3:23 PM
BG 125 mg/dl
[6.9 mmol/L]
lag Steady basalSteady basal
mini-pivot
2.5 hrs
5.6
140 mg/dl
[7.8 mmol/L]

39. 4/23/2016
39
Delta
wave
2.5 U Humalog
Mini-Pivot
BG 124 mg/dl
12U Tresiba (basal)
delta wave
2.5 U Humalog
BG 124 mg/dl
Mini-Pivot follow through

40. 4/23/2016
40
Where is the mini-pivot?
calibration
2 U Humalog
lag
duration
T
mini-pivot
delta wave
The heart of ultra tight blood sugar control:
The mini-pivot

41. 4/23/2016
41
0.65 U/hour basal rate via pump
4 GM Carbs
@ 6:44 PM
BG 79 mg/dl
[4.4 mmol/L]
mini-carb pivot
5.3
140 mg/dl
[7.8 mmol/L]
Delta wave
BG 80 mg/dl
8 gm carbs
8 gm carbs
Carb Pivot
BG 70 mg/dl

42. 4/23/2016
42
Delta wave
BG 80 mg/dl
8 gm carbs
8 gm carbs
Carb Pivot with follow through
Slow BG rise from
dinner @ 8PM
BG 157 mg/dl
5 U Humalog
‘Shelf pattern’
after prior
correction. BG
rising again.
BG 150 mg/dl
5 U Humalog
“shelf” effect
15 G carbs
Same dose,
different results
Insulin action
Lingering BG effect of
8PM meal
“Shelfing”

43. 4/23/2016
43
3 units Humalog
BG 114 mg/dl
[6.3 mmol/L]
8 gm glucose
BG 78 mg/dl
[4.3 mmol/L]
Two step pivoting
Step 1: set alert threshold
Step 2: wake up at alert and glance
Step 3: notice delta wave
Step 4: decide to act…or wait
Basic Night Pivot “by the numbers”

44. 4/23/2016
44
Step 5: acted. dosed @ 2:54 AM (4U lispro)
Step 6: raise the lower alert if needed*
Step 7: watch and wait…
Step 6: the lag and pivot occurred
lag
shelf
2 hr 20 min
pivot
delta
Basic Night Pivot “by the numbers”
4
* Optional
Basic Night Pivot “by the numbers”
Step 8: got up and showered.
Step 9: after 3-4 hours, BG plateaued
action
no action

45. 4/23/2016
45
What do you see here?
6 U Humalog
44
7 U Humalog
I I
food

46. 4/23/2016
46
6 U Humalog
44
7 U Humalog
I I
food
7 U Humalog
In and Out Burger
“Double-Double”
It’s all about
matching
food and
insulin.
Remember
your
“top ten”
approach!
Basal insulin: 13U Tresiba

47. 4/23/2016
47
Double double burger
7 units Humalog
Why Sugar Surfers PRACTICE THE “TOP 10” CONCEPT
39 gm carbs
12U Tresiba (basal)
0.65 U/hour basal rate via pump
1 U Novolog
@ 12:32 AM
BG 125 mg/dl
[6.9 mmol/L]
3.5U Novolog
@ 9:39 PM
BG 141 mg/dl
[7.8 mmol/L]
6U Novolog
@ 7:32 PM
BG 97 mg/dl
[5.4 mmol/L]
Steady basal
60 gm
carbs
Insulin-food mismatch and recovery
5.0
140 mg/dl
[7.8 mmol/L]

48. 4/23/2016
48
Delta wave
shelf
drop
5U Humalog
shelf
sleep awakeawake
L
Basal insulin: 12U Tresiba
176 mg/dl
2 hr
Basic Sugar Surfing™
Please start looking for these things
d d
ds ss s
Deltas, pivots and shelves
Can you see them?

49. 4/23/2016
49
™
Like The Power Within by Stephen Ponder MD, FAAP CDE
facebook.com/stephenponderMD

50. 4/23/2016
50
To unleash your …
Let go of…
• Judging yourself
• Feeling defective or broken
• Shame
• Fearing the future
• Isolation
• Pity
• Doubt/guilt
Embrace/cultivate…
• Acceptance
• A sense of normalcy
• Openness
• Enjoying the moment
• Teamwork
• Empowering/supporting
• Self-confidence

51. 4/23/2016
51
3 virtues of the well
managed
Sugar Surfer
“I’ve missed more than 9,000
shots in my career. I’ve lost
almost 300 games. 26 times I’ve
been trusted to take the game
winning shot and missed. I’ve
failed over and over and over
again in my life. And that is why
I succeed.”
Michael Jordan

52. 4/23/2016
52
Hang in there. Don’t give up!

