Travelling With Type 2

Up-dated 16th February 2022. Please advise me in the comments if amendment is needed.


Air travel

Travel by air has become a bit more complicated since 9/11 and covid. I was travelling through the USA on my first rtw trip in March 2003 when the Iraq war started. Security went nuts and within a week we missed a flight from St Louis to Atlanta because we spent two hours in security. TSA took a long time to find a way to secure air travel without grossly inconveniencing passengers. However, after the initial over-reaction things have settled a bit now.

COVID 

The rules for COVID vary for different countries and airlines. Always check those before you pay for a ticket and be wary of airline refund policies. Check vaccination rules and what tests (PCR, RAT etc) are required and their timing, check whether self-isolation or quarantine will be required on arrival and whether that will affect your access to needed medical supplies, food or drinks.

Food

Hypo protection

For the possibility of lows, I just carry jelly beans. Simple and not bulky, which is important these days for carry-ons with many airlines strictly enforcing size limits.

Mid Air Snacks.

Making some snacks up in advance is best because you can choose exactly what they are. You aren't restricted to the over-priced limited range available at the airport. I usually make up a small sealed plastic container of mixed nuts and raisins. It keeps well, can be kept in a pocket or purse for a quick nibble to stave off hunger and gives a good mix of protein, fats and carb. If that is not possible, I seek out something suitable in the air-side shops. Things like beef jerky (check the carb count), nuts, cheese-'n-crackers or similar. Not for meals, but for those times when you need something to nibble on during a long flight. I don't try for very low carb, but a mix of carbs, protein and fat, including about 5-10 gms carb in a snack.

I never go on a flight without sufficient for two or three snacks in my carry-on. It may be scheduled as a one-hour hop. But, after the first time you've waited three hours in the gate lounge and then sat in a delayed plane on the taxi-way for several hours without food, air-conditioning or information you realise that travelling in those conditions without snacks is not wise. It may only ever happen to you once, but that will be too often if you don't have food available every few hours.

In-flight Meals.

This is becoming a hypothetical subject, but there are still a diminishing number of Airlines that provide meals in cattle class.

Never, ever, ring in advance to advise that you have diabetes and wish to have a "diabetic" meal. If you do, be ready to eat a meal that will commence with a bread roll, followed by a main of low-fat starch, with sides of starch, washed down with fruit juice, followed by a piece of fruit and a dessert of low-sugar rice pudding or similar.

Instead, I have a standard procedure. I wait until the initial boarding rush is over and I can catch the attention of the steward. I advise the steward that I have diabetes that I manage with a strict diet. Then I patiently nod and smile through the set "you should have advised us in advance so we could have provided a special diabetic meal for you". I apologise for not doing so and request a look at the menu of the day. I then choose the least bad choice. Failure to do this means you are risking no choice at all when they run out of the beef casserole and you find that pasta and rice is the only choice left. On two notable occasions, when there were no remotely acceptable choices, the senior steward suggested that I might prefer something from the business class menu. You get a different class of service on Qantas and Air New Zealand.

For longer flights I carry a cooler pack with me. This thing wandered around the world twice with me:

It doubles as my carry-on for medications and other things I need to get at quickly. Most airlines will allow something like that as a second carry-on, but check if your airline has a one-bag limit.

I often prepare a salad the night before, usually with some cold cuts or similar, and pack it in an appropriate small plastic lunch container. The dry food will get through the TSA security, but liquids won't; I haven't tried a freezer brick through security since those rules changed, so I would transfer the food from the fridge to the pack as late as possible. After passing through security buy a cold drink which can also act as a cooler for the insulated section. If you don't want to pre-prepare you can nearly always buy a prepared salad, or jerky or something similar on the "air" side of security.

Don't try to get drinks through airport security - they will probably be confiscated. Buy your cans or bottles after the security check if you need them; I usually have a coffee instead. On board, I have never travelled on an airline that did not provide water or diet soda on demand, sometimes free.

