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 Travelling with VoyageMD to California
The annual clinical meeting of the Diabetes Technology Society was help recently in Los Angeles http://diabetesmd.blogspot.co.uk/ and VoyageMD used the opportunity to also spend 2 weeks in the San Francisco Bay on vacation rather than hang out in the smog of LA.
A few notes for travellers thinking about trying San Francisco as a holiday or business destination. Firstly and most importantly the weather in the city can be variable to say the least and is usually foggy at least some part of most days and significantly cooler than the surrounding Bay Area. If you are spending the day in San Francisco then take a coat just in case – if you find yourself shivering on the Golden gate Bridge then pop over to Chinatown where fleeces and jackets are at bargain basement prices.
The other practical point is that car hire is essential for anyone spending any length of time in the US and best to book on-line before arriving as it is often much less expensive. Beware however that most companies require you to pay to have the gas tank filled up at a premium price after you return the vehicle but you can haggle with them and it is certainly not unexpected to negotiate a lower price.
Eating out in California is a daily occurrence and many American friends rarely (sometimes never) cook a meal at home. Prices are reasonable but remember that the final bill will add sales tax and that 15-20% tip is expected. Here are a few of the more memorable places that VoyageMD sampled this time:
An American breakfast is always a real treat and you would struggle to find anywhere better that Nini’s in San Mateo http://www.facebook.com/pages/Ninis/40679569194 which has been operating since 1955. The walls are covered with an array of memorabilia, service fantastic and the food wonderful – my personal choice was teriyaki steak and eggs! Check out the reviews on yelp.com. If you prefer pastries for breakfast then hop over to Speciality’s Café and Bakery http://www.specialtys.com/. The menu lists calories so you can keep a check on the waistline. Carbohydrate content would also be very helpful for visitors with diabetes.
Other notable places VoyageMD samples included Tokai in Foster City for Japanese food http://www.tokaijapanese.com/ – the sushi is fresh and delightful and most importantly the staff are extremely welcoming and helpful, authentic Mexican dishes at Reposado in Palo Alto although it is not always easy to find a table if you have not booked http://www.reposadorestaurant.com/ and great Mediterranean dishes and pizza at the Waterfront again in Foster City http://www.waterfrontpizza.com/. The Cheesecake factory near San Mateo also remains very popular with locals http://locations.thecheesecakefactory.com/ca/san-mateo-156.html with a mind-blowing menu selection.
For those keen on the American burger experience the usual suggestion in California is to visit an In-and-Out restaurant but this time we sampled 5 Guys in Burlingame http://gofiveguys.com/Order/Order.aspx?VendorId=4121. Totally unhealthy but delicious and the calorie content is on the menu. Also 139 types of soda available from the fountain.
The best new gem on the latest trip was undoubtedly the Refuge in San Carlos http://www.refugesc.com/ which offers probably the best pastrami you will ever taste, a mouth-watering scallop salad and an astonishing selection of Belgian beers (18 on draft) as well as wine. It is a favourite hang-out of the Silicon Valley set so don’t be surprised to over-hear million dollar deals being down by incredibly youthful looking individuals dressed in tee-shirts and sneakers at the next table.
So after visiting all of these places, did VoyageMD gain weight – actually no – simply because of (a) the wonderful weather meant lots of running around, (b) the shopping requiring walking miles each day and (c) the facilities for exercise in this part of California. Unlike the rest of the US and the UK, most locals are positively sylph-like
The next trip for VoyageMD – St Petersburg, Russia.
Travelling with VoyageMD to Barcelona
Not the best day to choose to travel to Spain as a general strike was due to take place and the Spanish personality can occasionally be rather “volatile”. However the purpose of the trip was to discuss improving the safety of insulin so VoyageMD has no qualms about making the trip?
The drive to LHR was surprisingly quick given that this coincided with the rush hour but it did look as if most drivers were parked outside every petrol station in the land, at least in Dorset and along the M3 motorway – obeying the (now regretted) Government advice to “top-up your tank” given the possible tanker driver strike.
Yes business parking at Heathrow terminal 5 is grossly overpriced but I challenge anyone not to be impressed by the automatic Pod system that takes you from the car park to the terminal with the world’s most soothing and relaxing voice explaining the process on the gentle 5 minute trip.
The flight was full and www.BA.com coped admirably with the rather unusual number of travellers using wheelchairs as well as families with young children. It took of late but arrived only 5 minutes behind schedule.
No taxi this time as VoyageMD had a lift already organised but plenty of taxis, and little traffic because of the strike. The hotel http://www.novotel.com/gb/hotel-5560-novotel-barcelona-city/index.shtml was outside of the city centre but adjacent to the Glioria metro station and a tram so easy access (on a non-strike day) to the city centre. Service at the front desk was exemplary, the hotel had good facilities including a roof-top pool, the room was large and you could open the window.