53. 4/23/2016
53
Appreciate the flux of sugar levels in non-d persons
11.1
8.3
5.6
2.8
Glucose(mmol/L)
Average BG = 5.4 mmol/L
Remember: is all about managing…

54. 4/23/2016
54
“Flux and Drift”
4.3
140 mg/dl
[7.8 mmol/L]

55. 4/23/2016
55
“Life is not a matter of holding good cards, but
of playing a poor hand well.”
R.L. Stevenson (1850-1894)
“But Sugar Surfing stacks the deck in your favor”
S.W. Ponder (1956-present)
Diabetes care is about

56. 4/23/2016
56
Sugar Surfing requires the following…
1. A working knowledge of some basic
principles/concepts
2. Maintaining situational awareness
3. The ability to adjust to changing or
shifting conditions/circumstances
LIKE….
• Driving a vehicle
• Flying an airplane
• Walking a tightrope
• Surfing
Sources of variability
• Process of human digestion
• Human glucose metabolism
• Physical activity/exercise
• Blood glucose meters
• Insulin onset, peak, duration
• Insulin to carbohydrate ratios
• Insulin correction factors
• Stress
• Infections/illness/other meds

57. 4/23/2016
57
A pancreas can’t predict the future…
• But it acts so fast it doesn’t need to.
• Can shut off insulin immediately
• Can release premade insulin
• Insulin it releases start working in
minutes (plus other things)
• Can rapidly respond to changes in
sugar levels
• It’s the ultimate Sugar Surfer!
4 day non-diabetic CGM plot
“the only person with a straight line blood sugar is a dead person”
Ponder, 2008

58. 4/23/2016
58
Five practical a-dvanced diabetes care tips
1) Better synchronize insulin action with food action
2) Know your blood sugars 2-3 hours after meals
3) Correct all out of range sugars you discover (“treat to target”)
4) Aim to get morning blood sugars into target range (F-F-F)
5) Assess/analyze your own blood sugars constantly
This used to
be my job!
Ponder’s
pancreas
Diabetes is best approached 1 day at a time
5.1 mmol/L
120 mg/dl
[6.7 mmol/L]
60 mg/dl
[3.3 mmol/L]

59. 4/23/2016
59
Diabetes care must be individualized
“Chance favors the prepared mind” Louis Pasteur
…dude

60. 4/23/2016
60
“I haven't failed. I've just found 10,000 ways that won't work.” Thomas Edison
Thomas Edison (Considered that greatest inventor of all time, 1846 - 1931): Embrace your inner scientist/inventor
Five things to remember about T1D
1) Diabetes care isn’t a contest. It’s overrun with numbers. Don’t judge.
2) Let the remaining guilt (if any) go! NO one is perfect.
3) Diabetes care is not an action, it is a SKILL SET. Therefore, it can be
practiced and improved upon. Control exists “in the moment”
4) “Control” is the result of your decisions and choices. This applies to
minute to minute control as well as long term control.
5) NO health care provider “manages” anyone’s diabetes. They never can
and they never will. It’s a self managed condition.

61. 4/23/2016
61
5.6 mmol/L
©

62. 4/23/2016
62
Thank you!
I hope you learned something today

63. 4/23/2016
63
mmol/L
mmol/L
Basal checking…always
Look back….

64. 4/23/2016
64
mmol/L
1 unit Novolog
@ 5:07 AM @120 mg/dl
A small micro-bolus nudge
mmol/L
3 units Novolog
@ 6:29 AM @106 mg/dl
28 gm CHO
@ 6:52 AM (92)
Timing a dose and meal
The “bend”

65. 4/23/2016
65
mmol/L
2 unit Novolog
@ 8:02 AM @126 mg/dl
76 mg/dl
4 gm
9:19
65 mg/dl
4 gm
10:45
69 mg/dl
4 gm
10:30
“Overnudging” and micro-carbing
mmol/L
2 unit Novolog
@ 12:19 PM @ 71 mg/dl
28 gm CHO
@ 12:25PM (70)
Timing a dose and meal