Medications and Diabetes Supplies

When I fly I always carry a letter from my doc listing my ailments and medications. I have only rarely needed that letter, but on those rare occasions it saved me a lot of stress and hassle. For diabetes supplies read the current rules on the TSA web-site - they apply to all US airports and many overseas airports also use them as a general guide. 

This is a copy of TSA's blog Travel Tip: Traveling with Diabetes, updated 16th February 2022.

heck or Carry-on

We know that traveling with medical supplies can be a nerve-wracking experience, especially when your medication includes needles and other sensitive equipment. So here are some tips to help make your trip as smooth as possible.

Notify the Officers

When you arrive at the checkpoint, let our officers know about your medical device and any other equipment prior to screening. If you have an insulin pump, glucose monitor or other medical device attached to your body, inform the officers where it is located before the screening process begins. Although not required, you can provide them with a TSA notification card prior to screening to discreetly describe the medical condition.

If you have questions or concerns at any time during the screening process, please ask to speak to a supervisor.

Screening Process

Passengers in standard lanes may be screened by advanced imaging technology, metal detector or a pat-down. If the standard lane does not have advanced imaging technology, or if you are eligible for expedited screening through TSA PreCheck®, you may be screened by a walk-through metal detector. If you do not wish to go through screening by technology, inform the TSA officer and they will conduct a pat-down. Pat-downs are conducted by a TSA officer of the same gender, and you may request private screening at any time.

You will not be required to remove any medical devices attached to your body.

Medical Supplies

If you are traveling with medical equipment or supplies, they will need to undergo separate screening. The TSA officer will check the supplies and conduct any necessary testing. If your medical condition requires it, you are allowed to travel with a juice box or other liquid over 3.4oz., but be prepared for the liquid to receive additional screening.

In the event that your insulin pump or glucose monitor is attached to your body, the device is subject to additional screening, including visual inspection. You may be required to conduct a self pat-down of the actual device, followed by a test of your hands for any trace of explosives.

Still have questions? Visit our website for additional information.

TSA Cares

If you have any additional questions or need assistance at the checkpoint, reach out to TSA Cares at 855-787-2227. Simply call 72 hours prior to your trip or visit our TSA Cares website. Knowing more about the process may help to relieve any stress and anxiety!

See also US TSA rules for Disabilities and Medical Conditions. This mentions that the 3-1-1 gels and liquids rule is eased for Medications. That was a very useful tip explained to me by the TSA supervisor at DFW. It helped that I had my letter from my doc, but items not on the doc's list such as mosquito repellent, antiseptic and similar were also allowed.

Road Trips

 

When possible I prepare exactly the same snacks as I do for an air trip and carry the cooler pack on board. That gets a lot of use in the car, because there will always be a bottle or two of diet soft drinks, a bottle of wine and some cheese, crackers or similar. I add a couple of freezer bricks to keep things cold and fresh. Each night I put those in the room fridge, if it has one, or ask the hotel staff to keep them in the restaurant freezer. I've never had that request rejected but I have occasionally forgotten to collect them in the morning. No big deal, they only cost a couple of bucks. I also store small containers of olive oil for salad dressing or cooking oil, vinegar, salt and pepper in the side pockets.

If the accommodation I am using has cooking facilities I always prefer to cook my own simple breakfasts. While on the road it is easy to pick up some eggs, maybe an onion, mushrooms, cheese (or whatever you like) to make a simple omelette or scrambled eggs in the morning.

I look for diners and Mom and Pop restaurants when I'm on the road. The sort of place where I can get bacon and eggs for breakfast, or they will listen when I ask them to hold the fries and double the salad.

Breakfasts

Hotel breakfasts can vary from wonderful buffet choices to disastrous "continental" breakfasts of a tired croissant and grey cold imitation coffee. They can also be incredibly expensive, with minimum prices in the restaurant or high extras and tips on room service. I refuse to pay $20+ for some watery scrambled eggs and a coffee. If the hotel choice is OK or I can cook my own, wonderful. If not I have a standard routine on arrival at a hotel.

