This is a bit of a departure because I don’t blog very often about my daughter’s diabetes, but I wanted to give a book review of a book I read recently, Sugar Surfing by Dr. Stephen W. Ponder.
A little background info so you know where I am coming from: My now 13yo daughter was diagnosed with type 1 diabetes (T1D; aka juvenile diabetes or insulin dependent diabetes) almost 12 years ago at age 19 months. I think we are fairly diligent D-parents though I don’t claim to be an expert by any means (and nothing I say here should be taken as medical advice). My dd was on multiple daily injections (MDI) of NPH, humalog, and ultralente for the first nine months after diagnosis, then pumped using the Cozmo (RIP Cozmo) insulin pump for 5 years and then when back to MDI (Levemir and Novolog currently) by her own choice for the last 6 years or so. She has been using the Dexcom Continuous Glucose Monitor (CGM) for about 18 months now.
Dr. Ponder is an endocrinologist specializing in diabetes care and has had T1D himself for quite a number of years. The main thrust of his book is to discuss how one can best manage blood glucose (bg) levels of a person with T1D using the relatively new technology of CGMs. As such it fills a much needed gap in the literature out there on dealing with T1D.
My overall recommendation is that anyone with T1D or helping to care for someone with T1D should get this book and read it. I would particularly recommend it to those new to T1D and those who may have more experience but who are using CGMs. I do, however, have some hesitations about the book which I will get to.
Sugar Surfing is written in a conversational style and begins by discussing the author’s own experiences with T1D, having been diagnosed in the days before fast acting insulins, pumps, and even home bg testing. I love these sorts of stories so I found these bits rather interesting. One intriguing tidbit arising from this part of the book is that Dr. Ponder, while clearly knowing well that diabetes care has advanced leagues beyond how it was in his youth, seems nostalgic for those earlier days. In particular, he mentions how much less stress was involved in caring for diabetes way back when because one couldn’t know or even attempt to control all the many numbers involved. I kind of get this and I think it’s an interesting observation. It could be good to think more about how the pressure on those with T1D and those caring for them (particularly parents) may have increased with the advances in care without perhaps the same degree of increase in the support and understanding these people need.
Which brings me to what I think is the biggest contribution of this book — Dr. Ponder does a wonderful job of laying out all the factors that can influence bg and of showing how very uncontrollable it can be. My own experience was that when my very small daughter was sent home from the hospital we were told “do this and this and then her bgs will be this and that.” And then we got home and she was in the 300s for the first few weeks and we thought we were complete failures. I understand why the staff wanted to make it sound simple for us, that they didn’t want us to be overwhelmed at the start. But we were also misled in many ways and the result was confusion and a sense of failure. I think this is not an uncommon experience. I really wish I had had Ponder’s book much sooner. Though over the years, I have learned how very uncontrollable T1D can be on my own, I would definitely recommend reading the earlier chapters on all the influences on bg one has to try to cope with to anyone new to the world of T1D. It may be daunting, but it is realistic and that, I think, is a very good thing.
One of the quibble I have with Dr. Ponder, however, is in how he talks about our ability to control all those numbers. I find he is a bit inconsistent of this point. On one hand, he outlines all the influences on bg, many of which we clearly cannot control (eg. growth hormones, stress); on the other, he makes statements like this:
“In fact, almost any of the ever present forces that influence one’s blood sugar level can be managed with Sugar Surfing principles.” (p. 44)
“Control” is a big word in the diabetes world. We speak of “controlling bgs” after all and doctors (and nosy family members) ask us things like “how is your control?” The comforting part for me in the first part of this book is how Ponder makes me feel like there is so much I can’t control. But then he turns it around and really makes it about controlling again after all.
(Warning: if you don’t like religious talk, skip this bit.) One of the things I say on this blog is that our worldviews (though I hate that term) are important; they affect everything we do and even in a book on something as seemingly practical as bg control, they seep through. A big part of what I have learned from my dd’s T1D is that I cannot control everything — not even these things that are very essential to keeping my child alive. It is not that I say “Oh, I can’t control it therefore I am not going to try.” I do not use the fact that these things are so hard (or even impossible) to control as an excuse for bad bgs. Instead, I do everything I can and leave the rest to God. Because He can and does control everything. My take on this book would be that Dr. Ponder has looked at these same factors which make bg so hard to control and he comes away still trying to control them. How does he do this? Well, on one hand he has certain principles and tricks he uses (which he gets to in the latter half of the book). But he also relies on himself:
“Ultimately, you must believe in yourself and your equipment. Tapping into your “Power Within” is a driving motivational force behind Sugar Surfing.” (p. 114)
If there is any statement in this book I disagree with, it is this one. It all comes down to who is ultimately in charge. In my view, it is God who ultimately causes my best efforts to either succeed or fail. In Ponder’s, despite how long he spends telling us how very much in T1D is uncontrollable, he is still in control. One more little quote before I move on — Dr. Ponder says at one point that “I no longer fear [diabetes] like I did in my younger days” (p. 47). I think this is a very telling statement. One gets the impression that it is this (quite understandable) fear that has driven him to be where he is today. All of which is to say that while there ia a lot to recommend in this book, I have some fundamental problems with the worldview that underlies it.
Now, to stop psychoanalyzing strangers and return to the main point — in the latter part of the book Dr. Ponder gets to specifics of how he manages his T1D. In general, I wish the tips and tricks he uses were laid out a little more clearly. I do like his use of his own CGM readouts; the visuals are very helpful. Personally, there were only a few specific things in this book that I found new. Others I had either encountered on the internet previously (eg. the idea of waiting for the bend to begin eating) or somehow managed to stumble upon myself (Ponder’s i-chain method of bolusing for high fat meals is much like what I was doing anyway). More than specific methods, however, I was inspired to be more diligent in addressing bg numbers when they begin to stray from our target zone rather than waiting till they actually cross those lines.
A few more notes on the practical details in this book:
- Ponder says that his methods work for both pumpers and those on MDI. As someone who uses MDI I really appreciated this. It feels like there is a lot for pumpers out there. On the flip side, there were times when he presents techniques that work for pumpers but left me still frustrated looking for a way to do the same things with MDI (of course if I could get my dd to pump again, that wouldn’t be a problem).
- As the parent of a teenage girl, I was left wanting more info on dealing with the effects of hormones on bg. Of course, Ponder is giving us info based on his own experience and he has never been a teenage girl so the oversight is understandable. Still one must not expect to find answers to every question in this book.
- Ponder spends a chapter on dealing with kids with T1D the main point of which is to say that his techniques can’t all be applied to children. I could easily see how this book might provide more frustration than help for parents whose kids due to their age or compliance are not going to be able to make use of most of the techniques herein.
- Discussing the issue of kids and compliance, Ponder says that “for some reason which I don’t understand” teens who don’t comply “are still allowed to wear an insulin pump” (p. 116). I completely disagree with the idea that insulin pumps are somehow a reward for good diabetes behavior or that bg control and/or compliance will somehow be improved by taking away a kid’s pump.
- Ponders’ advice on calibrating your CGM, specifically saying to only calibrate in the middle of one’s bg range, is contrary to other advice I have heard.
To draw things to a conclusion, while I would definitely recommend Sugar Surfing and think it fills a great need in the diabetes community, both with its portrayal of the realistic challenges of managing T1D and with the specific methods it presents, one should not expect that this book will answer all questions or solve all the problems associated with T1D nor can I agree with Dr. Ponder’s fundamental assumptions about how much control we are able to have.