66. 4/23/2016
66
mmol/L
81 mg/dl
4 gm
3:05PM
82 mg/dl
4 gm
4:11
micro-carbing
28 gm CHO
@ 12:25PM (70)
mmol/L
6.0 units Novolog
@ 8:08 PM @ 113 mg/dl
3.0 units Novolog
@ 8:54 PM @ 89 mg/dl
Dinner: Soft Shell Crab/Roll
82 mg/dl
4 gm
4:11
1.5 units Novolog
@ 7:51 PM @ 113 mg/dl

67. 4/23/2016
67
mmol/L
Another day

68. 4/23/2016
68
Remember: You DON’T need an insulin pump to Sugar Surf!
It’s all about PIVOTING
20 units Lantus @ 9PM
Humalog as needed
Carbs as needed
5U Humalog
8U Humalog
Fried chicken,
mashed potatoes,
green beans
I-duration
I-duration
4U Humalog
Food duration
Fried Chicken dinner and associated insulin approach
20 U Lantus @ 9PM
“free range” eating using a dynamic management style

69. 4/23/2016
69
mmol/L
2U @ 5:54
1U @ 4:44
7.5U @ 7:52
3U @ 11:28
3U @ 6:52 2.5 U over 5 hr
Combo bolus
Fajitas, chips
& queso dip
?
0.650 U/hour pump basal rate (Apidra)
28 g 28 g
8 4
48
 Calibrations (in range)
 Basal (in range)
 Micro-dosing (carbs/insulin)
 Mystery BG surges (?)
 Combo bolus used
™
2U Humalog
@ 2:48 AM
12U Tresiba
7U Humalog
@ 6:45 PM
Fried chicken (thigh, 2 drumsticks)
Cream gravy
Green beans
Fried okra

70. 4/23/2016
70
Do I need to be on an insulin pump before using a CGM?
• No, you can be on injections (MDI) too
Must my diabetes be present for a period of time first?
• No
Do I have to wear it all the time? Can I take a break?
• Yes, certainly
Can I reuse a sensor?
• Yes. But the company does not condone it.
CGM Frequently Asked Questions
Can children use these devices?
• Yes. FDA has approved them for as young as age 2
CGM Frequently Asked Questions
Do US insurance companies cover these?
• Yes. Usually
Does Medicaid/Medicare cover these devices?
• Not generally but there have been some successes reported
Do I need special training to start using a CGM?
• Ideally yes. There are tutorials for how to get started. But a live trainer is best

71. 4/23/2016
71
Sugar Surfing: 1 month Proof of Concept
6 month CGM data summary
Average BG = 103 mg/dl
Standard deviation = 34 mg/dl
Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value

72. 4/23/2016
72
Sugar Surfing principles to live by…
• Get out in front of the sugar wave or drop (be aware)
• Practice micro-dosing at higher baselines to start
• Remember your successes, memorize your failures
• If the wave (or a drop) gets in front of you, be patient, attack it and
take the drop or the rebound
• Rearrange your food order based on the glucose situation
• Master nudges and shoves: they are at the heart of surfing
• Set and refine your personal “action thresholds”
• Calibrate and basal test daily

73. 4/23/2016
73
mmol/L
3 U Novolog
28G
carbs
3 U Novolog
2 U Novolog
0.6 U/hr basal rate0.46 U/hr
Engine brake
90 min120 min

74. 4/23/2016
74
A
B C
D
E

75. 4/23/2016
75
delta
Insulin
pivot
Effective duration
of insulin action
drop
A
B
C
D
E
Test your basic understanding of Sugar Surfing

76. 4/23/2016
76
mmol/L
0.6 U/hr Novolog
5 U Novolog
3 U Novolog
Answer: do nothing (wait)
MEAL
5 U Novolog
0.6 U/hr Novolog
3 U Novolog
What would you do here?
a) “Nudge” insulin dose
b) Raise basal rate
c) Nothing a
MEAL
mmol/L
mmol/L
What is this called?

77. 4/23/2016
77
mmol/L
What is this called?
mmol/L
What’s the message of this image?

78. 4/23/2016
78
mmol/L
What’s this image saying?
(hint: look at the time)
mmol/L
What does this image tell you?

79. 4/23/2016
79
mmol/L
What is this called?
mmol/L
What is it a good time for and why?

80. 4/23/2016
80
Penny stock day trading strategy
©

81. 4/23/2016
81
Thank you!
I hope you learned something today