I ask at reception where the nearest diners, cafes and restaurants are and for recommendations. At an appropriate time after I check in, usually after dinner, I take a walk around the district. If I arrived by car I will have already been watching for restaurants as I drove in. I use the walk for exercise and also to check out an appropriate place for breakfast. It is rare that there are no diners or similar within a reasonable walk - which also doubles as my morning exercise.

Eating Out

When I am travelling with my wife, eating out is much simpler. On two trips around the world with her we left a reputation behind us as Aussie cheapskates because, wherever we went, we would order one main course and a spare plate for the two of us. It took some cheek, but we didn’t put the weight back on. We also saved some cash, but that was a bonus, not the intention. Where it wasn’t possible because of language or embarrassment of others, we would order a main course and a side salad or starter – just to get the plate – then mix between the two. This allowed me to leave the high carb items for my non-diabetic wife.

We often found that we still left food on the plate, even when we shared. The food is actually the smallest cost in running most restaurants; many chefs provide enormous serves to attract customers.

When I travelled alone, it was more difficult. I, like many, was raised in an environment where waste was frowned upon - waste not, want not. As a post-WWII child I was taught to clean my plate before leaving the table.

It takes discipline to break the habits of a lifetime and leave over half the food on the plate when you know you are paying for it. But if you eat it, you will pay much more eventually. Specify that you absolutely, definitely do NOT want chips/fries. Many restaurants add them automatically.

For dinners, when travelling alone, I found the method I used most often was to order an appetiser and a side salad instead of a main course. If that was too small I would order a second appetiser. That led to some marvellous and delicious meals; often the appetisers are more varied than the main course and aren't accompanied by piles of potato, rice or fries.

My most common lunch when travelling is "Soup of The Day". But be a little careful of thick "cream" soups; they will often be thickened with cornstarch, flour or potato. In 2006 I happened to be wandering through Germany in Spargelsuppe season. Bliss.

I'm sure I'll recall other tips after I post this, so I'll probably return regularly and up-date it.

Bon Voyage

Cheers, Alan

Everything in Moderation - Except Laughter.

ADA Accomplishments in 2008

The ADA has just posted this review of their achievements in 2008 on their web-site:

In Diabetes Today 08-JAN-2009
American Diabetes Association Reflects on 2008 Accomplishments in the Fight Against Diabetes and Looks Ahead to Challenges in 2009

I read the whole thing through carefully. Unfortunately, the accomplishments I was looking for weren't in it. I read it twice to be sure.

What they did include as headlines were:

Research Funding
Fighting Discrimination Against People with Diabetes
Health ReformCreating A Healthy Environment
Those are all necessary and highly laudable achievements. I have nothing but praise for all of those involved in those areas. But that is a very limited list to my mind.

These are the headlines I missed:

"America's average A1c of diagnosed diabetics reduced significantly."or "Mortality rate of diabetics reduced."or "Rates of long-term complications reduced in diabetics."or "Fewer people with metabolic syndrome or pre-diabetes progressing to type 2 diabetes."

I didn't see anything remotely like those. Those, or similar accomplishments, are the headlines that would indicate to me that the ADA is making a real and significant difference to the diabetics of the world, or at least of America.

I searched again, but all I could find was:

"Since 1987, the death rate due to diabetes has increased by 45 percent"

Maybe I'm too simple to understand these things, but isn't that trend heading in the wrong direction? And at a rather high rate?

If beating the medical afflictions of the world was a team sport and the ADA was the most highly funded team in the Diabetes Division, don't you think that by now the fans would be screaming for a review of the team's aims, methods and tactics? Hopefully the recent change in coach will bear fruit.

They note that in "in 2008, the American Diabetes Association provided $42.5 million toward funding research to combat type 1 and type 2 diabetes in people of all ages and races."
How much of that money came from big Pharma ? Most. How much of that money went to discover the optimum SMBG testing and dietary regimen for type 2 diabetes? Any? I doubt it.

On a more optimistic note, back when I wrote Money, Medications and Motives, the ADA FY06 Corporate Recognition Program included several major grains, food and beverage companies. That link no longer works and I could not find the same level of sponsorship from that industry group on the present Become a Corporate Supporter page (although it is still top-heavy with Big Pharma). I hope that is a sign from the new coach of things to come and not just poor search techniques on my part.