This trip and hotel evoked memories of travel to Spain in the 1970’s and 80’s as the smell of sewage was pretty strong and although the fittings in the bathroom were ultramodern, nothing quite fitted or worked – the shower doors left just enough space to turn the bathroom into a swamp and slippery open at that and the water temperature ranged from scalding to arctic and back again every few minutes – plus ca change! Breakfast was unremarkable but despite years of travelling VoyageMD remains astonished at (a) how much some people can eat first thing in the morning and (b) how certain nationalities seem to enjoy mixing everything the hotel breakfast has to offer together on one plate!
Outside the hotel there is the astonishing Segrada Familia church (desgined by Gaudi) within walking distance – still being rebuilt but still fabulous although the number of dodgy looking characters (AKA pickpockets) hanging around seems to have multiplied in recent years. Otherwise not a lot except for a few bars ,restaurants and “ladies of the night” hanging around the roundabout next to the hotel.
Great meeting with healthcare professionals from 27 countries and the trip back was uneventful and again congratulations to BA on being on time.
Barcelona has everything – weather, history, culture, architecture, food, shopping and nightlife and this time even a general strike was tolerable!
 Travelling with VoyageMD to Edinburgh
VoyageMD is likely to be biased given his Scottish Roots but even so a trip to the capital is always an exciting prospect. The perennial problem however is what to pack in order to cope with unpredictable Edinburgh weather but at the same time avoid the excess costs of checking luggage in on Flybe (www.Flybe.com). VoyageMD travelled light. Whenever possible use the electronic check in machines for travelling with hand luggage – use the traditional counter method and you will be asked to squeeze your carry-on bag into a ridiculously small box to avoid the penalty of checking in luggage. Most fail and are £36 lighter.
Hats off to Flybe though – arrived in Edinburgh ahead of schedule and a very smooth and pleasant trip it was. On arrival it is easy to get to Edinburgh City Centre by bus and will only set you back £3.50 for a single ticket.
VoyageMD was staying the George Hotel – a perfect location to enjoy the city (http://www.edinburghgeorgehotel.co.uk). Thumbs up to the hotel (it has recently changed management so many of the reviews are out-of-date) on all aspects – service, room and especially breakfast (you might have to queue though). Good value provided you avoid the “rack-rate”. Across the road is the must-see Edinburgh bar – the Dome. (http://www.thedomeedinburgh.com).
Lunch was at the Grain Store in Edinburgh’s Grassmarket area. (http://www.grainstore-restaurant.co.uk/about). The food is a tribute to the best of Scottish fare without a deep-fried Mars Bar anywhere to be seen. Good, value with great service and you can also have a before lunch/dinner drink across the road at the Bow Bar – this traditional pub offers more than 200 whiskies and 8 real ales on draft.
In between VoyageMD had a very successful meeting focusing on “disruptive” technologies and approaches to blood glucose monitoring for people living with diabetes (more to report soon!!) so the evening meal was booked at Oloroso on Castle street (http://www.oloroso.co.uk/) to celebrate. Compared to the lunch, this was a big disappointment – mostly because of the price. A £55 “burger” actually turned out to be a huge meat feast with enough protein to induce temporary kidney failure but the steak and chips was simply not good value. The view is OK but not spectacular and the balcony option is unlikely to be popular given the traditional Edinburgh weather. Puddings were unremarkable so all-in all VoyageMD will probably not be back given the huge choice of eating places elsewhere in the City.
Next day back to Southampton on the using the propeller version from Flybe and arrived slightly early so well done again to the airline.
Edinburgh is a great place to visit for the history, culture, locals, food, entertainment etc but this is probably the only time where global warming is an attractive option.
Timesulin – for travellers with diabetes who need to take insulin injections
A UK based technology company (Patients Pending Ltd) just announced the launch of Timesulin, a novel replacement cap that fits on all major insulin pens.
A really simple and neat idea – the “smart” cap for the insulin pen shows how long it’s been since the last injection. Timesulin apparently works with all major insulin pens, straight out of the package without any programming required.
Continue reading Timesulin – for travellers with diabetes who need to take insulin injections
Ski Program – Fit for Skiing
This program has been designed for people that are about to go on a skiing holiday. The exercises shown here target the specific muscle groups that are used when you ski – the idea is to train them so that your holiday will be pain free!!!
The program should be completed at least 3 times a week to get the most benefit, more than 3 times a week will increase the benefits further.
Continue reading Ski Program – Fit for Skiing
Impact of High Altitudes on Glucose Control
Article published in the November 2011 issue of the Journal of Diabetes Science and Technology.
Authors: Johan Jendle, M.D., Ph.D.,1,2 and Peter Adolfsson, M.D.3
Airplane flight results in exposure to hypobaric conditions. At cruising altitude, usually 10,000 to 13,000 meters (30,000 to 42,000 feet), the pressure in the cabin is 0.75 atm, which is 75% of the pressure measured at sea level.