In that case I applaud the changes that are occurring and I hope they continue into other areas such as the focus for research funding. Maybe some day I will start to see the headlines I missed today.

Cheers, Alan

Diabetes and Dental health

A couple of years ago I wrote about the two-way relationship between Diabetes and Periodontal disease in Teeth, Gums, Diabetes and Death .

My main intent at that time was to emphasise that dental hygiene and blood glucose levels seem to be closely related. Poor dental hygiene causes poor blood glucose levels and poor blood glucose levels exacerbate dental problems. The reverse is also true, with improvements in either leading to improvements in the other. For more discussion on that read the earlier article.

One of the cites I provided, Periodontitis and diabetes interrelationships, had an interesting comment: "Thus, there is potential for periodontitis to exacerbate diabetes-induced hyperlipidemia, immune cell alterations, and diminished tissue repair capacity. It may also be possible for chronic periodontitis to induce diabetes." Induce diabetes? I noted that further research should be done there.

Further research has now been done and that possibility is becoming a little more plausible. This paper was published online on April 4, 2008 in Diabetes Care 31:1373-1379, 2008: Periodontal Disease and Incident Type 2 Diabetes

OBJECTIVE—Type 2 diabetes and periodontal disease are known to be associated, but the temporality of this relationship has not been firmly established. We investigated whether baseline periodontal disease independently predicts incident diabetes over two decades of follow-up.

RESEARCH DESIGN AND METHODS—A total of 9,296 nondiabetic male and female National Health and Nutrition Examination Survey (NHANES I) participants aged 25–74 years who completed a baseline dental examination (1971–1976) and had at least one follow-up evaluation (1982–1992) were studied. We defined six categories of baseline periodontal disease using the periodontal index. Of 7,168 dentate participants, 47% had periodontal index = 0 (periodontally healthy); the remaining were classified into periodontal index quintiles. Incident diabetes was defined by 1) death certificate (ICD-9 code 250), 2) self-report of diabetes requiring pharmacological treatment, or 3) health care facility stay with diabetes discharge code. Multivariable logistic regression models assessed incident diabetes odds across increasing levels of periodontal index in comparison with periodontally healthy participants.

RESULTS—The adjusted odds ratios (ORs) for incident diabetes in periodontal index categories 1 and 2 were not elevated, whereas the ORs in periodontal index categories 3 through 5 were 2.26 (95% CI 1.56–3.27), 1.71 (1.0–2.69), and 1.50 (0.99–2.27), respectively. The OR in edentulous participants was 1.30 (1.00–1.70). Dentate participants with advanced tooth loss had an OR of 1.70 (P <>

CONCLUSIONS—Baseline periodontal disease is an independent predictor of incident diabetes in the nationally representative sample of NHANES I."

What that means in layman’s terms was clarified in Endocrine Today online in November when an interview with one of the authors, Ryan T. Demmer, PhD, MPH was published. He said that these findings add a "new twist" to the association, suggesting that periodontal disease may lead to diabetes.

"It has been generally accepted that periodontal disease is a consequence of diabetes despite the fact that this association has not been studied with the same methodological rigor applied to coronary and stroke outcomes," he told Endocrine Today. "We found that over two decades of follow-up, individuals who had periodontal disease were more likely to develop type 2 diabetes later in life when compared to individuals without periodontal disease." For more details read that Endocrine Today issue where it is discussed with several other researchers in this field.

I still suspect that type 2 has a genetic cause, but I now believe that periodontal disease can be a trigger for type 2 diabetes in the same way that a poor diet or lifestyle can be. There is also the possibility the genetic tendency to type 2 diabetes may also be the initial cause of the precursor conditions of periodontal disease or obesity.

I already knew that it was important to have very good dental hygiene as a type 2 diabetic. Now it seems that it may be equally important for those of us who have offspring following in our genetic foot-steps to pass that message on loud and clear to them.

Cheers, Alan