The difference in pressure between 1.0 and 0.75 atm is what passengers experience as temporary ear discomfort at take-off and landing.
What does elevation have to do with diabetes then? It would be anticipated that people with diabetes travel as frequently as everybody else. It has been described in the literature1 that some glucose meters are affected with changes in altitude. The glucometers studied underestimated glucose levels by approximately 1–2% for each 300 meters/1000 feet of elevation after correlation for changes in temperature and humidity. The lower the oxygen partial pressure, the lower the glucose value. Most glucometers use glucose-oxygenase methods, which are dependent on oxygen in the surrounding environment.2 The partial pressure of oxygen in the airplane cabin is 16 kPa compared to 21 kPa at sea level, thus there is a risk that a glucometer can show a false hypo- or normoglycemia while in the air, when the true value in fact could be higher.
These effects of high altitudes do not apply only to flying conditions. There are many cities around the world situated at high altitudes: Colorado Springs, United States, 1840 meters (~6040 feet); Mexico City, Mexico, 2200 meters (~7220 feet), and La Paz, Bolivia, 3640 meters (~11,940 feet). It might be that people with diabetes living in these cities are taking much lower insulin doses than necessary because of false, low self-monitoring of blood glucose readings and therefore have a higher HbA1c level compared to a similar population living close to sea level. For instance a comparison between residents of Colorado Springs and Boston would be interesting to see.
Hypoglycemia has been reported, in connection to flying, in people with insulin-treated diabetes using continuous subcutaneous insulin infusion.3 This may be due to trapped air within the ampule/infusion set or related to a direct effect on the pump’s insulin delivery system, but this has not been completely investigated. With the increasing use of continuous glucose monitoring (CGM), especially in sensor-augmented pumps,4 it is of importance that sensor systems as well as insulin pumps be evaluated in various pressure conditions.5 The glucose oxygenase method is used by CGM systems and by most glucometers. However, the accuracy and performance of one CGM system was minimally affected when challenged under hypobaric conditions at 0.5 and 0.75 atm.6 The Food and Drug Administration has advocated that all sensors being used for glucose sensing be evaluated under relevant pressure conditions.
Author Affiliations: 1Endocrine and Diabetes Center, Karlstad Hospital, Karlstad Sweden; 2Department of Medicine and Health, Örebro University Hospital, Örebro Sweden; 3Pediatric Growth Research Center, Department of Pediatrics, Institute for the Health of Women and Children, The Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
Abbreviations: (CGM) continuous glucose monitoring
Corresponding Author: Johan Jendle, M.D., Ph.D., Endocrine and Diabetes Center, Karlstad Hospital, SE-65185 Karlstad, Sweden; email address
johan.jendle@liv.se
What then are the implications for our patients with diabetes?
It is commonly suggested to refrain from calibrating a CGM during flights. This should be done prior to take-off and/or after landing; however, this has not been investigated. Further studies are needed to assess accuracy and performance of both CGM systems as well as insulin pumps of patients with diabetes under in-flight conditions.
References:
1. Karon BS, Boyd JC, Klee GG. Glucose meter performance criteria for tight glycemic control estimated by simulation modeling. Clin Chem.
2010;56(7):1091–7.
2. Tang Z, Louie RF, Lee JH, Lee DM, Miller EE, Kost GJ. Oxygen effects on glucose meter measurements with glucose dehydrogenase- and oxidase-based test strips for point-of-care testing. Crit Care Med. 2001;29(5):1062–70.
3. King BR, Goss PW, Paterson MA, Crock PA, Anderson DG. Changes in altitude cause unintended insulin delivery from insulin pumps:
mechanisms and implications. Diabetes Care. 2011;34(9):1932–3.
4. Hermanides J, Nørgaard K, Bruttomesso D, Mathieu C, Frid A, Dayan CM, Diem P, Fermon C, Wentholt IM, Hoekstra JB, Devries JH.
Sensor-augmented pump therapy lowers HbA(1c) in suboptimally controlled Type 1 diabetes; a randomized controlled trial. Diabet Med.
2011;28(10):1158–67.
5. Price ME Jr, Hammett-Stabler C, Kemper GB, Davis MG, Piepmeier EH Jr. Evaluation of glucose monitoring devices in the hyperbaric chamber. Mil Med. 1995;160(3):143–6.
6. Jendle J, Adolfsson P, Örnhagen H, Shad R, Cooper K, Gautham R. Glucose sensor performance during pressure changes. Diabetologia.
2011;54(Suppl 1) S396.
7. Johan Jendle, M.D., Ph.D.,1,2 and Peter Adolfsson, M.D.3
www.journalofdst.org
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